Posttraumatic Fistula Research Articles

Traumatic arteriovenous fistula supplied by the middle meningeal artery

We read with great interest the article entitled “Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus” by Unterhofer et al. [3] in the Oct 2009 issue of Acta Neurochirurgica. The authors presented a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus and discussed the relevant literature. They pointed out that the laterobasal fractures involving the floor of the middle temporal fosse can lead to fistula formation between the middle meningeal artery and the sphenoparietal sinus. Therefore, they stressed the need to include selective angiographic catheterization of the external carotid artery when bone damage after head injury involves the lateral skull base and a fistula is suspected on clinical grounds. We agree with the authors’ opinion; however, we would like to comment on this issue. We previously reported a case of a traumatic middle meningeal arteriovenous fistula on the opposite side of a head injury [2].The patient hit the right side of their head. Computed tomography scans demonstrated a traumatic right temporal bone fracture, whereas there was no fracture on the left side. Cerebral angiograms 1 year after the head injury showed a dural arteriovenous fistula, which was fed by the left middle meningeal artery. Draining systems were mainly the middle meningeal vein and the sphenoparietal sinus. A review of the literature showed that there are some reported cases of traumatic middle meningeal arteriovenous fistula without skull fracture on the side of the lesion. Dura mater–bone separation [1] or distortion of the dura mater may cause the formation of a traumatic arteriovenous fistula fed by the middle meningeal artery without skull fracture. We suggest that a selective angiography of the external carotid artery should be performed in cases with clinical suspicions, even if there is no skull fracture.

Fístula arteriovenosa postraumática: tratamiento endovascular. Revisión de la literatura y presentación de un caso clínico

Traumatic arteriovenous fistulas of the head and neck region are uncommon. The majority are due to penetration of blunt injury. We describe a successful endovascular treatment of a posttraumatic fistula between the left maxillary artery and the external jugular vein due to a penetration injury. This case and a review of the literature illustrate the causes, manifestations, image studies and treatment for a posttraumatic fistula between the maxillary artery and the external jugular vein. This case demonstrate the utility of endovascular treatment of head and neck injuries complications.

Fistules artérioveineuse post-traumatiques des membres : expérience de 26 cas

Posttraumatic arteriovenous fistulas are not a rare event in military facilities during periods of armed conflicts, but are seldom seen in the civilian health care system. We report our approach to the management of 26 cases of posttraumatic limb arteriovenous fistulas colligated from 1996 to 2006. The main cause of our posttraumatic arteriovenous fistulas is the penetrating traumatism. Arteriography was the mostly used imaging exploration. The treatment was surgical for 24 patients. One case of thrombosis was reported. Our series of posttraumatic fistulas is characterized by a particularly high rate of penetrating trauma, in which case intervention is the rule. Our study shows that, in our experience, surgical treatment is still a safe and efficient therapeutic attitude.

Spontaneous closure of a posttraumatic scleral fistula in an atypical choroidal coloboma.

Scleral fistulas have been reported to occur in choroidal colobomas, and their repair has been described in the literature. Spontaneous closure of a posttraumatic fistula has not been reported. To describe the occurrence of posttraumatic scleral fistula formation and its spontaneous closure in an eye with an atypical choroidal coloboma. Interventional case report. Spontaneous closure of the posttraumatic scleral fistula was noted at 1-month follow-up. This was documented clinically and confirmed by B-scan ultrasound. Scleral fistula formation can occur at the base of a choroidal coloboma after blunt injury, and this can close spontaneously over a period of time.

Endoscopic Repair of Post-traumatic Fistulae of Posterior Urethra Using Hyaluronic Acid Dextranomer

Many surgical approaches to posterior urethral diseases are reported in published data. The authors report a case of a patient with prostatic urethral post-traumatic fistulae, probably developed from an abscess that developed after a surgical intervention to correct a pubic symphysis fracture. The fistulae were repaired with an unusual mininvasive endourologic procedure, using the hyaluronic acid dextranomer, which is commonly used in vesicoureteral reflux treatment.

Successful Transarterial Guglielmi Detachable Coil Embolization of Post-Traumatic Fistula between a Posterior Communicating Artery Aneurysm and the Cavernous Sinus

We describe a case of a post-traumatic posterior communicating artery (PCoA) aneurysm-cavernous sinus fistula, which is an extremely rare complication of craniocerebral trauma, successfully treated with endosaccular coil embolization via transarterial route. Endosaccular embolization with Guglielmi detachable coils via transarterial route appears to be a feasible, effective and minimally invasive option for the treatment of post-traumatic fistula between the PCoA aneurysm with a small ostia and the cavernous sinus in the subacute phase.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus

Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus. A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus. The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms. A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

TRAUMATIC RADIAL ARTERY-CEPHALIC VEIN FISTULA: CASE REPORT

Arteriovenous fistulas are abnormal communications between arteries and veins. They occur generally due to penetrating traumas but fistulas after blunt traumas have also been reported. We are presenting an extremely rare type of posttraumatic fistula which occurred between radial artery and cephalic vein. A 21 year old male patient admitted to our outpatient clinics suffering from the swelling and pain of his left hand and forearm. There was an arteriovenous fistula on his left wrist. He mentioned that his left wrist was injured at the time of a traffic accident 5 years ago. His complaints and the thrill disappeared after fistula ligation. Our case report shows the importance of systemic physical examination in the early diagnosis of arteriovenous fistulas as well as in preventing long term complications particularly in patients who have the history of trauma.

Transvenous embolization of a high-flow, posttraumatic fistula between the posterior communicating artery and retroclival venous plexus

Traumatic injuries of the posterior communicating artery are distinctly rare. We report an unusual case of traumatic tear of the posterior communicating artery with fistulous communication to the adjacent, retroclival venous plexus. The fistula, and an accompanying large venous aneurysm, was completely occluded via transvenous embolization. The patency of the posterior communicating artery was preserved.

Biliary Fistulas Resulting from Blunt Hepatic Injury Treated by Endoscopic Diversion of the Bile Flow

Biliary fistula is a fairly uncommon complication of blunt liver injury, but with more liberal use of a nonoperative approach to the treatment of hepatic injury, the incidence is rising. If present, it becomes evident with physical examination aided by common diagnostic modalities (ultrasonography, computed tomography, cholangiography). The treatment, though, still presents a significant dilemma and often results in high morbidity with prolonged hospital stay and unnecessary expenses.Information was collected prospectively on a group of 26 consecutive patients with blunt hepatic trauma. Three cases of biliary fistulas were diagnosed, all after bile peritonitis ensued, or after a continuous discharge of bile through a postoperative drain took place. In one case, the diagnosis was confirmed by ultrasonography and computed tomography. Endoscopic retrograde cholangiopancreatography was used in all cases for diagnostic work-up and therapy. Endoscopic placement of a nasobiliary catheter was the definitive treatment in all cases. In all three patients, abdominal drains were removed two days after placement of a nasobiliary catheter. Diversion of the bile flow was discontinued after 6–7 days with no recurrent bile leak. No mortality due to hepatic injury or its complications was observed. Conclusions: Posttraumatic bile fistulas are relatively easy to diagnose and their management with endoscopic drainage of the biliary tree through a nasobiliary tube is safe and effective. Adequate perihepatic drainage prevents relaparotomy for bile peritonitis. The possibility of biliary leakage does not reduce the relative safety of non-operative treatment of injury to solid organs.

Endovascular Repair of Traumatic Mesocaval Fistula

A patient presented with a posttraumatic fistula between the superior mesenteric artery and inferior vena cava with associated pseudoaneurysm after multiple thoracoabdominal gunshot wounds. Endovascular management with placement of two overlapping stent-grafts resulted in complete resolution of the lesions with documented patency at 15 months and no known complications. This minimally invasive therapy spared the patient the morbidity of conventional open surgical repair.

Successful treatment of parotid fistula with tympanic neurectomy

Parotid fistula is a cause of great distress and embarrassment to the patient. A host of treatment modalities have been described in past but no unanimity exists regarding the most satisfactory of all. Tympanic neurectomy is an effective procedure for persistent parotid fistula with no significant side effects. To describe our experience with tympanic neurectomy for the treatment of persistent parotid fistula and discuss the other treatment modalities described. Tertiary care referral centre. Two cases with post traumatic parotid fistula recalcitrant to conservative therapy were treated with tympanic neurectomy between 2004-2005. The cases were followed up regularly for any recurrence of fistula. Successful and immediate cessation of flow from parotid fistula with no recurrence in subsequent followup. Tympanic neurectomy is a safe and effective procedure for the successful treatment of persistent parotid fistula.

Endovascular treatment of carotid-cavernous fistula type A with platinium coils

Carotid-cavernous fistulas are abnormal communications between carotid arteries or their branches and the cavernous system caused mostly by trauma. Posttraumatic fistulas represent 70% of all carotid-cavernous fistulas and they are mostly high-flow shunts (type A). This type gives characteristic eye symptoms. This paper presents a 44-year old male patient with carotid-cavernous fistula as a result of penetrating head injury. In clinical presentation the patient had exophthalmos, conjunctival chemosis and weakening of vision on the right eye, headache and diplopia. Digital subtracted angiography showed high-flow carotid-cavernous fistula, which was vascularised from the left carotid artery and from vertebrobasilar artery. Endovascular embolization with platinum coils was performed through the transarterial route (endoarterial approach). Check angiogram confirmed that the fistula was closed and that no new communications developed. Embolization of complex carotid-cavernous fistula type A was successfully performed with platinum coils by endovascular approach.

Transnasal Endoscopic Repair of Cerebrospinal Fluid Fistulas and Encephaloceles: Surgical Indications and Complications

Transnasal endoscopic repair of cerebrospinal fluid (CSF) fistulas is recommended for patients with CSF leaks who do not respond to conservative treatment. It is a safer and more successful alternative to transcranial surgery. We present our experience on using transnasal endoscopy for the repair of anterior skull base cerebrospinal fluid fistulas. Between 1999 and 2003 we observed 20 patients with CSF rhinorrhea. The etiology was heterogeneous: post-traumatic in 6 cases, iatrogenic in 6 cases (one interesting case of meningioma of the sphenoethmoid plate), dysembryogenetic - due to encephaloceles - in 4 patients (one with Cruzon syndrome and one with Down syndrome) and idiopathic in the other 4 patients. Use of a rigid transnasal endoscope allowed the localization and repair of all fistulas, with the use of fluorescein in 6 cases. Different grafts were used, in particular fat, bone or chondral septum with mucoperiosteum or perichondral mucosa. Generally the graft was inserted with the underlay or the sandwich technique. Lumbar drainage was used in the postoperative period only in 6 cases. No antibiotic prophylactic therapy was used. Endoscopy was successful in 90 % of patients at the first attempt, and in 95 % of patients at the second approach. We had two late complications such as infections. In one child with a post-traumatic fistula and shunt for hydrocephalus, we observed meningitis 2 years after the first endoscopic surgery and he underwent both transnasal endoscopic surgery and transcranial surgery. The second patient was a woman with a spontaneous fistula, who had rhinoliquorrhea three years after the first surgical treatment. During surgery a strange similar purulent material filling the submucous space of the ethmoid roof was found, suggestive for an intranasal abscess that was removed. We did not see any complications such as hematomas or seizures. The follow-up (range: 6 months to 3 years) made both with MRI and rhinoscopy has not shown any relapse until now in 19 of 20 patients treated only with endoscopy. The endoscopic approach is highly effective and safe in the treatment of CSF fistulas, with great visualization and minimal invasiveness, for which it is associated to a very low morbidity. The fluorescein technique is extremely helpful for the diagnosis and surgery of CSF leaks.

The thrill is gone: Catheter-based exclusion of a posttraumatic arteriovenous fistula with a covered stent graft

Posttraumatic arteriovenous (AV) fistulae of the lower extremities may result from accidental trauma or iatrogenic surgical injuries. Large high-flow fistulae are commonly associated with disabling localized symptoms and impaired wound healing. Therapeutic options are particularly challenging for AV fistulae involving the infrapopliteal circulation. Surgical repair may further delay healing and contribute to greater morbidity. Alternatively, percutaneous coil occlusion in large high-flow fistulae mayenable coil embolization to the pulmonary circulation. Using a balloon-expandable covered stent graft, we describe the percutaneous exclusion of a large posttraumatic infrapopliteal AV fistula with immediate clinical symptom improvement and resolution within 3 months following intervention. No clinical symptom recurrence was documented at a 9-month follow-up visit.

Interventional Radiology Cases from the Royal Hospital for Sick Children, Glasgow: Transcatheter Embolisation of Post-Traumatic Hepatic Artery Pseudoaneurysm and Arterioportal Fistula

Percutaneous transcatheter embolisation techniques are being increasingly used in the treatment of post-traumatic bleeding and arteriovenous fistula formation. We describe a case where the technique has been used successfully to treat a combined pseudoaneurysm and arterioportal fistula in the liver of a child following blunt trauma.

Arteriovenous intracavernous post-traumatic fistula: clinical management and treatment by superselective embolization

Arteriovenous intracavernous post-traumatic fistula (FAV) is a rare post-traumatic lesion for which the first choice of treatment is superselective embolization. We present a case of post-traumatic fistula in a 45-year-old patient. The patient underwent penile blood gas analysis and color Doppler ultrasonography and was treated with superselective embolization with an acrylic co-polymer. Postoperative arteriography showed obliteration of the fistula. Color Doppler ultrasonography 60 days after the procedure showed reacquired physiologic patency of the cavernous artery with normal flow parameters. The results of this case confirm superselective embolization as the reference standard treatment of FAV. We propose the use of an acrylic co-polymer as a new, effective embolizing medium.

Percutaneous Management of Concomitant Post-Traumatic High Vertebrovertebral and Caroticojugular Fistulas Using Balloons, Coils, and a Covered Stent

Percutaneous Management of Concomitant Post-Traumatic High Vertebrovertebral and Caroticojugular Fistulas Using Balloons, Coils, and a Covered Stent

A prospective study of post-traumatic biliary and pancreatic fistuli: The role of expectant management

Background: Biliary or pancreatic fistulae occur frequently after operative repair of liver or pancreatic injuries. The existing literature is based on a few retrospective series. The objective of this prospective study is to evaluate the clinical course and efficacy of non-operative treatment of biliary fistuli (BF) and pancreatic fistuli (PF) post-traumatic fistulae. Study design: Patients who following a trauma laparotomy, developed BF or PF were prospectively followed during a 38-month period (June 1999–August 2001). Demographics, injury type and severity, fistula characteristics and daily output, complications, interventions and cost were recorded. Optimal nutrition, wound management, and control of infection were priorities in fistula management. A fistula was considered completely healed if the patient was on regular diet and the output was zero for at least 48 h. Results: Of 160 patients (injury severity score: 21+10) with trauma laparotomy for a liver or pancreatic injury, nineteen patients (12%) developed a fistula (11 BF, 8 PF). No patient died. Infections occurred in 45% (5/11) of BF patients and 50% (4/8) of PF patients. Only two patients required an operation, one for bilio-pericardium and one more for a pancreatic pseudo-cyst. Fistula management was responsible for more than half of the hospital stay and cost. Patients with PF had longer hospital stays (44+28 days) and charges (US$ 345,000+218,000) than patients with BF (22+12 days and US$ 103,000+61,000, respectively). Conclusions: Most post-traumatic BF and PF can be managed non-operatively. BF resolves earlier than PF. Both entities are responsible for substantial increases in hospital length of stay and charges.

Aortocava Fistula

Combined injuries of the aorta and inferior vena cava are rare. Mortality is over 70%, primarily from exsanguinating hemorrhage. Post-traumatic aortocava fistula can develop in survivors, who present in the postoperative period with manifestations of high output heart failure. This is a retrospective review of five male patients, age from 9 to 39 years, with aortocava fistulas that were referred with congestive heart failure, 2 days to 6 months after abdominal penetrating injuries. They had undergone surgery at another hospital and several organ injuries were treated. Retroperitoneal hematomas were not seen or were seen and left undisturbed. Four patients received a gunshot injury, had the fistula at the infrarenal level, and survived surgical repair. In one of the survivors, a left popliteal artery bullet embolism also occurred and was treated. Another patient sustained a thoracoabdominal stab injury and an aortocava fistula developed at the suprarenal level; he was in severe congestive heart failure and died during surgery. There are very few reports on this sequelae of vascular injuries at the abdominal level. Patients with aortic and cava injuries have a high mortality rate and arteriovenous fistula may develop with communicating pseudoaneurysms. If high output heart failure develops in a patient with a history of abdominal penetrating injury, an arteriovenous fistula must be suspected and arteriography will disclose the location of the fistula. Surgical treatment is necessary to prevent further heart damage. In the future endovascular procedures may have a role in the management of these difficult conditions.