Embolization of iatrogenic vascular injuries of renal transplants: immediate and follow-up results

PURPOSE

To evaluate the outcome in seven patients in whom iatrogenic vascular complications were treated with catheter embolization.

METHODS

Angiography showed an arteriovenous fistula in six of the seven patients, a pseudoaneurysm in three patients, and an arteriocaliceal fistula in three patients. Embolization was performed with GAW coils or microcoils in all cases. In three patients enbucrilate, polyvinyl alcohol, or absorbable gelatin powder was administered as an adjunct to the coils.

RESULTS

Angiographic success with total occlusion of the vascular injury was achieved in five of the seven patients and clinical success was achieved in four of seven cases. In two cases, nephrectomy after embolization was necessary because of renal artery occlusion or acute hemorrhage at the renal artery anastomosis, respectively. Infarction of 30%-50% of the renal parenchyma was seen in two cases.

CONCLUSION

Angiographically successful embolization is not necessarily associated with clinical success. The complication rate is high.

Direct packing of the isolated sinus in patients with dural arteriovenous fistulas of the transverse-sigmoid sinus

OBJECT

The goal of this study was to evaluate the efficacy of direct packing of the isolated sinus (occluded both distally and proximally) in patients with dural arteriovenous fistulas (AVFs) of the transverse-sigmoid sinus.

METHODS

Eight patients were included in this study. There were seven men and one woman, ranging in age from 47 to 75 years (mean 60.4 years). Five patients presented with intracranial hemorrhage or venous infarction, one with convulsions, and two with pulsatile tinnitus. Prominent retrograde cortical venous drainage due to sinus isolation was angiographically demonstrated in all patients. All patients were treated by a small craniotomy and direct sinus packing with microcoils; the procedure was performed with the aid of digital subtraction angiography. Five patients were pretreated with transarterial embolization to reduce arterial inflow before the procedure, and intrasinus pressure and sinus blood gases were monitored throughout the operation. Postsurgery, the dural AVF was completely obliterated in all patients. The sinus pressure was 29 to 58% of systemic blood pressure, and sinus blood gas levels were purely arterial before packing. There was no morbidity related to direct sinus packing; however, one patient died as a result of acute myocardial infarction. Over a follow-up period ranging from 1 to 5 years, a faint asymptomatic dural AVF recurred in one patient on the cortex adjacent to the occluded sinus but regressed spontaneously within 1 year.

CONCLUSIONS

Direct sinus packing was found to be highly effective for the treatment of dural AVFs that empty into the isolated sinus. Measurement of changes in sinus pressure and sinus blood gas levels was useful for monitoring the progress of direct sinus packing.

Conservative treatment of a traumatic direct low-flow carotid-cavernous sinus fistula: a case report

A case of a 17-year-old boy presenting with a traumatic carotid-cavernous sinus fistula (CCSF), associated with an intracavernous pseudo-aneurysm, is reported. On angiography, the CCSF proved to be a direct and low-flow shunt. Conservative management was chosen and definitive closure of the fistula was obtained in two months by daily self-compression of the common carotid artery.

Posterior spinal artery infarct

Acute medullary syndrome developed in a patient in whom glue had been inadvertently injected into the right posterior radiculomedullary artery during endovascular occlusion of a spinal dural arteriovenous fistula at T-11. MR imaging 40 days after the procedure showed signal changes and contrast enhancement in the posterior and right lateral column at T10-11. Circumscribed signal changes in the same areas without contrast enhancement were seen 4 months later. MR imaging was able to show this posterior spinal artery infarct.

Selective transvenous embolization of dural fistulas without occlusion of the dural sinus

Two patients with dural arteriovenous fistulas (DAVFs) and unsuccessful transarterial embolizations were treated with a technique for selective transvenous embolization. A 5F catheter was advanced from a femoral vein access into the internal jugular bulb and a catheter was navigated through the sinus lumen into the involved cortical veins or the parasinusal venous draining channels of the DAVFs. The venous recipients at the nidal level of the DAVFs were occluded by fibered platinum coils. Complete angiographic cure was effected in both patients, with occlusion of the venous recipients and the nidus, although the sinus segments next to the nidus of the DAVFs remained patent. Placement of coils in a transsinusal route into the venous channel of a DAVF yet outside the sinus lumen can result in complete obliteration of the fistula without damage to the physiological function of the dural sinuses.

Congenital arteriovenous fistula of internal thoracic artery: successfully managed by transcatheter embolization

An asymptomatic young woman was found to have a continuous machinery murmur over the second right interspace near the sternum. Investigations showed an arteriovenous fistula involving the right internal thoracic artery and accompanying vein. Selective transcatheter embolization was successfully performed.

[Cavernous dural fistulas: Importance of trans-ocular Doppler ultrasound in evaluating venous patency and therapeutic choices]

Transcranial Duplex scan is a relatively recent diagnostic tool with many unexplored clinical potentials. The authors insist on the role of transocular exploration, as a non-invasive substitute to angiography and discuss two patients with cavernous meningeal arteriovenous fistula, a benign but relatively uncommon disease. In the first patient, in whom symptoms recurred, Duplex scan was able to rule out thrombophlebitis and to show increased flow in the fistula, thus leading to proper treatment. In the second patient, the identification of a periorbital thrombophlebitis innocented the fistula and prompted anti-coagulation. We conclude that besides its diagnostic capabilities, Duplex scan may be helpful in selecting proper treatment and follow-up in specific neurovascular conditions.

Traumatic carotid cavernous fistula: anatomical variations and their treatment by detachable balloons

Endovascular balloon occlusion has become a standard mode of therapy in carotid cavernous fistulas. Many angioarchitectural variations are, however, encountered in individual cases, some of which influence the therapeutic mode and outcome. We report on three patients with carotid cavernous fistulas treated by endovascular techniques.

[Arteriovenous fistula after endoscopic dissection of the perforant vein of the lower leg with the neodymium:YAG laser in chronic venous stasis syndrome]

The endoscopic dissection of the perforating veins has been invented by Hauer in the last decade. He introduced the videoendoscopy to this surgical procedure. The avoidance of operative access through areas of trophic changes is very beneficial for reducing postoperative complications. Although postoperative thermic lesion have been reported on. Following an endoscopic laser coagulation of a Cockett perforating vein an arterio-venous fistula between the posterior tibial artery and vein developed by the mechanism mentioned. Persisting pain and the persistence of the ulcer led to several diagnostic measures including phlebography, digital subtraction angiography and CT-scan. After the fistula had been closed successfully by percutaneous embolization with four platin wires the ulcer disappeared.

Spontaneous hemothorax in a hemodialysis patient

An 8-year-old girl who had undergone chronic hemodialysis for 1 year presented with respiratory distress 24 h after a hemodialysis session. She had a massive pleural effusion of the left chest that was shown to be hemothorax by thoracentesis. After chest tube insertion, drainage was maintained for 2 days. Pleural effusion recurred after withdrawal of the chest tube. The antecubital arteriovenous fistula on the left arm was found to have an excessive flow with a thrill which was felt all over her left shoulder and left hemithorax. The pleural effusion resolved spontaneously a week after ligation of the fistula. Excessive flow in the arteriovenous fistula was thought to be the cause of the hemothorax and should be included in the differential diagnosis of hemothorax in hemodialysis patients.

Idiopathic renal arteriovenous fistula: treatment with embolization

We report a case of idiopathic renal arteriovenous fistula revealed by microscopic hematuria in a 36-year-old man with no predisposing history. Treatment with selective embolization achieved complete resolution with no parenchymal damage.

Pulmonary arteriovenous fistula: long-term results of percutaneous transcatheter embolization with spring coils

PURPOSE

The aim of this study was to assess the effectiveness of percutaneous treatment of PAVFs through the results of long-term follow-up.

PATIENTS AND METHODS

Transcatheter embolization of PAVFs using spring coils was performed in seven patients (six women and one man) with nine PAVFs, between 1989 and 1995, who were followed up at least one year. The size of the nine PAVFs ranged from 4 mm to 70 mm in diameter (mean 26 mm). Two fistulas were huge, 70 x 45 mm and 60 x 65 mm in diameter. Embolization was performed twice in three patients and once in four patients. In the two patients with huge PAVFs, after anchoring metallic "spiders" into the feeding artery, the largest coils were positioned and entangled with the "spider" followed by the placement of smaller coils to fill in the center of the feeding artery.

RESULTS

No severe complications were seen in the short-term follow-up. Arterial oxygen pressure improved in all patients with low oxygen pressure. Five patients with seven fistulas, six of which disappeared on chest X-ray film, are still alive after follow-up ranging from one year and 10 months to seven years and nine months. The two patients with huge fistulas died more than one year after treatment, one of hemoptysis of the contralateral lung and the other of pulmonary fibrosis.

CONCLUSION

Complete embolization of a medium-sized feeding artery can cure this anomaly.

Coil embolization of a trigeminal-cavernous fistula

A 53-year-old woman spontaneously incurred a right trigeminal artery-cavernous sinus fistula, manifested by an intracranial bruit and right sixth nerve palsy. This lesion was successfully managed by coil embolization via the transvenous and transarterial routes.

Cure of renovascular hypertension by percutaneous occlusion of a large idiopathic renal arteriovenous fistula. Case report

Percutaneous balloon occlusion of a large hypertensive idiopathic renal arteriovenous fistula is reported. A lumbar thrill was noted in a 52-year-old hypertensive woman. Intravenous digital substraction angiography identified the lesion. After arteriographic assessment a percutaneous embolisation was performed with a releasable balloon positioned on a coaxial micro-catheter. Immediate post-procedural angiographic control demonstrated complete occlusion with a small segmental area of renal hypoperfusion. The lumbar thrill disappeared. Normalisation of the blood pressure was noted two days later and confirmed eight months later. Persistent occlusion of the fistula was angiographically confirmed, whereas the area of renal hypoperfusion had partially decreased. Releasable balloon percutaneous embolisation appears to be a safe alternative to surgery in the treatment of large renal arteriovenous fistulas.

Severe vision loss and neovascular glaucoma complicating superior ophthalmic vein approach to carotid-cavernous sinus fistula

PURPOSE

To report a patient with unilateral vision loss and neovascular glaucoma after attempted superior ophthalmic vein embolization in the treatment of a carotid-cavernous sinus fistula.

METHODS

A 69-year-old man with a history of a left dural carotid-cavernous sinus fistula underwent attempted treatment with superior ophthalmic vein embolization. The procedure was unsuccessful, and the left superior ophthalmic vein was ligated.

RESULTS

Uncontrolled left proptosis and intraocular pressure necessitated urgent orbital decompression with severe vision loss and neovascular glaucoma.

CONCLUSION

Superior ophthalmic vein embolization in the management of carotid-cavernous fistula may be associated with vision-threatening complications.

Percutaneous transvenous coil embolization of a type 4 sagittal sinus dural arteriovenous fistula: case report

OBJECTIVE AND IMPORTANCE

To present an alternative endovascular therapy for a Type 4 sagittal sinus dural arteriovenous fistula (DAVF).

CLINICAL PRESENTATION

A 74-year-old man presented with right facial paresthesias. Magnetic resonance imaging revealed an enlarged left parasagittal cortical vein adjacent to the superior sagittal sinus. Angiography demonstrated a Type 4 sagittal sinus DAVF.

INTERVENTION

The DAVF was cured using percutaneous transvenous coil embolization.

CONCLUSION

This case represents the first report in which a sagittal sinus DAVF was cured using a percutaneous transvenous endovascular approach.

Wallstents and Craggstents in hemodialysis grafts and fistulas: results for selective indications

PURPOSE

To report the value of selective placement of self-expandable stents (Wallstent and Craggstent) for the treatment of limitations and, occasionally, of complications of dilation in hemodialysis access, and especially for delaying restenosis.

MATERIALS AND METHODS

This is a retrospective study of a 7-year period, during which 41 Wallstents and 11 Craggstents were placed in 26 polytetrafluoroethylene (PTFE) grafts, 15 native fistulas, and nine central veins of 47 patients. The indications were stenosis recoil (n = 13), recurrent restenosis within 6 months (n = 33), restenosis after 6 months (n = 3), and acute angioplasty-induced rupture (n = 1). Restenosis after stent placement necessitated redilation and percutaneous declotting and 10 additional stent placements.

RESULTS

Two initial misplacements were corrected immediately. Primary patency rates for PTFE grafts were 58% +/- 10% at 6 months and 23% +/- 10% at 1 year, respectively. Secondary patency rates were 100% at 6 months and 88% +/- 8% at 1 year, respectively. For native fistulas, primary patency rates were 47% +/- 12% at 6 months and 20% +/- 18% at 1 year. Secondary patency rates were 95% +/- 6% at 6 months and 79% +/- 14% at 1 year. It was necessary to reintervene after stent placement to maintain or to restore patency every 9 months for PTFE grafts and every 7.3 months for native fistulas. When stents were placed for treatment of early recurring restenosis, the mean interval between radiologic interventions (redilations or declottings) performed to maintain or to restore patency before stent placement was multiplied by 2.1 after stent placement for both grafts (3.2 months increased to 6.9, P < .01) and native fistulas (2.9 months increased to 6.2, P < .02).

CONCLUSIONS

Wallstents and Craggstents are valuable for the treatment of failure of regular dilation and they double the intervals between reinterventions for early (< 6 months) recurring stenoses in PTFE grafts and native fistulas.

Diagnosing and monitoring carotid cavernous fistulas with color Doppler imaging

Color Doppler imaging allows simultaneous bidimensional imaging and Doppler evaluation of blood flow in orbital vessels. We report 4 cases in which color Doppler imaging was used to diagnose and monitor carotid cavernous fistulas. In all cases, color Doppler imaging demonstrated dilated, arterialized superior ophthalmic veins; these findings were confirmed by angiography. Two patients underwent embolization with complete regression of the clinical findings. After embolization, color Doppler imaging revealed normal, laminar flow in the superior ophthalmic vein. This noninvasive technique represents a safe and fast method that is useful in the diagnosis and post-treatment follow-up of carotid cavernous fistulas.

[Symptomatic arteriovenous fistula of the thyrocervical trunk. A rare complication after implanting a subclavian catheter]

After the incidental puncture of a sidebranch of the thyreocervical trunk during a subclavian vein catheterization, a symptomatic avfistula developed. The diagnosis was confirmed by angiography. Using a microcatheter system the fistula was occluded with micro-coils.

Arteriovenous shunt measurement during endovascular therapy for cerebrospinal lesions

PURPOSE

To determine (a) whether superselective angioscintigraphy with technetium-99m macroaggregated albumin (99mTc-MAA) can be used for the evaluation of arteriovenous shunting in tumors and vascular malformations of the head and spine and (b) whether the amount of microparticles shunted is related to diagnosis, lesion size, or angiographic pattern.

METHODS

Particles of 99mTc-MAA with a calibrated diameter of 25 to 50 microm were delivered intraarterially in feeders of head and spine tumors and vascular malformations in 38 patients. The first estimation of the proportion of particles reaching the lungs was made on-line in the angiography suite using a hand-held lead-shielded detector. Evaluation of the intralesional shunt (pulmonary shunt index, or PSI) was derived from quantitative gamma camera recordings of tumoral and pulmonary activity after the embolization procedure was complete.

RESULTS

The PSI value ranged from 48% to 100% for vascular malformations and vascular tumors (n = 11), 82% to 95% for juvenile angiofibromas (n = 4), 63% to 70% for high-grade gliomas (n = 2), 0% to 50% for renal cell carcinoma metastases (n = 4), 0% to 86% for meningiomas (n = 11), and 0% to 36% for paragangliomas (n = 6). Angiographically, the presence of visible arteriovenous channels was predictive of a high PSI. In contrast, the presence of early venous drainage was associated with a wide PSI range.

CONCLUSION

Superselective 99mTc-MAA angioscintigraphy of tumors and vascular malformations of the head and spine is a valuable method for quantifying an intralesional arteriovenous shunt before embolization.

The arterioportal fistula syndrome: clinicopathologic features, diagnosis, and therapy

BACKGROUND & AIMS

Arterioportal fistulas (APFs) are rare vascular disorders of the mesenteric circulation. The aim of this study was to determine the etiology, anatomical location, and main symptom at presentation of APFs, and analyze the various modes of treatment.

METHODS

The etiology, clinical presentation, radiographs, and treatment of 12 patients with APFs are reported in detail, and another 76 cases published since 1980 are reviewed.

RESULTS

APFs result from trauma (n = 25, 28%), iatrogenic procedures (n = 14, 16%), congenital vascular malformations (n = 13, 15%), tumor (n = 13, 15%), aneurysm (n = 12, 14%), and other causes (n = 11, 12%). The origin of APFs is the hepatic artery in the majority of patients (n = 56, 65%). The main symptoms at presentation are lower or upper gastrointestinal bleeding (n = 29, 33%), ascites (n = 23, 26%), heart failure (n = 4.5%), or diarrhea (n = 4.5%). Radiological intervention provides definitive treatment in 42% (n = 33) of patients, whereas the remainder are treated by surgery alone (n = 27, 31%) or a combination of radiological intervention and surgery (n = 8, 9%).

CONCLUSIONS

APFs result in a protean syndrome variously combining portal hypertension and other hemodynamic imbalances (heart failure, intestinal ischemia). Single or multiple interventional radiological procedures using arterial and/or venous approaches allow definitive treatment of most APFs. With increasing technological advances, it is anticipated that surgery will only be indicated in rare instances after failure of radiological intervention(s).