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Case report: Hybrid endovascular and open surgical approach to a chronic, traumatic arteriovenous fistula.

Tyagi S, Sabat J, Fukuhara S, Farivar B, Kagen A, Bernik T - Int J Surg Case Rep (2016)

View Article: PubMed Central - PubMed

Affiliation: Mount Sinai Beth Israel, Department of Surgery, Baird 16th Floor, 1st Ave at 16th Street, New York, NY 10003, United States.

ABSTRACT

Chronic traumatic AVF leads to significant morbidity when allowed to progress.

Traumatic AVF may be approached with endovascaular, open, and hybrid techniques.

We describe a traumatic AVF which was left to progress for over 30 years.

Our staged, hybrid approach decreased venous hypertension and bleeding during surgery.

Our staged, hybrid approach decreased venous hypertension and bleeding during surgery.

No MeSH data available.


Related in: MedlinePlus

CTA showing markedly ectatic and dilated common and external iliac arteries up to 2.9 cm, dilated common iliac up to 5.7 cm in diameter, large 2.2 cm wide by 4.4 cm long profunda AVF to femoral vein with a calcified fistula pseudoaneurysm, and multiple embolized smaller AVFs and collaterals. Also shown is a pseudoaneurysm at the left common femoral access site, which resolved on subsequent imaging.
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fig0005: CTA showing markedly ectatic and dilated common and external iliac arteries up to 2.9 cm, dilated common iliac up to 5.7 cm in diameter, large 2.2 cm wide by 4.4 cm long profunda AVF to femoral vein with a calcified fistula pseudoaneurysm, and multiple embolized smaller AVFs and collaterals. Also shown is a pseudoaneurysm at the left common femoral access site, which resolved on subsequent imaging.

Mentions: Three months prior to presentation, the mass enlarged and his claudication symptoms increased. Echocardiogram revealed cardiomegaly but no evidence of congestive heart failure or pulmonary hypertension. Ankle Brachial Indexes were normal. Doppler ultrasound of his lower extremity showed a dilated, tortuous left iliac artery, loss of obvious normal vascular anatomy, and a large groin AVF to profunda with numerous smaller venous AVFs. CT angiography was performed revealing a normal right iliac artery and vein, dilated and tortuous distal aorta, left illiac artery and vein, dilated SFA and profunda branches, large profunda to femoral vein (FV) AVF, extensive collateralization, and multiple smaller mid-thigh AVFs (Fig. 1). Digital subtraction angiography was performed in the operating room revealing the large 2.2 × 4.4 cm AVF of the proximal profunda to the FV. Given the patient's young age, lack of commercially available peripheral stent graft with adequate diameter, and reluctance to use an aortic stent graft off label, we recommended an open repair (Fig. 2). Extensive fistulous collateralization of large profunda branches presented a challenge to conventional open ligation, and a two-staged hybrid approach consisting of endovascular embolization of the large fistulous collaterals was planned in order to avoid significant bleeding during an open intervention. The patient underwent coil embololization of all accessible AVF first in order to decrease the venous hypertension in preparation for an open ligation of the large left profunda to the femoral vein fistula. Access was attempted from the right side, however the left iliac artery was too tortuous to navigate. Therefore, access was obtained to the left femoral artery and the contralateral wire was snared from the right groin, effectively gaining antegrade access. The multiple fistulizing collaterals were selectively entered and coil-embolized with a total of 27 VortX™ (Boston Scientific) and Nester® (Cook Medical) coils ranging from 3–10 mm in size. The large 2.2 × 4.4 cm profunda AV fistula was visualized, but was confirmed to be too large for an Amplatzer™ plug (St. Jude Medical), Viabahn® covered stent (Gore Medical), or other endovascular intervention. The patient returned to the OR one week later for definitive profunda AVF exclusion with minimal venous bleeding and adequate vessel control despite a very difficult dissection (Fig. 3). The patient was followed for 16 months with resolution of his symptoms, decreased leg diameter, and control of venous hypertension. Follow up imaging at 1 year showed persistent occlusion of the AVF (Fig. 4).


Case report: Hybrid endovascular and open surgical approach to a chronic, traumatic arteriovenous fistula.

Tyagi S, Sabat J, Fukuhara S, Farivar B, Kagen A, Bernik T - Int J Surg Case Rep (2016)

CTA showing markedly ectatic and dilated common and external iliac arteries up to 2.9 cm, dilated common iliac up to 5.7 cm in diameter, large 2.2 cm wide by 4.4 cm long profunda AVF to femoral vein with a calcified fistula pseudoaneurysm, and multiple embolized smaller AVFs and collaterals. Also shown is a pseudoaneurysm at the left common femoral access site, which resolved on subsequent imaging.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4834720&req=5

fig0005: CTA showing markedly ectatic and dilated common and external iliac arteries up to 2.9 cm, dilated common iliac up to 5.7 cm in diameter, large 2.2 cm wide by 4.4 cm long profunda AVF to femoral vein with a calcified fistula pseudoaneurysm, and multiple embolized smaller AVFs and collaterals. Also shown is a pseudoaneurysm at the left common femoral access site, which resolved on subsequent imaging.
Mentions: Three months prior to presentation, the mass enlarged and his claudication symptoms increased. Echocardiogram revealed cardiomegaly but no evidence of congestive heart failure or pulmonary hypertension. Ankle Brachial Indexes were normal. Doppler ultrasound of his lower extremity showed a dilated, tortuous left iliac artery, loss of obvious normal vascular anatomy, and a large groin AVF to profunda with numerous smaller venous AVFs. CT angiography was performed revealing a normal right iliac artery and vein, dilated and tortuous distal aorta, left illiac artery and vein, dilated SFA and profunda branches, large profunda to femoral vein (FV) AVF, extensive collateralization, and multiple smaller mid-thigh AVFs (Fig. 1). Digital subtraction angiography was performed in the operating room revealing the large 2.2 × 4.4 cm AVF of the proximal profunda to the FV. Given the patient's young age, lack of commercially available peripheral stent graft with adequate diameter, and reluctance to use an aortic stent graft off label, we recommended an open repair (Fig. 2). Extensive fistulous collateralization of large profunda branches presented a challenge to conventional open ligation, and a two-staged hybrid approach consisting of endovascular embolization of the large fistulous collaterals was planned in order to avoid significant bleeding during an open intervention. The patient underwent coil embololization of all accessible AVF first in order to decrease the venous hypertension in preparation for an open ligation of the large left profunda to the femoral vein fistula. Access was attempted from the right side, however the left iliac artery was too tortuous to navigate. Therefore, access was obtained to the left femoral artery and the contralateral wire was snared from the right groin, effectively gaining antegrade access. The multiple fistulizing collaterals were selectively entered and coil-embolized with a total of 27 VortX™ (Boston Scientific) and Nester® (Cook Medical) coils ranging from 3–10 mm in size. The large 2.2 × 4.4 cm profunda AV fistula was visualized, but was confirmed to be too large for an Amplatzer™ plug (St. Jude Medical), Viabahn® covered stent (Gore Medical), or other endovascular intervention. The patient returned to the OR one week later for definitive profunda AVF exclusion with minimal venous bleeding and adequate vessel control despite a very difficult dissection (Fig. 3). The patient was followed for 16 months with resolution of his symptoms, decreased leg diameter, and control of venous hypertension. Follow up imaging at 1 year showed persistent occlusion of the AVF (Fig. 4).

View Article: PubMed Central - PubMed

Affiliation: Mount Sinai Beth Israel, Department of Surgery, Baird 16th Floor, 1st Ave at 16th Street, New York, NY 10003, United States.

ABSTRACT

Chronic traumatic AVF leads to significant morbidity when allowed to progress.

Traumatic AVF may be approached with endovascaular, open, and hybrid techniques.

We describe a traumatic AVF which was left to progress for over 30 years.

Our staged, hybrid approach decreased venous hypertension and bleeding during surgery.

Our staged, hybrid approach decreased venous hypertension and bleeding during surgery.

No MeSH data available.


Related in: MedlinePlus