Large Arteriovenous Fistula Research Articles

Contemporary Management of Giant Renal and Visceral Arteriovenous Fistulae

To evaluate our experience with treatment of giant arteriovenous fistulae (AVFs) involving the renal and visceral vasculature and assess outcomes. Clinical data from 12 consecutive patients (10 women; median age 58 years, range 37-79) undergoing intervention for 14 giant renal/visceral AVFs over a 15-year period (1994-2008) were retrospectively reviewed. Only patients with extra-parenchymal, wide arteriovenous communications were included. Thirteen were located in the renal artery and one in the splenic artery. The etiology was most likely post-traumatic/iatrogenic in 6 patients, idiopathic in 4 (1 bilateral), congenital in 1 (bilateral), and one was associated with fibromuscular dysplasia. In 4 cases, the lesion was asymptomatic. Two large renal AVFs were treated with open surgery: one elective AV fistula repair early in our experience and the other an emergent nephrectomy for rupture. Twelve AV fistulae were closed successfully using endovascular techniques performed solely through the feeding vessel without cannulating the draining vein. All symptomatic patients, except one with continued dyspnea from cardiac causes, had complete symptomatic relief. There was no mortality. Morbidity included 2 access site hematomas that were managed conservatively. Loss of renal parenchyma ranged from 5% to 30%, but median serum creatinine levels remained stable. Endovascular treatment of giant renal/visceral AVFs is challenging but feasible and safe, with good organ preservation. Endovascular techniques have replaced open surgical repair as a first-line treatment for these challenging lesions.

A large renal arteriovenous fistula treated by transcatheter embolization: a case report

患者女,57岁.体检B超检查发现右肾血管畸形5 d入院.既往无肾脏疾病及外伤史.体检:体温36.6℃,心率78次/min,血压140/70 mm Hg(1 mm Hg=0.133 kPa),意识清,精神可,腹平软,全腹无压痛及反跳痛,肝脾肋下未及,双侧肾区无叩痛,右腰背部听诊闻及连续性隆隆样杂音,心肺听诊未发现异常.实验室检查:尿常规、血沉、肝功能、肾功能、血糖、血脂、电解质、CRP、血常规、凝血功能均在正常范围。

Occlusion of Pulmonary Arteriovenous Malformations Using the Amplatzer Vascular Plug/Duct Occluder for a Family With Hereditary Hemorrhagic Telangiectasia

An 8-year-old girl was referred because of frequent epistaxis and acrocyanosis. The family history showed that her father, aunt, uncle, and grandfather also experienced recurrent epistaxis. Based on her clinical information, we diagnosed her condition as hereditary hemorrhagic telangiectasia, also known as Rendu-Osler-Weber disease, which is characterized by multiple telangiectases, recurrent epistaxis, arteriovenous malformation, and familial inheritance. Chest radiography and computed tomography (CT) showed two large pulmonary arteriovenous fistulas (PAVFs) in the posterobasal and mediobasal segment of the left lower lung (Fig. 1). Percutaneous transcatheter embolization then was planned. After right heart catheterization and pulmonary angiography had been performed, we confirmed a large PAVF (diameter, 8.2 mm) in the posterobasal part of left lung, with a smaller lesion (diameter, 2.9 mm) in the pulmonary artery of the left middle lobe. A 10 9 12-mm Amplatzer duct occluder (AGA Medical Corporation, Golden Valley, MN, USA) was selected for the larger PAVF, and a Gianturco coil (4 9 3 mm; Cook Inc., Bloomington, IN, USA) was chosen for the smaller feeding artery (Fig. 1). After a successful procedure, percutaneous oxygen saturation at rest rose to more than 95% with room air compared with about 71% before the procedure. Recently, the girl’s father also was evaluated for mucocutaneous telangiectases on his tongue and in his nasal mucosa. Chest radiography and multidetector CT again showed bilateral multiple PAVFs. A cardiac catheterization with pulmonary angiography showed four large PAVFs of the right upper (feeding vessels of 2.8 mm), right lower (3.5 mm), left upper (3.2 mm), and left lower (4.2 mm) lung. Considering their large sizes, we decided to perform percutaneous closure using Amplatzer vascular plugs for all four PAVFs. Devices 30–50% larger than the selected vessel diameter were chosen: 4 9 7 mm for the right upper lesion, 6 9 7 mm for the right lower and left upper lesion, and 8 9 7 mm for the left lower lesion. Angiograms obtained at the end of each procedure confirmed good positioning of the devices with no significant residual flow (Fig. 2). About 20–30% of patients with hereditary hemorrhagic telangiectasia are thought to be affected with PAVFs [4]. Various methods for transcatheter embolization have been reported, including coils and detachable balloons. Although transcatheter embolization with coils is considered the preferred method for PAVFs, it is not ideal for large fistulas with large feeding arteries due to disadvantages such as the risk for paradoxical device embolization, the need for multiple coils, and the high recanalization rates [1–3]. The Amplatzer vascular plug/duct occluder has been reported as a new alternative for the occlusion of PAVFs. An additional advantage of the Amplatzer vascular plug is the relatively smaller introduction system than that used for the Amplatzer duct occluder. Although most reported cases involve adult patients, the reported familial case including an 8-year-old girl demonstrates that the Amplatzer vascular plug and duct occluder also provide excellent results for young patients with multiple large PAVFs. M. J. Cho Department of Pediatrics, Pusan National University Hospital, Ami-dong, Seo-gu, Busan 602-739, Republic of Korea

Chronic ischaemic leg ulcer as a late complication of post-traumatic arteriovenous fistula

Chronic post-traumatic arteriovenous fistula (AVF) is a late complication of vascular injury and can be presented with symptoms of congestive heart failure, venous hypertension and distal ischaemia. We present an unusual case of chronic ischaemic leg ulcer in young adult caused by post-traumatic AVF. Case report A 29-year-old male patient was admitted to our hospital with symptoms of chronic ulcer located on the lateral side of the lower left leg. Arterial pulses distally from the groin were absent. His medical history revealed him to have sustained gunshot injury of the left thigh in the war conflict 18 years before. Angiography showed a large AVF between superficial femoral artery and femoral vein. The patient underwent surgical repair of AVF with reconstruction of superficial femoral artery by saphenous vein interposition under spinal anaesthesia. Completion angiography confirmed AVF exclusion. Leg ulcer healed within a month. Chronic leg ulcer may be the only symptom of large post-traumatic AVF in young adults.

Recanalization and reuse of early occluded radial artery within 6 days after previous transradial diagnostic procedure

Late radial artery (RA) thrombosis occurs in 3-9% after transradial interventions. RA occlusion has made this approach unsuitable for repeat interventions and obviated the need for alternative vascular access for catheterization, e.g., left RA (with certain risk of bilateral RA occlusion) or femoral artery with its shortcomings and, sometimes, life-threatening complications requiring surgical treatment (large groin hematoma, arterio-venous fistula or false aneurysm, retroperitoneal hemorrhage). We demonstrate the possibility of retrograde RA recanalization, dilatation, and restoration of the RA patency within 6 days after first transradial coronary diagnostic catheterization complicated with acute RA occlusion. Thus we were able to recanalize previously occluded RA and reuse it for repeat transradial coronary interventions.

Pulmonary Arteriovenous Malformations: Clinical and Radiological Presentation

History Exertional dyspnea for 4 years, medical and family history unremarkable Exertional dyspnea for 2 years, migraine headaches, medical and family history unremarkable Symptoms Central cyanosis, finger clubbing, no abnormalities on heart and lung examination Central cyanosis, finger clubbing, growth retardation (body weight <3rd percentile) no abnormalities on heart and lung examination Laboratory tests RBC, 6.26 T/L; Hct, 54.2%, Hb, 18.8 g/dL, PaO2, 55 mm Hg RBC, 6.02 T/L, Hct, 52.8%, Hb, 18.4 g/dL PaO2, 52 mm Hg Chest radiograph Well-defined round opacity in the midLarge, well-defined oval opacity in the midT were treated in our institution; in both cases, the initial symptoms included exertional dyspnea and cyanosis. The signs and symptoms as well as results of laboratory tests and chest radiographs on admission are presented in the Table. The masses found on chest radiographs were further assessed by contrast-enhanced spiral computed tomography. Computed tomography identified both lesions as large pulmonary arteriovenous fistulas (PAVFs) (Figures 1 and 2). A small PAVF in the right upper lobe was also demonstrated in case 1 (Figure 3; available at www.jpeds.com). In both cases, underlying diseases such as hereditary hemorrhagic telangiectasia were excluded. The patients were treated with percutaneous coil embolization. This resulted innormalization of PaO2, RBC, and Hb values and subsequent resolution of clinical symptoms. Pulmonary arteriovenous fistulas are a rare clinical entity. The most common clinical presentation of large PAVFs in

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.

Renal arteriovenous fistula

tion of both legs and dyspnea on exertion. His pain-free walking distance was below 200 m. In 1979, a diagnosis of IgA-nephropathy was established following an open leftsided renal biopsy. His kidney disease was progressive and from 1984 until 1993 the patient underwent chronic hemodialysis. In 1993, he received a renal allograft into the right iliac fossa. His current serum creatinine is 1.28 mg/dl. Upon presentation pulses were palpable in both ankles. Blood pressure was 130/80 mmHg. The ankle–brachial index of the right and left leg were 0.80 and 0.85, respectively. Owing to his symptoms magnetic resonance angiography of the aorta and both legs was performed. Angiography revealed a large arteriovenous fistula of the left kidney (solid arrow) with rapid filling of the inferior vena cava (Panel A). In addition, a stenosis of the right external iliac artery proximal to the renal transplant was noted (dashed arrow, Panel A). The patient underwent coiling of the renal arteriovenous fistula and balloon angioplasty of the stenosis. A follow-up magnetic resonance angiogram 3 months later revealed complete closure of the fistula and no Vascular Medicine 15(5) 433–434 © The Author(s) 2010 Reprints and permission: sagepub. co.uk/journalsPermissions.nav DOI: 10.1177/1358863X10376000 http://vmj.sagepub.com

Transarterial embolization of large complex arteriovenous fistula associated with hip joint surgery

Arteriovenous fistula may be due to a vascular injury during various orthopedic surgeries. It may cause massive, unexpected bleeding during or following an operation or during rehabilitation. We report herein the case of a 48-year-old woman with a previous history of hip joint surgery due to congenital hip dislocation who experienced massive bleeding during a second operation. Postoperative pelvic angiography revealed large, complex arteriovenous fistulas with combined venous aneurysm. She was managed successfully by transarterial embolization.

Transcatheter embolization of a huge renal arteriovenous fistula with Amplatzer Vascular Plug

A large renal arteriovenous fistula (RAF) may lead to heart failure, renal insufficiency, hematuria, and progressive increase in size of renal vessels. Here we present the case of a 67-year-old man with a huge left RAF, who suffered from exertional dyspnea, nocturnal orthopnea, and impaired renal function. The left renal vein and inferior vena cava were dilated to 4 cm. An Amplatzer Vascular Plug with the largest size of 30 mm in disk diameter was deployed to block the fistula, with balloons inflated at renal artery and vein in advance, to reduce the renal flow in order to prevent plug migration. The decrease of shunt flow after embolization was suboptimal. However, dyspnea ameliorated, which was associated with decreased cardiac murmur, subsided abdominal bruit, normalization of the lowered diastolic pressure, and better renal function. In addition, more microcoils can be applied, using the lodged plug as a framework, to achieve the best clinical improvement.

Transcatheter occlusion of multiple pulmonary arterio venous malformations

Pulmonary arterio venous malformations are one of the rare vascular anomalies. Usually single large pulmonary arteriovenous fistula (PAVF) can be closed through transcatheter route but multiple PAVF require surgical lobectomy. We describe a case of an 8-year-old boy with multiple PAVF, who underwent successful transcatheter closure with multiple coils.

Vertebral Arteriovenous Fistula Presenting as Cervical Myelopathy: A Rapid Recovery with Balloon Embolization

A 24-year-old male presented with progressive cervical myelopathy of 2 months' duration. Magnetic resonance imaging of the cervical spine and angiography revealed a large arteriovenous fistula arising from the left vertebral artery. The present case highlights the clinical features and dramatic recovery following endovascular balloon occlusion of a giant cervical arteriovenous fistula.

Postrenal biopsy AVM leading to severe hypertension and dilated cardiomyopathy

A 3-year-old girl with Alport syndrome presented with decompensated heart failure from hypertension-induced cardiomyopathy 6 months following renal biopsy. Selective renal angiography revealed a large left renal arteriovenous fistula (AVF) with poor perfusion to the left renal parenchyma. The AVF was treated by transcatheter embolization using an Amplatzer vascular plug. Her blood pressure normalized after embolization, and her cardiac function normalized over the following 4 months.

Clinical-pathology review: Supratentorial cerebral arteriovenous fistula

Objective We present the first report in the literature on the bilateral tentorial herniation after the endovascular embolization of a large brain arteriovenous fistula. Clinical presentation A 7-year-old boy who had chronic headaches underwent computed tomography (CT), which disclosed an abnormal intracranial mass in the right cerebral hemisphere. Magnetic resonance imaging (MRI) scan shows multiple tortuous signal void lesions suggesting vascular lesions. Cerebral angiography revealed a cerebral arteriovenous fistula with a very large venous pouch. The patient was referred to Beijing Tiantan Hospital for further treatment. Intervention Partial embolization of the AVF from the arterial side was initially attempted successfully resulting in a reduction of the shunt flow. The patient developed swelling of his right hemisphere and caused bilateral tentorial herniation. Although the decision was made to attempt resection of the thrombosed varix, there was yet any recovery of blindness caused by herniation. Conclusion Our study suggests that tentorial herniation can cause compression of optic tracts leading to complete blindness with conscious clarity. Clinicopathologic considerations of the complete bilateral blindness produced from the above events are discussed in detail. Prevention is the only therapeutic approach to this type of visual catastrophe. The outcome of radical surgical intervention for this kind of patients is still unclear and further investigation should be given.

Giant arteriovenous fistula after implantation of a percutaneous left ventricular assist device

Percutaneous left ventricular assist devices are an important tool in the management of patients with severe cardiogenic shock. Limited experiences concerning vascular complications after long term implantation of these devices exist. We report on a large arteriovenous fistula after placement of a left ventricular assist device, which has not been described in the literature. The arteriovenous fistula was of clinical relevance because it represented a supplementary cardiac burden in a patient with impaired left ventricular function after a severe myocardial infarction.

Repair of a high-flow iliac arteriovenous fistula using a thoracic endograft

Open surgical repair of iliac arteriovenous fistulas is associated with significant morbidity and mortality, making endovascular repair an attractive alternative. This report describes a 39-year-old man who was admitted with two-pillow orthopnea, edema, and fatigue. He had sustained a gunshot wound to the pelvis 13 years previously. Six years after the gunshot wound, he was diagnosed with cardiomegaly and high-output congestive heart failure. A magnetic resonance angiography documented a large pelvic arteriovenous fistula. A diagnostic contrast angiogram confirmed a high-flow fistula between the left distal main internal iliac artery and left common iliac vein. A Gore TAG thoracic endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz) was used to repair this large, high-flow internal iliac artery-common iliac vein arteriovenous fistula.

Treatment of Superior Mesenteric Artery Portal Vein Fistula with Balloon-Expandable Stent Graft

Visceral artery to portal vein arteriovenous fistulas are rare and difficult to treat. Covered stents have made treatment of pseudoaneurysms and arteriovenous fistulas feasible utilizing minimally invasive techniques. We present a case of a 46-year-old male with a remote history of an exploratory laparotomy after a motorcycle accident who presented with abdominal pain, malaise, and jaundice. A computed tomographic scan revealed a superior mesenteric artery to portal vein arteriovenous fistula. A large arteriovenous fistula was confirmed by arteriography. A balloon-expandable stent graft was placed across the arteriovenous fistula in the superior mesenteric artery. Postprocedure, the patient's abdominal pain resolved and his bilirubin decreased from 2.9 to 0.4. Endovascular repair of a superior mesenteric to portal arteriovenous fistula utilizing a stent graft is feasible and minimally invasive.

Endovascular management of a large post-traumatic iliac arteriovenous fistula: Utilization of a septal occlusion device

We describe the management of a large iliac arteriovenous fistula in a 48-year-old patient presenting with heart failure and pulmonary hypertension. The presumptive etiology was a left-lower back stab wound approximately 20 years earlier. A large communication between the left internal iliac artery and the left internal iliac vein was successfully treated with a septal occlusion device.

Splenic Arteriovenous Fistula Treated with Percutaneous Transarterial Embolization

Splenic arteriovenous fistula is a rare complication following splenectomy. We report a case of a large splenic arteriovenous fistula 23 years after splenectomy in a 50-year old male with abdominal pain, gastro-intestinal bleeding, ascites, diarrhoea, dyspnoea, portal hypertension and heart failure. The arteriovenous fistula was successfully treated with percutaneous transarterial embolization and the patient gained almost complete recovery. This case demonstrates the usefulness of embolization of an otherwise surgical demanding arteriovenous fistula.

Percutaneous treatment of a large superior mesenteric artery pseudoaneurysm and arteriovenous fistula: A case report

The combination of superior mesenteric artery (SMA) pseudoaneurysm and arteriovenous (AV) fistula is a rare complication following penetrating abdominal trauma. We report a case of a post-traumatic SMA pseudoaneurysm and large fistula between the SMA and superior mesenteric vein (SMV), which was successfully treated with an endovascular stent graft.