High-flow Fistula Research Articles

Transarterial detachable coil embolization of direct carotid-cavernous fistula: Immediate and long-term outcomes

BackgroundTransarterial embolization is a standard method for management of direct carotid-cavernous fistula (DCCF). The purpose of this study was to report our experiences, and immediate and long-term outcomes of endovascular embolization of DCCFs by using detachable coils (DCs). MethodsOver 8 years, 24 patients with 25 DCCFs underwent endovascular DC embolization. There were 15 men and nine women; age ranged from 8 to 82 years (mean, 39 years). Immediate and long-term angiographic as well as clinical outcomes after endovascular DC embolization were retrospectively analyzed. The number and the length of DCs used to occlude the fistula were also evaluated. ResultsEighteen DCCFs were successfully occluded by single-session endovascular embolization with preservation of the parent artery. Retreatments by transvenous (n = 5) and/ or transorbital routes (n = 3) had to be performed in seven patients because of residual fistula (n = 4) or recurrent fistula (n = 4) occurring within 3 weeks after embolization. The average numbers and length of coils to occlude the fistulas were 14 (range, 2–31) and 189 cm (range, 16–756 cm), respectively. Four patients had small residual fistulas with spontaneous thrombosis on follow-up angiography. Three patients had transient cranial nerve impairment of the third (n = 1) or sixth (n = 2) nerve. There was no significant procedure-related neurological complication. The follow-up period was 3–48 months (mean, 19 months) ConclusionEndovascular DC embolization of DCCFs was proved both efficacious and safe in managing high-flow fistulas with sustained angiographic and clinical effects, particularly in those DCCFs with small fistula track and/or cavernous sinus. However, retreatment via various routes may be necessary in some patients because of residual or recurrent fistulas.

Communicating hydrocephalus caused by an unruptured perimedullary arteriovenous fistula in the lumbar region of an infant

Spinal arteriovenous malformations are rare in children, although perimedullary arteriovenous fistulas (PMAVFs) may account for up to 24% of spinal arteriovenous malformations in this age group. Reported presentations of PMAVFs have included progressive or acute myelopathic symptoms, pain, hematomyelia, and subarachnoid hemorrhage. No known reports of an unruptured PMAVF causing communicating hydrocephalus have been previously published. A 17-month-old girl presented to the authors' clinic with a 6-month history of back and leg pain, gait regression, constipation, and marked lumbar hyperlordosis due to a PMAVF. A brain MRI study also demonstrated advanced hydrocephalus. The patient underwent embolization with Onyx of 2 feeding arteries from the right L-1 and 1 feeding artery from the left L-1 lumbar arteries. Postembolization follow-up imaging demonstrated a reduction in size of the L-1 pedicles and no residual supply of the fistula. Three-year clinical follow-up showed normal bowel and bladder function with significant improvements in the patient's back pain, gait, and hyperlordosis. The patient's ventricular enlargement improved without direct management of her hydrocephalus. To the authors' knowledge, this is the first reported case of communicating hydrocephalus caused by an unruptured PMAVF. The authors postulate that the origin of hydrocephalus was either central venous hypertension caused by the high-flow fistula or a change in fluid dynamics reducing CSF resorption through arachnoid granulations in the lumbar region of the spinal cord. The exact role that spinal arachnoid granulations play in CSF resorption is not currently known. Regardless of pathogenesis, initial treatment should focus on management of the fistula with additional hydrocephalus management only when necessary.

Endovascular Repair of a Left Common Carotid Pseudoaneurysm Associated With a Jugular–Carotid Fistula After Gunshot Wound to the Neck

The management of traumatic injury of the common carotid artery has traditionally required a conventional surgical intervention, which is associated with a high mortality rate. Endovascular procedures might offer a less invasive alternative to treat these injuries, with a lower rate of mortality and morbidity. We report the case of a 30-year-old man who presented after penetrating injury due to a low-velocity gunshot wound to the neck. Angiography demonstrated a high-flow arteriovenous fistula and large false aneurysm of the common carotid artery. A self-expanding covered stent was placed across the injured portion of the artery, resulting in thrombosis of the aneurysm and preservation of the parent artery, without any significant complication. Covered stent placement is an alternative approach to treating carotid artery pseudoaneurysms associated with a jugular-carotid fistula.

Paraplegia in Pregnancy

A case report. To present improvement of paraplegia due to spinal vascular malformation after delivery with no intervention. Pregnancy has been reported rarely in patients with Klippel-Trenaunay syndrome (KTS). A combined case of spinal arteriovenous malformations (AVMs) within KTS has not been reported before. A case report of KTS with paraplegia is presented and the pertinent literature is then reviewed. A pregnant woman who was diagnosed with KTS in childhood presented with newly developed paraplegia due to spinal AVMs. Magnetic resonance image showed a vascular malformation at the T9-T12 levels without evidence of spinal cord hemorrhage. Diagnostic angiography that was performed after delivery revealed a high-flow arteriovenous fistula with AVM. Pregnancy complicated by paraplegia is thought to be secondary to venous engorgement and to the resulting spinal cord ischemia in this case. Her neurological symptoms and signs gradually improved over the few days after cesarean delivery.

Valvular Heart Disease and Dialysis Access: A Case of Cardiac Decompensation after Fistula Creation

L/min (4). However, the effects of AVFs on patients with aortic stenosis have not been studied although one fifth of dialysis patients have aortic stenosis (5). AVFs can achieve high blood flow and can have a significant hemodynamic impact within a few days after their placement. Patients with advanced heart failure or aortic stenosis may benefit from an alternative access strategy such as tunneled catheters or peritoneal dialysis. If AVF is chosen in these patients, close monitoring and potentially early ligation of the AVF should be considered upfront. In addition, because of the high prevalence and quick progression of aortic stenosis in dialysis patients, periodic assessment of cardiac functions is necessary, especially in patients with high flow fistulae or grafts.

Cirsoid aneurysm of the right pre-auricular region: an unusual cause of tinnitus managed by endovascular glue embolisation

We report an interesting case of a right temporal pre-auricular arteriovenous fistula (cirsoid aneurysm) causing intractable tinnitus successfully managed by transarterial n-butyl cyanoacrylate glue embolisation. A 52-year-old female presented with a one-year history of tinnitus and pulsatile swelling in the right pre-auricular region. A colour Doppler ultrasound test and magnetic resonance angiography revealed a high-flow scalp arteriovenous fistula with a feeder vessel from the distal superficial temporal artery, which drained into the corresponding, dilated, tortuous vein. The patient underwent diagnostic digital subtraction angiography. This was followed by transarterial embolisation of the fistula using a 50 per cent mixture of n-butyl cyanoacrylate glue and Lipiodol®, with manual distal venous occlusion. A successful outcome was achieved with instant relief of symptoms. Cirsoid aneurysms of the facial region, an uncommon cause of tinnitus, can be effectively managed by endovascular embolisation. This treatment obviates the need for surgery, which is associated with an increased risk of complications such as scarring, deformity and bleeding.

Flow control techniques for Onyx embolization of intracranial dural arteriovenous fistulae

ObjectivesExperience of flow control techniques during endovascular treatment of intracranial dural arteriovenous fistulas (DAVFs) using the Onyx liquid embolic system is reported, with an emphasis on high flow shunts.MethodsData were...

Use of detachable balloon in the treatment of arteriovenous fistula at a teenage case

In this article, we present a teenage female with a traumatic, distal femoral arteriovenous fistula (AVF). She was admitted to our cardiovascular clinic with the complaints of swelling, pain, cyanosis and ulceration at her right lower extremity. She had a history of gun shot injury 10-years ago. A skin scar was observed at this region due to surgery. Physical examination revealed swollen superficial varicose veins and ulceration of the right lower extremity. Heart failure was absent. We suspected an AVF with clinical findings. The high-flow fistula was diagnosed using multi-dedector computed tomography and confirmed on angiography. The fistula was successfully embolized with the detachable balloon technique.

A Case of Dual Coronary Sinus Fistulas Originating From Right Coronary Artery and Left Ventricle

A man aged 73 years who had undergone coronary artery bypass graft presented with orthopnea. Echocardiography showed marked dilatation of the coronary sinus (CS), with a massive intramural thrombus andflow acceleration at its opening, and a high velocity jet from the left ventricle through its posterior wall into an enlarged coronary vein, suggesting dual cardiac fistulas to the CS. Multidetector computed tomography revealed a large aneurysm of the right coronary artery (RCA) with a RCA-CS fistula (red arrows), a left ventricular-CS fistula via posterior coronary vein (blue arrows), and a large CS aneurysm (green arrows) with a massive intramural thrombus (Fig. 1). Cardiac catheterization showed a 3.4:1.0 left-to-right shunt at the level of the right atrium. The highflow RCA-CS fistula was successfully treated by transcatheter coil embolization. The postoperative course was uneventful, and the patient was free of symptoms at a 1-year follow-up. Although there have been several case reports of RCA fistula to

De novo development of dural arteriovenous fistula after endovascular embolization of pial arteriovenous fistula

BackgroundThe development of de novo dural arteriovenous fistula(s) following endovascular embolization of a prior high-flow pial arteriovenous fistula (PAVF) has not previously been reported and the natural history is unknown....

Vena Cava Filter Scaffold to Prevent Migration of Embolic Materials in the Treatment of a Massive Renal Arteriovenous Malformation

Transcatheter occlusion of high-flow arteriovenous malformations (AVMs) or arteriovenous fistulas may be complicated by migration of embolic materials intended to impede flow. Reducing antegrade flow during catheter embolization via balloon occlusion or inhibiting migration with anchoring devices may improve procedural safety in high-flow settings. We describe the use of an inferior vena cava filter as a scaffold to support complete vascular occlusion of a large renal AVM.

Treatment of High-Flow Carotid Cavernous Fistula Using a Graft Stent: Case Report

Direct high-flow carotid cavernous fistula (CCF) may be associated with traumatic fracture of the skull base and the sphenoid bone, which produces a direct communication between the internal carotid artery (ICA) and the cavernous sinus (CS). The clinical manifestation of CCF is related to the venous drainage pattern, which may lead to various symptoms, such as pain, exophthalmos, conjunctival chemosis, visual impairment, ocular movement disorder, and intracranial hemorrhage. The goal of treatment of high flow CCF is to obliterate the arteriovenous shunt at the site of the fistula, while preserving the patency of the ICA as much as possible. The current treatment of choice is transarterial obliteration of the fistula with detachable coils. However, the use of detachable coils can lead to incomplete or temporary occlusion of the fistula due to its high blood flow velocity. An increasing body of evidence has demonstrated that a graft stent lined with polyfluorotetraethylene or Gore-Tex is an alternative for the treatment of CCF. We present our experience using a graft stent to treat high-flow CCF and review the pertinent literature to identify potential indications for a graft stent. Case Report

Zastosowanie okludera naczyniowego Amplatzer do zamknięcia tętnicy wątrobowej jako metoda leczenia szybkoprzepływowej przetoki tętniczo-wrotnej przed przeszczepem wątroby.

Arterioportal fistula (APF) is an abnormal, direct connection between hepatic artery or its branch and the portal vein. Fistula can be acquired or, rarely, congenital. One of the acquired causes of fistula is a liver biopsy. Patients with liver cirrhosis are particularly vulnerable to its development due to the large number of performed biopsies. APF increases mortality and morbidity of liver transplantation procedure and may be a contraindication to it. The authors present a patient with liver cirrhosis, in whom percutaneous APF closure facilitated liver transplantation. We describe a case of a 50-year-old patient with liver cirrhosis and APF, probably formed as a result of liver biopsy. Due to the presence of a high-flow fistula, which elevated portal hypertension, patient did not qualify for the liver transplantation. Patient was transferred to the interventional radiology department, where the fistula's vascular supply was endovascularly closed using the Amplatzer occluder. This subsequently enabled the execution of transplantation. Percutaneous closure of APF should be considered a relatively simple and fast-acting tool to facilitate or even enable liver transplant surgery. Currently, there are more and more products available such as e.g. Amplatzer occluder to simplify the procedure and shorten the duration of exposure to ionizing radiation.

A Direct Carotid-Cavernous Fistula due to Penetrating Trauma by a Knitting Needle to the Temporal Region

Traumatic carotid-cavernous fistulas (CCF) usually occur after closed head injuries. In addition, CCFs can also be caused by penetrating injuries with stab or gunshot injuries. We present the case of traumatic CCF that was caused with a knitting needle directly penetrating through the temporal region. A 46-year-old man consulted with a progressive left swollen eye. His head computed tomography (CT) revealed a left temporal lobe contusion and fracture of the left temporal bone. Digital subtraction angiography (DSA) showed a direct high-flow fistula (Type-A lesion). After the balloon occlusion test, which was well tolerated by the patient, the internal carotid artery was occluded by the interventional radiologist. A review of the literature demonstrated that all of the traumatic CCFs occurred due to penetrating stab injuries through the orbita. To our knowledge, such a case has not been previously reported.

Vertebral artery occlusion with Amplatzer vascular plug 4 to prevent subsequent endoleak in stent-graft treatment of subclavian artery gunshot injury

Endovascular treatment options have evolved in many ways and become an important alternative for open surgical repairs in various vascular territories. Herein, we present a case of an 18-year-old man with complex injury to the left subclavian artery and vein caused by a gunshot 4 months ago. After the gunshot, a high-flow fistula between the left subclavian artery and the vein occurred with pseudoaneurysm formation. This fistula led to a significant left subclavian steal phenomenon. A stent-graft was deployed along the injured left subclavian artery after embolization of the left vertebral artery by Amplatzer vascular plug 4 (AVP-4) in order to prevent subsequent endoleak due to the subclavian steal syndrome.

Oclusão de fístula arteriovenosa pulmonar com plug vascular em paciente com embolia cerebral paradoxal prévia

A embolização percutânea transcateter tornou-se o tratamento de escolha para fístulas arteriovenosas pulmonares (FAVPs), na maioria dos casos em substituição à intervenção cirúrgica. Os dispositivos clássicos, tais como coils intravasculares e balões destacáveis, provaram ser um sucesso para oclusões percutâneas de FAVPs pequenas ou médias; porém, não são ideais nas fístulas maiores e de alto fluxo pelo risco de embolização para a circulação sistêmica. Relatamos o caso de uma mulher de 49 anos de idade com FAVP de alto fluxo e manifestações neurológicas isquêmicas prévias, submetida com sucesso a fechamento percutâneo com AmplatzerTM Vascular Plug II, um dispositivo projetado para oclusão de anormalidades vasculares.

Endovascular repair of posttraumatic multiple femoral-femoral and popliteal-popliteal arteriovenous fistula with Viabahn and excluder stent graft

Traumatic arteriovenous (AV) fistula is considered to be a pathologic communication between the arterial and venous systems following injury caused mostly by firearms, sharp objects or blasting agents. Almost 50% of all traumatic AV fistulas are localized in the extremities. In making diagnosis, besides injury anamnesis data, clinical image is dominated by palpable thrill and auscultator continual sounds at the site of fistula, extremities edemas, ischemia distally of fistula, pronounced varicose syndrome, and any signs of the right heart load in high-flow fistulas. We presented a male 32-year-old patient self-injured the region of the right lower and upper leg by shotgun during hunting in 2005. The same day the patient was operated on in a tertiary traumatology health care institution under the diagnosis of vulnus sclopetarium femoris et cruris dex; AV fistula reg popliteae dex; fractura cruris dex. The performed surgery was ligatura AV fistulae; reconstructio a. popliteae cum T-T anastomosis; fasciotomia cruris dex. Postoperatively, in the patient developed a multiple AV fistula of the femoral and popliteal artery and neighboring veins. The patient was two more times operated on for closing the fistula but with no success. Three years later the patient was referred to the Clinic for Vascular Surgery, Military Medical Academy, Belgrade, Serbia. A physical examination on admission showed the right upper leg edema, pronounced varicosities and high thrill, signs of the skin induration and initial ischemia with ulceration in the right lower leg, as well as numerous scars in the inner side of the leg from the previously performed operations. Due to the right heart load there were also present easy getting tired, tachypnoea and tachycardia. CT and contrast angiography verified the presence of multiple traumatic AV fistulas in the surface femoral and popliteal artery and neighboring veins of the highest diameter being 1 cm. Also, numerous metallic balls--grains of shotgun were present. After the preoperative preparation under local infiltrative anesthesia, transfemoral endovascular reconstruction was done of the surface femoral and popliteal artery by the use of stent grafts Viabahn 6 x 50 mm and excluder PXL 161 007. Within the immediate postoperative course a significant reduction of the leg edema and disappearance of thrill occurred, and, latter, healing of ulceration, and disappearance of signs of the foot ischemia. Also, patient's both cardiac and breathing functions became normal. In patients with chronic traumatic AV fistulas in the femoropopliteal region, especially with multiple fistulas, the gold standard is their endovascular recon struction which, although being minimally traumatic and invasive, offers a complete reconstruction besides keeping integrity of both distal and proximal circulation in the leg.

Endovascular treatment of high-flow cervical direct vertebro-vertebral arteriovenous fistula with detachable coils and Onyx liquid embolic agent

We report the first experience in the treatment of high-flow cervical direct vertebro-vertebral arteriovenous fistula (VVAVF), which was successfully occluded with detachable coils and Onyx through transarterial approach. A 20-year-old female presented with 2-month history of paresis of bilateral extremities. Magnetic resonance imaging (MRI) showed that the dilated ventral epidural veins as well as the dilated left paraspinal veins compressed the spinal cord. Digital subtraction angiography demonstrated high-flow VVAVF between the left vertebral artery (VA) and the surrounding venous plexus at the C3 cervical level. The fistulas were also fed by backward flow from the right VA and left ascending cervical arteries. Transarterial endovascular treatment was performed by using detachable coils and Onyx; immediate angiographic obliteration was achieved. VVAVF-related symptoms resolved gradually, and there was complete neurologic recovery without clinical consequences on clinical follow-up. The fistulas remained closed, as ascertained by 2-month follow-up computed tomography angiography and MRI. No new neurological deficit related to the procedure was detected. The endovascular treatment of direct VVAVF with combination of detachable coils and Onyx is feasible, safe, and highly effective with low morbidity and mortality.

Treatment of brain arteriovenous malformations with high-flow arteriovenous fistulas: risk and complications associated with endovascular embolization in multimodality treatment

High-flow fistulas associated with brain arteriovenous malformations (AVMs) pose a significant challenge to both stereotactic radiosurgery (SRS) and surgical treatment. The purpose of this study was to examine the outcomes of multimodality treatment of AVMs in association with a large arteriovenous fistula (AVF), with a special focus on endovascular embolization and its associated complications. One hundred ninety-two patients harboring cerebral AVMs underwent endovascular treatment in the authors' department between 1997 and 2003. Of these, the authors selected 74 patients presenting with an AVM associated with high-flow AVF(s) for a retrospective analysis based on the findings of superselective angiography. After endovascular embolization, 32 patients underwent resection, 33 underwent either SRS or hypofractionated stereotactic radiotherapy (HSRT), and 3 underwent both surgery and SRS. Six patients underwent embolization only. Immediate and midterm treatment outcomes were analyzed. Fifty-seven (77%) of the 74 patients had AVMs that were Spetzler-Martin Grade III or higher. A complete resection was achieved in all 32 patients. Of patients who underwent SRS/HSRT, 13 patients (39.3%) had either complete or > 90% obliteration of the AVM, and 2 patients (6.1%) had incomplete obliteration. Fourteen patients (42.4%) with residual AVM underwent repeated radiotherapy (and remain under observation). Of the 3 patients who underwent both SRS and resection, resection was complete in 2 and incomplete in one. No follow-up was obtained in 6 patients (8.1%). An endovascular complication was observed in 4 patients (5.4%). Fistula embolization was safely performed in every patient, whereas every endovascular complication was associated with other procedures such as nidus embolization. Endovascular occlusion of the fistulous component was successfully achieved in every patient; every endovascular complication in this series was related to other procedures such as nidus embolization. The importance of the fistula treatment should be emphasized to minimize the endovascular complications and to maximize the treatment effect when a multimodality therapy is used to treat brain AVMs with large AVF.

Massive Coronary Subclavian Steal Syndrome

Coronary subclavian steal syndrome is an unusual cause of angina, secondary to decreased or reversed flow in patients with patent "in situ" internal mammary-to-coronary artery graft. The most frequent cause of coronary subclavian steal syndrome is ipsilateral subclavian artery stenosis. We present a 60-year-old man with cerebrovascular and peripheral artery disease and a documented massive coronary subclavian steal syndrome, which impaired cardiopulmonary bypass weaning after multiple coronary artery bypass with double T-mammary artery graft.