Rupture Of Arteriovenous Fistula Research Articles

Spontaneous spinal epidural hematoma due to rupture of an arteriovenous fistula

Spontaneous spinal epidural hematoma (SSEH) is a neurosurgical emergency that requires prompt diagnosis and treatment. We report a 24-year-old woman who presented with acute onset of paralysis in both lower limbs and sensory disturbance below the fourth-thoracic dermatome. Spinal magnetic resonance image (MRI) revealed an intraspinal, extradural mass is extending from the fifth to the seventh thoracic vertebrae with compression of the spinal cord. Laminectomy of the T5 to T7 vertebrae was performed 12 h after onset. During the procedure, an epidural hematoma with hypervascularization and an abnormal vascular network were observed grossly on the dorsal dural surface. Postoperative angiography and MRI revealed complete resolution of the hematoma and no evidence of residual vascular lesion in the intra- or extra-dural region. At 6-month follow-up, the patient had regained full muscle power and sensation in the lower limbs. There was no evidence of urinary or stool incontinence. The patient had a history of remaining seated for prolonged periods of time, which may have elevated the spinal venous return pressure, resulting in spontaneous hemorrhage due to rupture of the spinal epidural arteriovenous fistula. This case report shows that patients with SSEH can have excellent neurologic outcomes if the condition is treated early with decompressive laminectomy.

Clinical Experience With Office-Based Duplex-Guided Balloon-Assisted Maturation of Arteriovenous Fistulas for Hemodialysis

To examine the effect of office-based duplex-guided balloon-assisted maturation (DG-BAM) on arteriovenous fistula (AVF), we retrospectively analyzed our experience. Over the past 10 months, we performed 185 DG-BAMs (range, 1-8 procedures; mean, 3.7) in 45 patients (29 male, 16 female; mean age, 68.2 ± 12.8 years) with 31 radial-cephalic, 7 brachial-cephalic, and 7 brachial-basilic AVFs. Balloon sizes (3-10 mm) were chosen based on duplex measurements (1-2 mm larger than minimal vein diameter). Forearm AVFs were dilated to 8 mm, and arm AVFs were dilated to 10 mm. All cases but one (99.5%) were successfully dilated. This exception was a large AVF rupture that required surgical repair. AVFs failed to mature in seven of the remaining 44 patients (16%) despite DG-BAM because of proximal vein stenoses (PVS). Four patients had cephalic arch stenoses, and three had proximal subclavian vein stenoses. Arm AVFs were more commonly associated with PVS (6 of 14 patients, 43%) as compared with the ones placed in the forearm (1 of 30 patients, 3.3%), with a P value of 0.0024. All these seven AVFs subsequently matured after successful balloon angioplasty of the venous outflow. These data suggest that office-based DG-BAM of AVFs is feasible, safe, and averts nephrotoxic contrast and radiation. PVS appear to be the most common cause of failure for AVFs subjected to BAM. Because arm AVFs are at increased risk of PVS, we suggest that a careful duplex evaluation of the outflow be performed in these cases and in all AVFs that fail to mature.

HUGE HAEMATOMA CAUSING CHEST WALL COMPRESSION FROM RUPTURE OF ARTERIOVENOUS FISTULA

A 71-year-old man was transferred from a local hospital to our emergency department due to rapid swelling of his left forearm, arm, and chest wall down to the left upper quadrant of his abdomen. He had a history of diabetes mellitus and hypertension and started peritoneal dialysis for end-stage renal disease 1 year before. A left arm brachio-basilic arteriovenous fistula (AVF) was constructed due to poor peritoneal dialysis ultrafiltration efficacy 10 months later, and he just underwent cannulation before transfer. At arrival, hypotension (78/46) and tachycardia (120) were found. Physical examination showed extreme bulging of the left chest wall and asymmetric arm size. Laboratory study showed a drop in haemoglobin from his baseline level 9.0 g/dL to 6.4 g/dL. Aggressive component therapy and tourniquet compression over the puncture site were immediately applied. An extremity and chest CT showed a huge haematoma extending from the left arm to the axilla and left chest wall, resulting from the left arm AVF rupture (Fig. 1). The haematoma gradually stabilized in size after tourniquet compression, with careful distal limb pulsation monitoring. His hypotension also improved, and the swelling resolved one week later without invasive intervention. AVF rupture is a rare complication during routine cannulation of haemodialysis access, and incidence of rupture requiring surgical intervention is estimated at 1.1% (1). Causes of rupture usually involve endovascular manipulation (2), inappropriate insertion technique, and an underlying access infection or pseudo-aneurysm should always be considered, especially preceded by the “herald bleeding”. In our patient, such anatomic defect was not identified, but it is very rare that this haematoma expanded so broadly as to compromise his haemodynamic status. Peri-procedural AVF rupture is usually managed with immediate balloon tamponade or stent grafting, and conservative management has not been reported before. However, in this patient, such management turned out to be useful when instituted early in the course. If cautiously applied, a tourniquet compression for AVF rupture haemostasis could be an effective on-site management if angiographic suite or surgical service is not immediately available. REFERENCES

Severe Symptomatic Vasospasm following Intraventricular Hemorrhage from Arteriovenous Fistula

The authors present a rare case of severe vasospasm following the rupture of arteriovenous fistula. On initial CT scan, hematoma in the corpus callosum and left inferior frontal region with surrounding cerebromalacia and all ventricles without apparent subarachnoid hemorrhage were seen. Angiograms showed arterivenous fistula but did not show cerebral vasospasm. Thirteen days after admission the neurological state of patient suddenly deteriorated and bilateral motor weaknesses developed. Following angiograms revealed severe narrowing on the supraclinoid portion of bilateral internal carotid arteries, bilateral anterior cerebral arteries and bilateral middle cerebral arteries. Transluminal angioplasty and intra-arterial papaverine infusion were performed. The patient remained stable with moderate neurologic deficits.

Rupture of arteriovenous fistula after in situ saphenous vein bypass

Residual saphenous vein tributaries function as arteriovenous fistulas after in-situ lower extremity bypass. Whether or not all of these tributaries need to be ligated at the time of bypass is controversial since many will close spontaneously. Other consequences of retained fistulas range from local skin problems to diminished graft flow and ultimate graft thrombosis. A complication not previously reported is rupture of a retained arteriovenous fistula. This unusual and potentially catastrophic complication should be discoverable at an earlier stage by periodic graft surveillance by means of duplex sonography. The routine policy of selective ligation of saphenous vein tributaries needs to be reexamined.

Rupture of arteriovenous fistula after in situ saphenous vein bypass

Residual saphenous vein tributaries function as arteriovenous fistulas after in-situ lower extremity bypass. Whether or not all of these tributaries need to be ligated at the time of bypass is controversial since many will close spontaneously. Other consequences of retained fistulas range from local skin problems to diminished graft flow and ultimate graft thrombosis. A complication not previously reported is rupture of a retained arteriovenous fistula. This unusual and potentially catastrophic complication should be discoverable at an earlier stage by periodic graft surveillance by means of duplex sonography. The routine policy of selective ligation of saphenous vein tributaries needs to be reexamined.