Multiple Arteriovenous Fistulas Research Articles

Spinal Dural Arteriovenous Fistulas in a Patient with Cowden Syndrome and a Phosphatase and Tensin Homolog Mutation.

Cowden syndrome (CS) is an autosomal dominant syndrome characterized by the development of hamartomas and an increased cancer risk. Most CS patients harbor mutations in the phosphatase and tensin homolog (PTEN) gene. We herein report a 70-year-old patient with CS who presented with lower extremity weakness caused by multiple thoracic dural arteriovenous fistulas. Genetic testing revealed a truncated PTEN mutation (c.485_487delACAinsCC and p.D162Afs*5). Vascular malformations are common in CS, particularly in the extremities. However, spinal dural arteriovenous fistulas (AVFs) are extremely rare. Furthermore, in our case, the number of AVFs increased, and both lower limbs became flaccid four months after embolization. Therefore, we suggest that physicians carefully observe the changes in symptoms for prolonged periods after embolization.

Abstract Number ‐ 116: Palliative Embolization on an Infantile Dural Sinus Malformation with Giant Lakes.

Introduction Dural Sinus Malformation (DSM) is a rare and high risk mortality vascular pathology identified early postnatal due to common clinical symptoms like macrocephaly, downward wandering eyes, bulging and pulsatile fontanels and heart failure. Most DSMs resolves prenatally. It is characterized by giant venous lake at the torcular region expanding towards the infratentorial and supratentorial spaces with usually existence of Dural arteriovenous fistulas (dAVF). Pathophysiology of DSMs are ballooning and malformation of the distal jugular bulb or persistence abnormal of the transverse sinus. Methods We performed the staged trans arterial Onyx‐18 embolization 5 times of a 3 mo infant boy with dural sinus malformation with multiple arteriovenous fistula using the 4 French GlideSim 2 Catheter, Headway Duo 167 micro catheter, and numerous microwires including Aristotle 014, Chikai Black Soft 014 and 010 and Synchro 014, 010 and 080 through alternated sides of transfemoral accesses. Embolizations were performed through the bilateral branches of the left and right middle meningeal arteries, posterior meningeal arteries and left occipital artery. Limitations during procedure are body weight to use contrast, fluoroscopy time and access sides. Results Post embolization injections demonstrated significant flow reduction into the malformation through ECA branches. No neurological complications occurred due to the procedures. MRI Brains in following weeks did not show large thrombus formation, hydrocephalus, or parenchymal injury. Patient showed clinical improvements with stable macrocephaly and decreased frontal pulsation and bulging. Conclusions Staged trans arterial embolization seems a safe approach on high mortality DSM. Thrombus is not formed all at once and mass effect from thrombosed sinus is avoided. Sinus has time to shrink.

An Unusual Case of Hematemesis

Question: A 68-year-old African-American man with history of end-stage renal disease with multiple previous indwelling central venous catheters and current left-side arteriovenous fistula, essential hypertension, and no known history of liver disease presented to the emergency department after an episode of large-volume hematemesis during his routine session of hemodialysis. His blood pressure on presentation was 81/52 with a heart rate of 106 beats per minute. Physical examination was notable for venous distention in the neck and anterior chest wall.

Acute Neurologic Deterioration Associated with Multiple Dural Arteriovenous Fistula Improved by Endovascular Procedure

Acute Neurologic Deterioration Associated with Multiple Dural Arteriovenous Fistula Improved by Endovascular Procedure

Rupture of an Aneurysmal Arteriovenous Fistula in an In Situ Vein Bypass.

We report a case of rupture of an aneurysm on a residual arteriovenous fistula, five years after a femoral to posterior tibial artery bypass for critical ischemia of the right lower limb. This is a 48-year-old patient admitted to the emergency room for hemorrhagic shock following a rupture of a varicose bundle at the level of the posterior surface of the right thigh. The CT angiography confirmed the presence of multiple residual arteriovenous fistulas, which became aneurysmal. The exclusion of the latter by ligature-section made it possible to stop the hemorrhage while preserving the bypass.

Successful endovascular treatment with a stent graft for chronic deep vein thrombosis with multiple arteriovenous fistulas: a case report

BackgroundDeep vein thrombosis with arteriovenous fistulas is rare, with few therapeutic options available for chronic-phase deep vein thrombosis. Moreover, the effectiveness of endovascular treatment for chronic-phase deep vein thrombosis with arteriovenous fistulas has not been established. We describe herein a case of successful endovascular treatment for chronic deep vein thrombosis with multiple arteriovenous fistulas.Case presentationWe describe the case of a 72-year-old Asian woman who had begun experiencing left leg swelling and intermittent claudication 2 years prior. Enhanced computed tomography revealed left common iliac vein occlusion with vein-to-vein collateral formation and several arteriovenous fistulas. Angiography and ultrasound showed the arteriovenous fistulas to run from the common and internal iliac arteries to the external iliac and superficial femoral veins. We opted against surgical repair for the arteriovenous fistulas due to their complex nature and complicated morphology. Since her condition was progressive, endovascular treatment with a stent graft was performed for the deep vein thrombosis, after which her symptoms gradually improved. Four months following the procedure, enhanced computed tomography confirmed remarkable reduction of the vein-to-vein collaterals and arteriovenous fistulas.ConclusionsIn the present case, enhanced computed tomography with a stent graft was effective in improving symptoms. This strategy may therefore be a treatment option for intractable chronic deep vein thrombosis with arteriovenous fistulas.

A surgical method to be reminded for the treatment of symptomatic ipsilateral central venous occlusions in patients with hemodialysis access: Axillo-axillary venous bypass case report and review of the literature.

In this case report, we present two chronic hemodialysis patients with upper extremity swelling due to central venous occlusions together with their clinical presentation, surgical management and brief review of the literature. The first patient who was a 63-year-old female patient with a history of multiple bilateral arteriovenous fistulas (AVFs) was referred to our clinic. Physical examination demonstrated a functioning right brachio-cephalic AVF, with severe edema of the right arm, dilated venous collaterals, facial edema, and unilateral breast enlargement. In her history, multiple ipsilateral subclavian venous catheterizations were present for sustaining temporary hemodialysis access. The second patient was a 47-year-old male with a history of failed renal transplant, CABG surgery, multiple AV fistula procedures from both extremities, leg amputation caused by peripheral arterial disease, and decreased myocardial functions. He was receiving 3/7 hemodialysis and admitted to our clinic with right arm edema, accompanied by pain, stiffness, and skin hyperpigmentation symptoms ipsilateral to a functioning brachio-basilic AVF. He was not able to flex his arms, elbow, or wrist due to severe edema. Venography revealed right subclavian vein stenosis with patent contralateral central veins in the first patient. She underwent percutaneous transluminal angioplasty (PTA) twice with subsequent re-occlusions. After failed attempts of PTA, the patient was scheduled for axillo-axillary venous bypass in order to preserve the AV access function. In second patient, venography revealed right subclavian vein occlusion caused secondary to the subclavian venous catheters. Previous attempts for percutaneously crossing the chronic subclavian lesion failed multiple times by different centers. Hence, the patient was scheduled for axillo-axillary venous bypass surgery. In case of chronic venous occlusions, endovascular procedures may be ineffective. Since preserving the vascular access function is crucial in this particular patient population, venous bypass procedures should be kept in mind as an alternative for central venous reconstruction, before deciding on ligation and relocation of the AVF.

Spontenous regression of hemorrhagic multiple pial arteriovenous fistula: case report and review of the literature

Spontenous regression of hemorrhagic multiple pial arteriovenous fistula: case report and review of the literature

A Staged Approach for Repair of Multiple Arteriovenous Fistula Aneurysms Reduces the Need for Temporary Central Venous Catheter for Hemodialysis

A Staged Approach for Repair of Multiple Arteriovenous Fistula Aneurysms Reduces the Need for Temporary Central Venous Catheter for Hemodialysis

P-OT004. Recurrent direct carotid cavernous fistula after embolization, a case report

Introduction. Carotid cavernous fistula (CCF) is a rare case defined as an abnormal communication between carotid artery and cavernous sinus. Anatomically, CCF is classified as direct and indirect. Radiological imaging with Head CT scan and CT angiography (CTA) has an important role in CCF’s diagnosis and management. Endovascular embolization technique is one of the effective management for CCF. Results. A 16-year-old male complained left cephalgia and progressive visual lost on his left eye after endovascular embolization 3 years ago. Patient was diagnosed with CCF since he was 12. From physical examination, we found negative light perception on the left eye. From the former CT angiography, there was vascular malformation, suspected as multiple arteriovenous fistula at level carotid cavernous level urged bulbus oculi for 10 mm and also at left jugular external carotid. We performed the second head CT scan and CTA, with conclusion that there was vascular malformation which urged bulbus oculi for 17 mm. Patient was administered with clopidogrel 75 mg. Conclusion. Endovascular embolization as CCF’s management is effective but recurrence can happen.

MO772PRIMARY AND SECONDARY HYPEROXALURIA IN CHRONIC DIALYSIS PATIENTS: FOCUS ON VASCULAR ACCESS

Abstract Background and Aims Hyperoxaluria is a rare metabolic disorder chacterized by widespread calcium oxalate deposition, if plasmatic oxalate level (pOx) overcomes saturation threshold. It could be primary (PH), a recessive disease associated with mutation of the liver enzyme LDH, or secondary (SH), in 75% due to intestinal malabsorption. Urolithiasis could be the first complication, and renal involvement could progress until end-stage renal disease (ESRD). Mean pOx is higher in chronic dialysis patients than healthy individuals because of impaired renal clearance. Oxalate molecular weight (MW) is 88 Da and its clearance is that of low MW uremic toxins. Our aim is to assess an association between arteriovenous fistula (AVF) failures and Hyperoxaluria. Method In the period between 1/1/2004 and 12/31/2020, diagnosis of Hyperoxaluria was carried out in 6 patients out of 1530 chronic dialysis patients (0.39%). The median age of patients was 65.5 [26-72] years, the male/female ratio was 3:3 and the median dialysis vintage was 36 [1-181] months. Three patients come to nephrological referral at stage 5 of CKD while 1 patient came to Italy when chronic HD was already started. At that time pOx was not considered. In these 4 patients the presumptive diagnosis of ESRD was urolithiasis and diagnosis of Hyperoxaluria was carried out after the beginning of chronic dialysis, when pOx and genetic analysis were performed. In 1 case biopsy on the kidney graft and in 1 case kidney biopsy after nephrectomy were performed: oxalate deposition was detected. For 2/6 patients diagnosis was carried out after biopsy of native kidneys before starting dialysis. All patients started medical therapy for hyperoxaluria. Five out of 6 patients were eligible to HD, 1/6 to PD. AVF was judged the first choice vascular access. Results PH was diagnosed in 3/6 patients: mutations were detected on chromosome 2. Malabsorption secondary to short bowel syndrome and chronic pancreatitis could be assumed as causes of SH in 3 patients. Patient 1 underwent 2 combined liver-kidney transplantation: the first failed by arterial grafts thrombosis and the second by renal primary non-function but the liver was still functioning, he died on HD after 12 years. Patient 2 underwent liver and kidney transplantation and she is nowadays dialysis-free. The median pOx pre-dialysis and before diagnosis was 165 [98-259] umol/L (Table 1). Patients on chronic HD underwent median of 3 [2-5] AVF interventions. Nine AVFs were distal and 4 were proximal. The most frequent complication was AVF thrombosis despite ASA treatment: half of the cases showed secondary AVF non-function, the other half of AVFs failed to mature. Six tunneled cuffed permanent catheters (TCCs) as definitive vascular access were successfully placed in the 5 patients on chronic HD. Warfarin therapy was started to avoid TCCs thrombosis. The median survival of TCCs was 9.5 [3-48] months. All the patients had a history of deep venous thrombosis (DVT). Conclusion To our knowledge this is the first case series of multiple AVF failures in patients with hyperoxaluria. In our experience TCCs show longer survival then AVF in this group of patients, even if it could not be excluded the role of warfarin in favoring this result. Even though a link between hyperoxaluria and thrombosis is well established, the exact underlying mechanism is still uncleared. The role of PD as dialysis technique of “first choice” should be enhanced also when residual renal function is abolished. In ESRD patients with urolithiasis, diagnosis of Hyperoxaluria should be ruled out before AVF placement.

Critical Limb Ischemia as a Consequence of Multiple Spontaneous Arteriovenous Fistulas and Peripheral Arterial Disease

Critical Limb Ischemia as a Consequence of Multiple Spontaneous Arteriovenous Fistulas and Peripheral Arterial Disease

Post-traumatic pseudoaneurysm of the medial plantar artery with arteriovenous fistula treated by coil embolization of the main feeding artery and percutaneous thrombin injection

Endovascular treatment for post-traumatic pseudoaneurysm (PsA) has been deemed effective and minimally invasive. However, embolization of all feeding and outflow vessels is difficult if multiple fine arteriovenous fistulas (AVFs) are present. In the present case, PsA of the medial plantar artery with AVF was diagnosed 1 month after injury by a rusty nail. Treatment using a combination of embolization of only the main feeding artery and percutaneous thrombin injection into PsA was successful. This approach can completely resolve PsA in narrow vessels, such as in the foot, particularly when AVF is present with numerous connected vessels.

Management of dual traumatic arterial-venous fistula from a single shotgun injury: a case report and literature review

BackgroundTraumatic arteriovenous fistula (TAVF) is an uncommon vascular entity that arises in various locations, often from penetrating injuries, with a wide spectrum of signs and symptoms. This case report highlights the importance of suspecting multiple TAVFs after a single gunshot wound, especially if it involves pellets. It also sheds light on adapting treatment, whether endovascular or open repair, to the location and characteristics of each fistula.Case presentationA 35-year-old male, with history of shotgun wound 5 months earlier, presented to our clinic with right lower extremity (RLE) edema and pain. Arterial duplex scan and subsequent angiogram showed two TAVFs at the popliteal and posterior tibial (PT) arteries, both of which could not be exactly localized with a computed tomography angiography (CTA) due to artifacts. The fistula connecting the posterior tibial artery (PTA) and vein was repaired endovascularly using a covered-stent, while the fistula between the popliteal artery and vein was repaired surgically. Postoperative follow-up at 3 months showed no arteriovenous fistula (AVF), patent vessels and distal stent stenosis at the PTA.ConclusionsPatients who sustain gunshot injuries with shrapnel or pellets and develop TAVF consequentially need to be followed up with the possibility of multiple AVFs in mind. Arterial duplex scan is highly sensitive to detect those AVFs, yet angiography remains gold standard, particularly with extensive metal artefacts. Endovascular repair, when feasible, should be considered first, unless the patient is unstable or has anatomical constraints that increase the risk of complications. Lastly, surgeons should be weary of deep venous thrombosis (DVT), the Branham effect and arterial aneurysmal dilation postoperatively.

Transcatheter coil embolization of multiple symptomatic coronary arteriovenous fistulas: lessons from long‑term follow‑up.

Transcatheter coil embolization of multiple symptomatic coronary arteriovenous fistulas: lessons from long‑term follow‑up.

High-output cardiac failure due to multiple femoral arteriovenous fistulae.

A 39-year-old woman presented with symptoms of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, weight loss, night sweats and fatigue that were present for 3-months. She had been diagnosed with human immunodeficiency virus (HIV) infection in 2016 but had defaulted her antiretroviral therapy. She had a low CD4 count of 17 cells/μl and her HIV viral load was log 6.16 copies/ml. She had evidence of high-output cardiac failure on clinical examination that included a wide pulse pressure with a blood pressure of 138/59 mmHg, radial pulse had a collapsing character and the pulse rate was 125 beats per minute, jugular venous distention was observed, the apical impulse was displaced with no audible murmurs and bibasilar crackles were present. She had a thrill palpable over the right femoral artery and a continuous bruit was audible. Significant laboratory results included a hemoglobin concentration of 6.7 g/dL and an erythrocyte sedimentation rate of more than 140 mm/hour. Importantly, rapid plasma reagin, anti-nuclear antibodies and anti-neutrophil cytoplasmic antibodies were negative. Computed tomography angiogram (CT angiogram) revealed fusiform aneurysmal dilatation of the distal abdominal aorta and right common iliac artery with multiple right lower limb arteriovenous fistulae and venous aneurysms. There were no other clinical or radiological findings to suggest a large-vessel vasculitis such as Takayasu´s arteritis. Mycobacterium tuberculosis was cultured from multiple sources including a gastric aspirate, blood and sputum samples. A diagnosis of tuberculous arteritis was made. Anti-tuberculous and heart failure treatment were commenced and her antiretroviral therapy was reinitiated. She reported significant improvement of her symptoms. However, 1-week following hospital discharge, the patient demised.

A Novel Inside-out Access Approach for Hemodialysis Catheter Placement in Patients With Thoracic Central Venous Occlusion

Left-sided internal jugular and all subclavian central venous catheters (CVCs) cause thoracic central vein occlusions (TCVOs) more often than right-sided internal jugular catheters. To enable right-sided CVC placement in patients with TCVO, an inside-out access (IOA) approach was established at 3 vascular access centers in Europe involving use of a novel IOA device advanced from the right femoral vein. In the current analysis, we assessed the eligibility and success rate of this IOA approach in a cohort of patients with TCVO requiring a tunneled dialysis catheter. Retrospective multicenter observational study. 36 patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June2018. Application of the IOA approach to gain vascular access. The primary end point was the success rate of passing the TCVO to gain dialysis access using the IOA approach. Secondary end points were catheter patency at 3 months and procedure-related complications (early infections, bleeding, hematoma, and pericardial effusions). Descriptive statistics to characterize eligibility, success rate, and complications of the IOA approach. 36 patients with TCVO and history of multiple CVCs and arteriovenous fistulas were referred to the participating centers for vascular access. 32 (89%) patients were eligible for the IOA approach. 39 treatments were performed, with 7 patients undergoing the IOA procedure a second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. No comparison to other methods to place CVCs and the observational study design. The IOA approach is a promising method to enable rapid access to the right jugular vein in the setting of pre-existing TCVO. Additional experience is needed to understand the generalizability of these observations.

Simultaneous Diagnosis and Treatment of Double Synchronous Spinal Cord Vascular Malformation

Although multiple concurrent spinal arteriovenous fistulas (DAVFs) are a well-known anatomical and clinical entity, the management of these lesions and timing of surgical intervention is still a matter of debate.A 74-year-old man with a 2-year history of progressive weakness of both lower limbs and lower back pain was diagnosed angiographically with a thoracic DAVF. During the surgical procedure, double independent spinal DAVFs were identified. With the aid of neurophysiologic monitoring, we proceeded to the closure of both fistulas in a one-step surgery.Neurophysiologic monitoring represents a valid, widely available, minimally invasive tool for the detection of immediate motor fiber damage due to disruption of the incorrect vessels during DAVF surgery and facilitates a safe treatment in a one-step procedure.

Abstract No. 477 Endovascular arteriovenous dialysis fistula intervention: outcomes and factors contributing to fistula failure

To determine post-intervention patency rates and contributing factors for fistula failure in pre-dialysis patients with arteriovenous (AV) dialysis fistulas. Institutional review board approval was obtained for this single-institution retrospective study. All pre-dialysis patients who underwent upper extremity AV fistula creation for anticipated dialysis between October 1995 and January 2015 and who required subsequent endovascular therapy to maintain patency were reviewed. A total of 210 patients were identified. The medical record was queried for patient demographics, procedural details and outcomes. Multiple AV fistula configurations were reviewed: 138 brachiocephalic, 39 radiocephalic, 30 brachiobasilic, 2 ulnocephalic and 1 radiobasilic. Median post-intervention primary patency was 2.7 years, median post-intervention primary-assisted patency was 3.2 years, and median post-intervention secondary patency was 3.6 years. There were 293 initial stenosis treated. This included 5 stenosis in the inflow artery, 50 at the anastomosis, 71 in the juxta-anastomotic segment, 71 in the cannulation zone of the outflow vein, 16 in the noncannulation zone, 10 at the swing point of basilic vein transpositions, 57 in the cephalic arch, and 13 in the central veins. Stenoses in the non-cannulation zone of the outflow vein had the highest rate of target lesion revascularization (TLR) (76.7%), whereas central venous stenosis had the lowest rate of TLR (7.7%). The radiocephalic fistula configuration had better post-intervention primary patency (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.35-0.96; p=0.034). Conversely, brachiocephalic fistulas had higher risk for loss of post-intervention primary patency (HR 1.90; 95% CI 1.13-3.20; p=0.015). Among predialysis patients who undergo initial endovascular therapy to maintain patency of the AV fistula, the radiocephalic configuration was found to have the best post-intervention primary patency compared to other configurations. While the majority of hemodynamically significant lesions occurred at the anastomosis, lesions in the non-cannulation zone of the outflow vein had the highest rates of TLR.

A Case of the Multiple Dural Arteriovenous Fistula with Hyperhomocysteinemia

A Case of the Multiple Dural Arteriovenous Fistula with Hyperhomocysteinemia