Development of superior vena cava to pulmonary vein fistulae following modified Fontan operation: case report of a rare anomaly and embolization therapy

A patient with double inlet single ventricle, L-transposition of the great arteries, and atrioventricular valve regurgitation developed progressive heart failure necessitating modified Fontan operation at 16 months of age. The procedure included replacement of the atrioventricular valve and pacemaker insertion. Eight years following the operation, the patient developed progressive cyanosis. Catheterization confirmed the presence of fistulae from the superior vena cava and innominate vein to the pulmonary veins as the cause of cyanosis. Coil embolization of several fistulae was performed successfully at catheterization. Contributing factors for fistula formation in Fontan patients are discussed, and therapy is reviewed.

Endovascular treatment of mural-type vein of Galen malformations

OBJECT

In this study the authors report on the results of endovascular treatment for mural-type vein of Galen malformations (VGMs) in a group of infants.

METHODS

Eight children (six infants and two neonates) who suffered from symptoms caused by a mural-type VGM were treated by means of endovascular therapy. Their age at the time of treatment ranged from 13 days to 19 months (mean 7.6 months). Two neonates and three infants who presented with hydrocephalus and increased head circumference, one of whom was stabilized with a shunt, underwent elective closure of the malformations 3, 4, 6, 6, and 13 months later, respectively. Two patients presented with hemorrhage; one had an intraventricular hemorrhage (IVH) on the 1st day of life and one, a 5-month-old infant, suffered a large parenchymal hemorrhage and an IVH; both patients were immediately cured by means of endovascular techniques. One child presented with a seizure and cortical venous drainage that were treated immediately. Eleven separate treatment sessions were conducted; eight via transarterial femoral access and the remaining three via a transvenous approach. Two patients were treated by using transfemoral transvenous embolization with fibered coils, and one patient required a transtorcular transvenous approach to permit complete closure of the fistula with electrolytically detachable coils. The embolic devices used included silk suture emboli (three patients), electrolytically detachable coils (three patients), and fibered platinum coils (seven patients). In seven patients, complete closure was demonstrated on postembolization arteriographic studies. The eighth patient had stagnant flow in a giant 6-cm varix treated with arterial and venous coils but has not yet undergone follow-up studies. Late follow-up arteriography was performed in four patients at times ranging from 11 to 24 months postprocedure. In one patient, thrombosis of the malformation and shrinkage of the varix were confirmed on follow-up computerized tomography scanning. The remaining three patients have not yet undergone follow-up angiographic examination. Two asymptomatic complications occurred, including separation of the distal catheter, which was removed with a snare device, and a single platinum coil that embolized to the lung, producing no symptoms in 101 months of clinical follow up. The follow-up period ranged from 3 to 105 months, with a mean of 52 months.

CONCLUSIONS

Endovascular therapy is the treatment of choice for mural-type VGMs and offers a high rate of cure with low morbidity.

[A case of renal arteriovenous fistula diagnosed by pharmacoangiography]

A 17-year-old man, who had previously been followed for Nutcracker phenomenon, presented with back pain and gross hematuria. As he developed tamponade of the urinary bladder repeatedly, and the hemoglobin level decreased, we thus performed emergency angiography. A selective left renal venogram revealed the left renal vein to be compressed between the superior mesenteric artery and the abdominal aorta, while the development of an extensive peri- and para-renal collateral circulation was also observed. We next performed epinephrine pharmacoangiography in order to better visualize any abnormal vessels. A left renal arteriovenous fistula was thus diagnosed by this method, and treated successfully by transcatheter embolization using a platinum coil.

[Endovascular treatment of arteriovenous vertebro-vertebral fistula]

Vertebral arteriovenous fistulae are relatively rare, with limited experience in most centers. We report our experience in the treatment of a vertebral arteriovenous fistula treated by interventional method. A review of the literature is made and the etiology, presentation and treatment of this unusual lesion are discussed. The endovascular occlusion is now the treatment of choice of vertebral fistulae.

[Carotid-cavernous fistula with spontaneous remission]

Carotid-cavernous fistulas (CCF) represent the complication of traumatic injuries mostly of bone structures of skull base and face, and rarely of soft neck tissues with the fast development of the shunt and imperiled hemodynamics that in a short time endangers the patient for the increase of intracranial mass. The therapy of this clinical entity significantly changed in the last few years. In this report, we present the case of spontaneous CCF healing with the complete restitution of neurological deficit and CCF healing in control angiographies.

Endovascular coil occlusion of a traumatic basilar-cavernous fistula: technical report

OBJECTIVE AND IMPORTANCE

We describe an unusual case of an 8-year-old male patient presenting with a traumatic basilar artery aneurysm associated with a basilar-cavernous fistula.

CLINICAL PRESENTATION

The fistula occurred as the result of an accident involving a vehicle and a pedestrian. The patient originally presented in a coma and with a dense left hemiparesis.

INTERVENTION

The traumatic basilar aneurysm and basilar-cavernous fistula were successfully occluded by endovascular coil embolization in two sessions. By 6 months after injury, the patient had made an excellent neurological recovery, requiring only a left leg brace for walking.

CONCLUSION

Endovascular coil embolization provided an effective treatment option in the case of this complex and unusual arteriovenous fistula. We discuss the radiological and clinical features of related traumatic neurovascular lesions.

Dural carotid cavernous fistulas: role of conventional radiation therapy--long-term results with irradiation, embolization, or both

PURPOSE

To evaluate the long-term results of irradiation alone or of embolization with or without irradiation in patients with dural carotid cavernous fistulas (DCCFs).

MATERIALS AND METHODS

Between 1984 and 1996, symptomatic DCCFs in 26 patients were treated by using irradiation alone (protocol 1, n = 12) before April 1988 and by using embolization as an initial treatment (protocol 2, n = 14) during and after April 1988. When angiography showed no improvement after embolization, irradiation was added (n = 6). On the basis of drainage flow speed, DCCFs were classified as fast, medium, or slow.

RESULTS

With irradiation alone, all six patients with slow- to medium-type DCCFs had cure with a mean follow-up of 62 months. Four of six patients with fast-type DCCFs had cure or improvement, but the remaining two had no change. In the embolization group, irradiation was added in six patients with fast-type DCCFs. With a mean follow-up of 24 months, four of the six patients had cures, one had improvement, and one had no clinical change. Those who underwent protocol 2 had cures significantly earlier than those who underwent protocol 1 (P < .05).

CONCLUSION

Conventional radiation therapy resulted in cure of DCCFs in nine (75%) of the 12 patients and in improvement of signs and symptoms in one (8%). Fast-type DCCFs may not always be improved. Radiation therapy may be useful in DCCFs after embolization.

Late development of renal arteriovenous fistula following gunshot trauma--a case report

A 43-year-old man presenting with symptoms of congestive heart failure, cardiomegaly, and impaired left ventricular (LV) function was diagnosed as having a huge left renal arteriovenous (AV) fistula. The AV fistula might be attributed to a gunshot wound suffered during his military service twenty years ago. Percutaneous transcatheter arterial embolization utilizing multiple spring coils in conjunction with cyanoacrylic glue successfully occluded the fistula, with subsequent improvement of LV function and reduction of LV size on his serial echocardiographic follow-up.

[Clinical study of transcatheter arterial embolization for pulmonary arteriovenous fistula]

PURPOSE

To evaluate the efficacy of transcatheter arterial embolization for pulmonary arteriovenous fistula (PAVF).

MATERIALS AND METHODS

Eight patients with 14 PAVFs were treated by TAE for feeding arteries. In 5 of 8 cases, detachable balloons were used, and, in 3 of 8 cases, metalic coils were used for embolization of the feeding arterial branch. Detachable balloons or a series of metalic coils were placed at the feeding artery proximal to the fistula. The diameter of detachable balloons was twice the diameter of the feeding arterial branch. The diameter of metalic coils was 1 mm larger than the diameter of the feeding artery.

RESULTS

No complications were apparent in our cases. All PAVFs were completely occuluded by the embolization of a feeding branch. One month after the procedures, the arterial oxygen pressure increased to normal values in all cases and clinical symptoms disappeared. On postcontrast CT, the fistulas treated by the embolization of a feeding arterial branch were not enhanced.

CONCLUSION

The embolization of a feeding branch provided a radical cure for PAVFs.

Pedunculated hepatic haemangioma with arterioportal shunt: treated with angio-embolization and surgery

A case of symptomatic cavernous haemangioma of the liver with an unusual arterio-portal shunting, which was treated by pre-operative angiographic embolization, is described. The arterio-portal shunting has been reported previously in only two cases.

[Endovascular treatment of dural arteriovenous fistulas with medullary venous drainage. Experience with 18 patients]

INTRODUCTION AND OBJECTIVE

The authors report a series of 18 patients with myelopathy who were diagnosed of dural arteriovenous fistulas with venous medullary drainage (DFVMd). Purpose was to assess the effectiveness, initial and long term, of embolization, as the initial treatment, using polyvinyl alcohol particles (PVA) and liquid adhesives. N-butyl-cyanoacrylate (NBCA).

MATERIAL AND METHODS

Magnetic resonance images were obtained in all patients showing spinal cord tissue changes consistent with an isquemic process secondary to venous hypertension. All 18 patients showed initially an improvement in clinical symptoms, demonstrating previous MR images resolution.

RESULTS

The neurological status of 8 patients subsequently deteriorated with angiographically proven recurrences of their DFVMd. These patients underwent a second successful embolization procedure using NBVA. PVA embolization is long term ineffective and is not without risk. Endovascular treatment is less invasive than surgery, its morbidity is less, and it ensures earlier recovery for the patients. If embolization has failed, surgery can still be done.

CONCLUSIONS

We recommend that NBVA embolization be the initial treatment of choice for DFVMd if referring the patient to an experienced interventional Neuroradiology unit is available. Careful clinical and neurologic examination is necessary to establish the diagnosis of DFVMd. Finally, we strongly recommend that patients be followed closely and aggressively. Periodic clinical and radiologic assessments, including MR and spinal angiography, are essential to achieve complete cure.

Diagnosis and treatment of dural arteriovenous fistulas

Dural arteriovenous fistulas (DAVFs) are abnormal vascular connections located within the dura mater which are thought to be promoted by venous hypertension and venous sinus thrombosis. The symptoms associated with DAVFs depend on the direction and adequacy of venous drainage pathways, the amount of arteriovenous shunting and specific location of the fistula. Our experience over a period of eight years with 268 patients suffering from cranial DAVFs in the transverse, sigmoid, superior sagittal, ethmoidal, inferior and superior petrosal, cavernous, and marginal sinuses are presented. The clinical presentation, radiographic evaluation, and treatment modalities for DAVFs in each of these locations are summarized.

Direct arteriovenous fistulas (carotid-cavernous and vertebral-venous). Diagnosis and intervention

Carotid-cavernous and vertebral-venous fistulas are direct arteriovenous fistulas. Their symptoms range from benign to extremely severe ophthalmologic or neurologic complications. Mechanism of symptoms is mostly related to venous drainage. Therapy is widely indicated, as today's endovascular techniques--using mostly detachable balloons and coils--have a high success rate and very few complications.

Endovascular embolization of arteriovenous fistulas of the external carotid artery

BACKGROUND

External carotid arteriovenous fistulas (AVFs) are rare and most hospitals have limited experience with their management. This study was designed to evaluate the effectiveness and safety of endovascular embolization of AVFs of the external carotid artery under angiographic control.

METHODS

A series of 13 patients with AVFs involving the branches of the external carotid artery, all treated with endovascular embolization, were reviewed. There were 10 males and three females ranging in age from nine to 46 years, with a mean of 27 years. The most frequent presenting symptoms were pulsatile tinnitus, followed by bruit and/or thrill, ocular problems, headache and a pulsatile mass in the neck. The middle meningeal artery was most often involved, followed by the internal maxillary artery and the occipital artery. The AVFs were caused by trauma in 10 patients and occurred spontaneously in three. N-butyl-2-cyanoacrylate was used to embolize the fistula in 11 patients and a detachable balloon was used in two.

RESULTS

All the patients were cured and no significant complications were observed. No recurrence was noted after a clinical follow-up of three months to seven years (mean, 37 months).

CONCLUSIONS

Endovascular embolization proved to be a safe and effective procedure. It should be the treatment of choice for repair of external carotid AVFs.

The value of long-term clinical follow-up for cases of spontaneous carotid cavernous fistula

To clarify the value of clinical long-term follow-up with radiological examination, ranging from 12 to 63 months (average: 35 months), 18 consecutive patients suffering from spontaneous carotid cavernous fistula (CCF), were studied prospectively. Five aged patients without aggressive symptoms were treated conservatively, and the other 13 underwent transarterial embolization. The radiological follow-up was primarily by magnetic resonance angiography (MRA), performed from 2 to 6 times (average: 4.1 times) during the follow-up period. In three cases, CCFs persisted, but the other fifteen (83%) demonstrated complete cure as defined by long-term follow-up MRA. The three patients with persistent CCFs were comparatively young, less than 60 years old, had no atherosclerotic factors and demonstrated multiple venous drainage routes with cortical venous drainage on angiography. In two of them, the symptoms completely disappeared, and the other had only mild chemosis. However, surprisingly, in two, MRA revealed residual CCF with drainage into only cortical veins through the sphenoparietal sinus, this radiological finding being well known to signify danger. During the follow-up period, central retinal vein thrombosis occurred in two cases. The common point in these cases was that the superior ophthalmic vein was the only venous drainage route. This is also a point requiring care. We therefore emphasize the importance of careful long-term radiological follow-up for spontaneous CCF patients even when their symptoms improve or disappear. MRA is particularly suitable for this purpose and applicable in the out-patient clinic because of its non-invasive nature.

The ophthalmology of intracranial vascular abnormalities

PURPOSE

To provide a practical review of the ophthalmologic manifestations of intracranial vascular abnormalities.

METHODS

We reviewed ocular manifestations of the most common intracranial vascular abnormalities: intracranial aneurysms, carotid-cavernous fistulas, arteriovenous malformations, and cavernous malformations.

RESULTS

Unruptured aneurysms can compress the third cranial nerve and the anterior visual pathways. Ruptured aneurysms and subarachnoid hemorrhage can result in Terson syndrome and papilledema. Direct and indirect carotid-cavernous fistulas most commonly cause the classic triad of proptosis, conjunctival chemosis, and cranial bruit but can masquerade as chronic conjunctivitis. Arteriovenous malformations, with or without hemorrhage, may compress portions of the retrochiasmal pathways, causing visual field loss. Cavernous malformations, when in the brainstem, commonly cause abnormalities of supranuclear, nuclear, and fascicular ocular motility.

CONCLUSIONS

The ophthalmologist may be the first physician to encounter clinical manifestations of intracranial vascular abnormalities that may herald devastating neurologic complications. Prompt diagnosis facilitates appropriate management and therapy.

Coil occlusion of arteriovenous fistula of the vertebral artery in a child

A 5-year-old boy with congenital fistula between the right vertebral artery and concomitant veins underwent a successful transcatheter fistula occlusion with a Gianturco coil.

Preliminary experience with an electrolytically detachable fibered coil

We report our preliminary experience with a new embolic device, the electrolytically detachable fibered coil, in the treatment of four patients with high-flow arteriovenous shunting.

[Congestive myelopathy caused by spinal dural arteriovenous fistulas. Anamnesis, clinical aspects, diagnosis, therapy and prognosis]

Congestive myelopathy, formerly referred to as varicosis spinalis or Foix-Alajouanine syndrome, is caused by a spinal dural arteriovenous fistula (SDAVF). So far, the blood supply from the meningeal arteries draining through the fistula into the medullary venous system can only be verified by spinal angiography. Patients predominantly male and over the age of 60 are afflicted. Initially reversible functional disorders caused by the congestion of the spinal cord veins eventually become irreversible, the most common symptom being an increasingly paretic gait disorder, the signs of which generally begin symmetrically and progress from distal to proximal signs. Simultaneously, predominantly transverse sensory dysfunctions develop, as well as bladder and bowel dysfunctions, most often leading to incontinence. MRI typically shows a central medullary signal enhancement with slight swelling of the afflicted region, initially indicative of a reversible congestive edema and later of an irreversible infarction, and extended perimedullar vessels. Thus, if the clinical course and the characteristic MRI findings suggest the possibility of disease related to congestive myelopathy, spinal angiography becomes indispensable. Since ensuing the success of therapy and prognosis depends on rapid determination of the extent of the illness, a speedy diagnostic reaction is mandatory to institute the treatment necessary to prevent paraplegia.

Transvenous embolization of a dural arteriovenous fistula of the cavernous sinus through the contralateral pterygoid plexus

We report a new transvenous endovascular route for treatment of dural arteriovenous fistulas of the cavernous sinus. The cavernous sinus was approached from the contralateral pterygoid plexus and embolization of a dural fistula was performed successfully with Guglielmi detachable coils.

Use of platinum microcoils to embolize vascular abnormalities in children with congenital heart disease

Many vascular anomalies found in children with congenital heart disease can be embolized with catheter-delivered steel coils. Platinum microcoils delivered through a microcatheter broaden the spectrum of lesions amenable to transcatheter closure. Platinum microcoil delivery technique is described, and representative cases demonstrating microcoil utility and benefits are presented.