Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas

Comparison of Open and Endovascular Aneurysm Repair in Native Arteriovenous Fistulas

BACKGROUND

Arteriovenous accesses develop aneurysms (FA) during their active use, resulting in pain, erosion, bleeding, and difficulty in cannulation. This study aims to evaluate the outcomes of open and endovascular management of single FA in arteriovenous fistulas (AVF).

METHODS

A retrospective review of all upper extremity primary AVFs over 12 years was undertaken at a single center. Patients undergoing elective open and endovascular repair of a single FA were identified. Thirty-day outcomes, cannulation failure, line placement, re-intervention, and functional dialysis (continuous hemodialysis) for 3 consecutive months were examined.

RESULTS

Three hundred and seventy nine patients presented with a single FA that met the requirements for intervention: 126 (33%) underwent endovascular repair, and the remainder 253 (67%) underwent open repair. Preoperative fistulogram identified anatomically significant issues in 91% of the cases, and these were treated by balloon angioplasty: 10% within the fistula tract, 44% within the outflow tract, and 47% in the central veins. In open repair, 57% underwent plication, 35% underwent resection and re-anastomosis, and the remainder (8%) underwent interposition grafting. In endovascular repair, successful placement of a stent was achieved in all cases with 1 ± 2 (mean ± standard deviation [SD]) covered stents (diameter: 6 -8 mm) placed, achieving successful exclusion of the FA. The combination of early thrombosis and cannulation failures led to the greater need for a tunneled central line in endovascular repair (6.5% vs. 2.4%; endovascular versus open repair; P = 0.04). As a result, the mean time for establishing renewed access in the index AVF was significantly higher in endovascular repair (2 ± 3 vs. 2 ± 2 weeks, mean ± SD; endovascular open repair versus open repair; P = 0.001). In follow-up, there were more secondary interventions per year in the endovascular compared to open repair groups (3.1 vs. 1.4 secondary interventions per year; endovascular versus open repair; P = 0.04). Median functional dialysis durations were superior in the open repair (48 ± 6%, mean + standard error) compared to the endovascular repair at 5 years. (26 ± 7%; P = 0.03).

CONCLUSIONS

Open repair results in a more rapid return to access use, lower need for a tunneled central line, lower secondary re-intervention rates, and superior functional dialysis durations compared to endovascular repair. Open FA repair should be considered for symptomatic single FA repairs before endovascular FA repair.

Comparison of three different treatment methods for traumatic and Iatrogenic peripheral artery pseudoaneurysms

Objective

To compare the efficacy of open surgery (OS), endovascular interventions (EIs), and ultrasound‐guided thrombin injection (UGTI) for the treatment of peripheral arterial pseudoaneurysms (PAs).

Methods

From January 1, 2001, to February 10, 2021, 38 patients diagnosed with traumatic and iatrogenic PAs treated with OS, EI, and UGTI were retrospectively analyzed. There were 18 females and 20 males, with an age of 56.47 ± 14.08 years (range,17–87 years). Anesthesia modality, operation duration, blood transfusion, duration of hospital stay, primary and secondary success rates, and complication rate were used to evaluate the surgical outcomes.

Results

There were 11 cases under regional anesthesia and 4 under general anesthesia in OS group, 9 under regional anesthesia and 1 under general anesthesia in EI group, and no regional or general anesthesia was required in UGTI group. There was no significant differences between any two groups (χ² = 39.80, p < 0.05). The blood tranfusion amount (units) were 3.6 ± 6.0, 0.8 ± 2.5, 0.0 ± 0.0 for OS, EI, and UGTI groups, respectively, with significant difference between OS and UGTI groups (F = 3.03, p < 0.05). The operation duration (minutes) of OS, EI, and UGTI groups were 80.0 ± 41.9, 56.0 ± 8.4, and 22.7 ± 5.3, respectively, with significant difference between any two groups (F = 15.69, p < 0.05). The duration of hospital stay (days) were 47.7 ± 39.0, 31.5 ± 17.6, and 16.3 ± 9.5, repectively, with significant difference between any two groups (F = 47.73, p < 0.05). The primary clinical success rates were 80% (12/15), 90% (9/10), and 92.3% (12/13) in OS,EI, and UGTI groups, respectively, with no significant difference between any two groups (χ² = 0.34, p > 0.05). The secondary clinical success rates were 100% for all three groups. The overall complication rates of OS, EI, and UGTI groups were 20% (3/15), 10% (1/10), and 7.7% (1/13), respectively, with no significant difference between any two groups (χ² = 1.00, p > 0.05). The infection rates were 13.3% (2/15), 10% (1/10), and 0% (0/13) in OS, EI, and UGTI groups respectively, with no significant difference between any two groups (χ² = 1.80, p > 0.05). The reintervention rates were 6.7% (1/15), 0% (0/10), 7.7% (1/13) in OS, EI, and UGTI groups, respectively, with no significant difference between two groups (χ² = 0.95, p > 0.05). Neuralgia was relieved in all patients.

Conclusions

OS, EI, and UGTI are efficacious and safe options for the treatment of appropriate patients with traumatic and iatrogenic PAs. UGTI would be considered as a first‐line therapy for this condotion.

Acute right upper extremity ischemia resulting from true aneurysmof right brachial artery: A case report

We report a case of 66-year-old woman with true aneurysm of the right brachial artery. She presented with acute upper extremity ischemia. The hand was cold and parenthesized and distal pulses were absent. CT angiography (CTA) revealed a 20*25 mm true brachial artery aneurysm. The aneurysm was thrombosed without distal run-off. We excised the aneurysm and reestablished the arterial flow by a reverse saphenous interposition graft. The postoperative course was uneventful.

Iatrogenic subclavian arteriovenous fistula during permanent pacemaker implantation: Closed by endovascular coiling

Iatrogenic arteriovenous fistula is a unique complication during pacemaker implantation. A 55-year-old man was posted for pacemaker implantation for recurrent unexplained syncope with trifascicular AV block. After axillary/subclavian venous puncture and introduction of RV lead, arterial spurting was immediately noticed as the the sheath was peeled away. After dissecting the overlying pectoralis muscle, deep sutures and manual compression achieved hemostasis. However, Subclavian arteriogram revealed an arteriovenous fistula from a lateral thoracic artery branch to the innominate vein. Hilal coils were deployed near the fistulous orifice, leading to complete resolution of the leak. After 3 days, pacemaker was implanted from right side. A multidisciplinary approach was the key to successful outcome.

Endovascular Repair of Incidentally Found Subclavian Artery Aneurysm: A Case Report From an Urban Level 1 Trauma Center

Subclavian artery aneurysms (SAAs) are historically rare peripheral aneurysm. However, it can be associated with serious life-threatening complications including rupture, thrombosis, and embolism. The majority of such aneurysms are found incidentally. Historically, SAA have been repaired via an open approach. Increasing case reports demonstrate successful management of SAAs with endovascular repair. The present report describes a case of incidentally discovered large proximal saccular subclavian aneurysm with suspected remote traumatic etiology with a successful endovascular repair.

Utilization of stent grafts in the management of arteriovenous access pseudoaneurysms

Objective Endovascular stent graft repair for exclusion of pseudoaneurysm is currently being explored to replace open surgical repair as current management. The objective of the study was to evaluate the clinical safety and efficacy of endovascular stent graft intervention in pseudoaneurysms complicating arteriovenous reconstructions in patients on chronic hemodialysis. Methods A retrospective analysis of all pseudoaneurysms treated with stent grafts at our institution over a period of five years was performed. The indications for endovascular intervention included bleeding from the pseudoaneurysm, infection, and significant skin compromise overlying the pseudoaneurysm or combination of the above. The rates of technical success, complication, and primary patency were measured at one-week, one-month, and six-month follow-up. Results A total of 33 endovascular stent graft interventions in 29 patients were performed for the treatment of pseudoaneurysms. The average age of patients was 68 years (range 31-90 years), with 13 female. Diabetes and hypertension were present in 15 and 22 patients, respectively. In eight patients, there was evidence of active infection at the fistula site. The choice of stent grafts include Viabahn ( n = 31), Wallgraft ( n = 1), and i-Cast ( n = 1). The initial technical success rate was 94%. The two failed interventions included occlusion of inflow artery with immediate conversion to open procedure ( n = 1) and incomplete pseudoaneurysm exclusion ( n = 1). Primary patency at one month and six months was 83 and 60%, respectively. An additional balloon angioplasty of outflow tract or central stenosis was performed in 18 cases (54%). The explanation of stent grafts due to persistent or recurrent bacteremia/site infection was required in four out of eight patients. The average time to explanation was 93 days (range 6-204 days). Conclusion The stent graft implantation is a safe, minimally invasive and efficient way to control and manage arteriovenous accesses with pseudoaneurysms. In the presence of infection, this approach may be less durable.

Giant true aneurysm of superficial femoral artery in patient with multiple atherosclerotic aneurysms: A case report

True atherosclerotic aneurysms of superficial femoral artery (SFA) are rare and often associated with other peripheral or aortic aneurysms. We report the case of a 84-year-old patient presenting a giant degenerative ruptured aneurysm of the superficial femoral artery. The patient underwent successful aneurysm resection and bypass grafting, with a satisfying long-term follow-up and patency of the graft. The patient was also operated one year before, for a ruptured aneurysm of the abdominal aorta. This case report is rare, because we described a case of patient with multiple atherosclerotic aneurysms, who present, for the second time, a life threating ruptured aneurysm. In this report, we see extreme and rapid evolution of SFA Aneurysm before being symptomatic. Degenerative aneurysms of the lower extremity most commonly involve the popliteal artery, while they are rarely detected in the femoral region (Leon et al., 2008). In this region, aneurysms most frequently involve the common femoral artery (CFA), whereas true aneurysms of the superficial femoral artery (SFA) represent only 15% to 25% of femoral arterial aneurysms [1-5]. Degenerative aneurysms of the SFA display peculiar characteristics (in terms of clinical onset, diagnostic timing, and clinical behavior) so that they differ from other peripheral aneurysms. Because the relative rarity of this location, our case report can be useful to participate to increase the number of reported cases, and define the therapeutic approach for this rare location.

Endovascular Exclusion of Popliteal Artery Aneurysms With Expanded Polytetrafluoroethylene Stent-Grafts: Early Results

There is increasing interest in using endovascular methods instead of surgical reconstruction to treat popliteal artery aneurysms. Exclusive use of the Viabahn stentgraft, a nitinol stent covered with expanded polytetrafluoroethylene, was assessed in the treatment of patients who presented with popliteal artery aneurysms in the absence of acute limb ischemia. Technical success, endoleaks, graft patency, freedom from amputation, and aneurysm sac flow and size changes were assessed by duplex ultrasound. From June 2004 to March 2006, 16 men (mean age, 76 years; range, 65-83) underwent endovascular exclusion of 23 popliteal artery aneurysms (mean diameter, 2.5 cm; range, 1.3-6.7 cm). Nine lesions had partial thrombus on preprocedural duplex imaging. Nineteen of the 23 limbs treated had at least 2-vessel tibial artery runoff. Procedures were performed under local anesthesia using ipsilateral percutaneous antegrade arterial access. All patients received 75 mg/day of clopidogrel afterward. Follow-up assessments included direct clinical examinations and duplex ultrasonography performed 1, 3, 6, and 12 months after the procedure. Primary patency and amputation-free survival were calculated using Kaplan-Meier analysis. Complete aneurysm exclusion (technical success) was achieved in all cases. During the mean follow-up of 7 months (range, 1-21 months), 22 of 23 treated limbs remained asymptomatic. One stent-graft thrombosis occurred 6 months after the procedure and was successfully treated with percutaneous mechanical thrombectomy, balloon angioplasty of a stent-graft stenosis, and insertion of an uncovered nitinol stent. No popliteal artery aneurysm sac size enlargements or endoleaks were detected. At 12 months, the treated limb mean anklebrachial index was 1.0 (range, 0.82-1.31) and the primary and secondary patency rates were 93% and 100%, respectively. Early results with Viabahn endovascular stent-graft exclusion of asymptomatic popliteal artery aneurysms are promising. Patient selection for endovascular repair depends on suitable popliteal artery anatomy, extent of aneurysmal degeneration, and quality of tibial arterial runoff.

Role of Vascular and Interventional Radiology in the Diagnosis and Management of Acute Trauma Patients

Vascular and interventional radiology provides an important service in the diagnosis and management of the acute trauma patient. Historically angiography was used primarily as a diagnostic tool for both vascular and solid organ injuries. However, with technological advances, such as the advent of stents, stent grafts, newer embolization materials and sophisticated delivery devices, micro-catheters, and steerable guide wires, vascular and interventional radiology can now offer definitive treatment in selected cases. Transcatheter embolization can effectively treat acute hemorrhage and is useful in locations that are difficult to access surgically, or when surgical disruption of fascial planes, which may eliminate a tamponade effect, is less desirable. Stents and stent grafts have been used to preserve, rather than sacrifice, an injured blood vessel. In splenic, hepatic, and renal trauma, a trend in nonoperative management has been developed by traumatologists. Transcatheter embolization can increase the success rate of nonoperative management in selected injuries. In general, despite the injury grade, if evidence of ongoing hemorrhage is present, angiography and transcatheter embolization should be considered. Peripheral vascular injuries can be treated with transcatheter embolization or stents and stent grafts. Transcatheter embolization in trauma was first applied to bleeding associated with pelvic fractures and dislocations, and continues to be an important treatment option. Carotid and vertebral artery injuries can now be repaired using stents or stent grafts, although the experience of this treatment strategy is somewhat limited. Likewise, acute traumatic aortic injury has been successfully treated with stent grafts in small series. Conventional catheter thoracic aortography is now used as an adjunctive diagnostic test for indeterminate or questionable findings on noninvasive imaging studies, primarily computed tomography scans of the chest. In summary, vascular and interventional radiology maintains an important role in the diagnosis and management of acute vascular and solid organ injury. The following review illustrates its current status in acute trauma.

Initial Experiences with Percutaneous Endovascular Repair of Popliteal Artery Lesions Using a New PTFE Stent-Graft

Purpose:

To report the percutaneous endovascular management of popliteal artery lesions with a new polytetrafluoroethylene (PTFE) stent-graft.

Methods and Results:

Three patients have undergone endovascular treatment in the popliteal region owing to: (1) an iatrogenic false aneurysm with arteriovenous fistula, (2) entrapment syndrome, and (3) an isolated arterial aneurysm. In each case, arterial occlusion was treated initially with thrombolysis. The underlying vascular lesions then were stented using the new Hemobahn endograft, a nitinol stent covered internally with PTFE. Each percutaneous procedure was completed successfully without major complications. During early follow-up (6 to 7 months), no signs of intimal hyperplasia, occlusion, or stent migration have been observed.

Conclusions:

Based on these early experiences, percutaneous treatment of stenotic and aneurysmal lesions in the popliteal artery using the Hemobahn endograft appears feasible and effective. Further experience and longer follow-up are required to evaluate this new prosthesis.

Open versus Endovascular Repair of Para-Anastomotic Aneurysms in Patients Who Were Morphological Candidates for Endovascular Treatment

Purpose:

To compare the outcomes of open versus endovascular repair of para-anastomotic aneurysms (PAA) in the aortic and iliac arteries in a cohort of patients who fulfilled morphological criteria for endovascular repair.

Methods:

A retrospective review of 31 consecutive patients with PAA treated between 1985 and 2002 identified 26 (84%) patients who would have been candidates for endovascular repair based on preoperative computed tomography and angiography. Of these 26 patients, 10 (9 men; median age 65 years, range 60–75) underwent endovascular repair; the remaining 16 patients (14 men; median age 61.5 years, range 49–78) had open repair. The baseline data and outcome measures were compared between the treatment groups.

Results:

The patient groups were well matched for age, sex, weight, risk factors, comorbidities, aneurysm length, and elapsed time from initial graft placement. Both groups had technically successful PAA repairs; however, median blood loss (300 versus 1000 mL; p = 0.05) and procedural time (100 versus 215 minutes; p<0.001) were significantly reduced in the endovascular group. Median transfusion volume was significantly greater (1000 versus 0 mL; p = 0.01) in the surgically treated patients. The median stay in ICU was similar (18 versus 24 hours in the surgical cohort). Length of stay was significantly shorter in the endovascular group: 7.5 versus 17.0 days (p = 0.001) after the repair and 11 versus 22 days (p = 0.01) for overall hospitalization. One (10%) patient in the endovascular group died from a myocardial infarction on the third postoperative day. In the open group, there were 3 (19%) procedure-related deaths.

Conclusions:

Patients with PAA who were endograft candidates but who were treated with open repair experienced more morbidity and had more complications than patients treated with stent-grafts. If long-term follow-up demonstrates durable results, stent-graft repair may become the therapy of choice in PAAs.

Transluminal Stent-Graft Repair for Pseudoaneurysm of PTFE Hemodialysis Grafts

Purpose:

To report the use of endovascular techniques to treat two cases of nonanastomotic pseudoaneurysm of a bridge graft fistula (BGF).

Methods and Results:

Two men with fully functional polytetrafluoroethylene (PTFE) BGFs both presented with an enlarging mass adjacent to their arteriovenous shunt. The false aneurysm in both instances was located by ultrasound and confirmed by shunt angiography at the time of surgery. Both fistulas were repaired by transluminally introducing a stented graft composed of a balloon-expandable Palmaz stent covered with a PTFE graft. Completion arteriography confirmed normal flow through the graft with no communication between the lumen and the aneurysmal cavity. Both patients recovered without complications and were discharged on the day of the procedure. Follow-up data reveal that both fistulas remain fully functional up to 5 and 6 months, respectively.

Conclusions:

Endovascular repair using stent-grafts can be a safe and effective method of excluding pseudoaneurysms associated with PTFE BGFs.

Popliteal artery pseudoaneurysm treated with covered stent placement and thrombolysis: a case report

Pseudoaneurysms of the popliteal artery are a rare clinical entity, accounting for <4% of all popliteal aneurysms. Accurate diagnosis and effective intervention is required to prevent potentially limb-threatening complications. We present the case of a 37-year-old man with acute limb ischaemia due to distal calf vessel thrombosis secondary to a popliteal pseudoaneurysm that was managed with covered stent placement and thrombolysis.

Donor Artery Aneurysm Formation following the Ligation of Haemodialysis Arteriovenous Fistula: A Systematic Review and Case Reports

Purpose

The purpose of this study is to investigate the pathogenesis, presentation and diagnosis of donor artery aneurysm formation following arteriovenous fistula (AVF) ligation and reach a consensus on their management.

Methods

A systematic review of literature in Ovid, MedLine, Embase, Scopus and CINHAL in the English language from 1951 to 2014 was performed. This was accompanied by two case reports. A total of 12 articles with 23 case reports were identified. Variables including patient's demographics, signs, symptoms, fistula type, duration of fistula use, time to aneurysm formation, renal transplantation, diagnostic modality, aneurysm type and size, type of surgery and outcome were reviewed.

Results

The data demonstrate a male predominance (5:1) and a median age of 47 years (range, 27-75 years). The median duration of access was 54 months (range, 6-300 months). The median time from ligation to aneurysm was 120 months (range, 6-280 months). The commonest aneurysm was of the brachial artery (BA, n = 21, 84%). The commonest type of AVF was radiocephalic (n = 15, 60%) followed by brachiocephalic AVF (n = 9, 36%). The management of choice was aneurysmectomy followed by interposition vein grafting (n = 12, 50%) with a median reported patency of 12 months (range, 1-38 months). This was followed by polytetrafluoroethylene (PTFE) grafting (n = 6, 25%) with a median reported patency of 6 months (range, 1-48 months).

Conclusions

The pathogenesis of donor artery aneurysms remains contentious. This review suggests that duplex is the investigative modality of choice and aneurysmectomy with interposition grafting is preferred over bypass.

Percutaneous cyanoacrylate glue embolization for peripheral pseudoaneurysms: an alternative treatment

Post-traumatic pseudoaneurysms are rare in the peripheral arteries and usually occur as a late sequel of trauma. Surgery has traditionally been considered as the gold standard of therapy for traumatic peripheral pseudoaneurysms. We report 2 cases of post traumatic pseudoaneurysms successfully treated by percutaneous cyanoacrylate glue (N-Butyl 2 cyanoacrylate) embolization. This method offers complete exclusion of the pseudoaneurysm, at the same time avoiding the morbidity of open surgery.

Dissecting pseudoaneurysm of the proper hepatic artery repaired by primary anastomosis: a case report

Background. Although rare, visceral artery pseudoaneurysms often present as surgical emergencies with a specific mortality rate as high as 35% related to aneurysmal rupture. Risk factors for the development of iatrogenic pseudoaneurysms include anticoagulation, female gender, obesity, and vessel calcification. Case Report. We present a case of an elderly female who developed a dissecting pseudoaneurysm of the proper hepatic artery after undergoing routine surgery to resect a large duodenal adenoma. Surgical repair comprised of resection and primary anastomosis was employed resulting in a favourable outcome. Discussion/Conclusion. Surgical management reduces the risk of hepatic ischemia, biliary complications, and abscess formation. Although stenting, coil embolization, and thrombin injection are all plausible options for management, we propose that surgical reconstruction be considered seriously as a treatment for such spontaneous pseudoaneurysms.

Endovascular management of axillo-subclavian arterial injury: a review of published experience

BACKGROUND

The role of endovascular treatment for vascular trauma, including injury to the subclavian and axillary arteries, continues to evolve. Despite growing experience with the utilization of these techniques in the setting of artherosclerotic and aneurysmal disease, published reports in traumatic subclavian and axillary arterial injuries remain confined to sporadic case reports and case series.

METHODS

We conducted a review of the medical literature from 1990 to 2012 using Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of subclavian or axillary artery injuries. Thirty-two published reports were identified. Individual manuscripts were analysed to abstract data regarding mechanism, location and type of injury, endovascular technique and endograft type utilized, follow-up, and radiographic and clinical outcomes.

RESULTS

The use of endovascular stenting for the treatment of subclavian (150) or axillary (10) artery injuries was adequately described for only 160 patients from 1996 to the present. Endovascular treatment was employed after penetrating injury (56.3%; 29 GSW; 61 SW), blunt trauma (21.3%), iatrogenic catheter-related injury (21.8%) and surgical injury (0.6%). Injuries treated included pseudoaneurysm (77), AV fistula (27), occlusion (16), transection (8), perforation (22), dissection (6), or other injuries otherwise not fully described (4). Initial endovascular stent placement was successful in 96.9% of patients. Radiographic and clinical follow-up periods ranging from hospital discharge to 70 months revealed a follow-up patency of 84.4%. No mortalities related to endovascular intervention were reported. New neurologic deficits after the use of endovascular modalities were reported in only one patient.

CONCLUSION

Endovascular treatment of traumatic subclavian and axillary artery injuries continues to evolve. Early results are promising, but experience with this modality and data on late follow-up remain limited. Additional multicenter prospective study and capture of data for these patients is warranted to further define the role of this treatment modality in the setting of trauma.

Chronic ischaemic leg ulcer as a late complication of post-traumatic arteriovenous fistula

OBJECTIVE

Chronic post-traumatic arteriovenous fistula (AVF) is a late complication of vascular injury and can be presented with symptoms of congestive heart failure, venous hypertension and distal ischaemia. We present an unusual case of chronic ischaemic leg ulcer in young adult caused by post-traumatic AVF. Case report A 29-year-old male patient was admitted to our hospital with symptoms of chronic ulcer located on the lateral side of the lower left leg. Arterial pulses distally from the groin were absent. His medical history revealed him to have sustained gunshot injury of the left thigh in the war conflict 18 years before. Angiography showed a large AVF between superficial femoral artery and femoral vein. The patient underwent surgical repair of AVF with reconstruction of superficial femoral artery by saphenous vein interposition under spinal anaesthesia. Completion angiography confirmed AVF exclusion. Leg ulcer healed within a month.

CONCLUSION

Chronic leg ulcer may be the only symptom of large post-traumatic AVF in young adults.

An Isolated True Aneurysm of the Superficial Femoral Artery in a Young Woman - A case report -

A 39-year-old woman was admitted to the hospital due to a pulsatile mass on her right inner thigh that was evident for two months. She did not exhibit any risk factors of atherosclerosis, no evidence of vasculitis, or any signs of previous trauma history. Ultrasound and computed tomography revealed an adult fist-sized aneurysm on the distal superficial femoral artery. The aneurysm was resected and peripheral circulation was restored with the interposition of a saphenous vein graft. The resected aneurysm had three layers that showed atherosclerosis on histological examination.

False traumatic aneurysms and arteriovenous fistulas: retrospective analysis

BACKGROUND

The purpose of this study was to analyze the incidence, clinical presentation, diagnosis, and treatment of false traumatic aneurysms and arteriovenous fistulas as well as the outcomes of the patients.

METHODS

A retrospective, 16-year survey has been conducted regarding the cases of patients who underwent surgery for false traumatic aneurysms (FTA) of arteries and traumatic arteriovenous fistulas (TAVF). Patients with iatrogenic AV fistulas and iatrogenic false aneurysms were excluded from the study. There were 36 patients with TAVF and 47 with FTA. In all, 73 (87.95%) were male, and 10 (12.05%) were female, with an average age of 36.93 years (13-82 years).

RESULTS

In 25 (29.76%) cases TAVF and FTA appeared combat-related, and 59 (70.24%) were in noncombatants. The average of all intervals between the injury and surgery was 919. 8 days (1 day to 41 years) for FTA and 396.6 days (1 day to 9 years) for TAVF. Most of the patients in both groups were surgically treated during the first 30 days after injury. One patient died on the fourth postoperative day. There were two early complications. The early patency rate was 83.34%, and limb salvage was 100%. There were no recurrent AV fistulas that required additional operations.

CONCLUSIONS

Because of their history of severe complications, FTA and TAV fistulas require prompt treatment. The treatment is simpler if there is only a short interval between the injury and the operation. Surgical endovascular repair is mostly indicated.

Treatment of hemodialysis graft pseudoaneurysms with stent grafts: institutional experience and review of the literature

Hemodialysis access grafts are an important component of the treatment of patients with renal failure. Because access sites are limited, maximizing graft lifespan is of major importance to dialysis patients. Pseudoaneurysm formation is a rare, but important complication potentially limiting the longevity of dialysis grafts. With rapidly advancing technology, placement of stent grafts in patients with end-stage renal disease is an important step in prolonging the life of the graft. We conducted a review of the literature regarding stent-graft use for hemodialysis access. In addition, we looked at our experience utilizing the Viabahn(®) (W. L. Gore & Associates, Newark, DE) stent graft in pseudoaneurysm repair. Our patients achieved primary patency of their grafts for 1, 5, and 9 months, respectively. No complications related to stent-graft implementation have been encountered in six stent-graft implants over the course of 29 months.

Correção cirúrgica de aneurismas saculares de fístula arteriovenosa para hemodiálise utilizando a técnica de aneurismorrafia

Uma das complicações mais frequentes da fístula arteriovenosa (FAV) para hemodiálise é o desenvolvimento de um aneurisma. A formação de aneurismas geralmente decorre de um enfraquecimento da parede venosa devido às repetidas punções, e sua rotura causa hemorragia intensa que pode levar à morte. Descrevemos o caso de uma paciente com dois aneurismas saculares de FAV, tratados através de aneurismorrafia, detalhando a técnica cirúrgica utilizada e a evolução pós-operatória. A técnica de rafia simples da parede constitui uma boa alternativa no reparo da parede da FAV quando o aneurisma é de curta extensão, evitando a colocação de um material protético e a confecção de duas anastomoses.

Dialysis access pseudoaneurysm: endovascular treatment with a covered stent

Iatrogenic pseudoaneurysms of the brachial artery are rare complications of haemodialysis access procedures and can lead to substantial morbidity and mortality if not managed promptly; however, surgery is also associated with the potential risk of severe complications. We describe the clinical and radiological findings relating to a dialysed patient who developed a huge iatrogenic pseudoaneurysm of the brachial artery (due to an inadvertent artery puncture), which was successfully treated by means of the percutaneous implantation of a polytetrafluoroethylene (PTFE)-covered stent.

Ruptured brachial artery aneurysm in a patient with type 1 neurofibromatosis

Vascular lesions associated with neurofibromatosis type 1 (NF1) are rare but can lead to catastrophic complications if disrupted. Ruptured aneurysms in NF1 patients are difficult to treat surgically because of vascular wall fragility. We describe a female NF1 patient with a ruptured aneurysm of her brachial artery. This is the first published case of successful reconstruction of a ruptured brachial aneurysm associated with NF1, using a saphenous vein graft.

Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels

BACKGROUND

Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times.

METHODS

A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma.

RESULTS

In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%.

CONCLUSION

The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

Chronic traumatic pseudoaneurysm of polytetrafluoroethylene axillofemoral bypass graft in a quadriplegic patient

A case of nonanastomotic pseudoaneurysm of a polytetrafluoroethylene (PTFE) axillofemoral bypass graft due to chronic abrasion and pressure of the graft by external sources is reported. A quadriplegic patient presented with a pulsatile mass beneath his seatbelt straps in the mid-left chest region, consistent by computed tomography angiography and duplex ultrasound with a pseudoaneurysm of the PTFE graft, which had been placed 9 years previously. The patient underwent a successful endovascular repair of the pseudoaneurysm, and at 6-month follow-up the mass had resolved. To our knowledge this represents the first case of a chronic nonanastomotic pseudoaneurysm of a PTFE axillofemoral bypass graft secondary to abrasion and pressure that was repaired via an endovascular approach.

Tratamento endovascular do trauma arterial dos membros

Geralmente o tratamento das lesões arteriais traumáticas é realizado com técnicas tradicionais de revascularização. Cada vez mais, porém, as lesões vasculares podem ser corrigidas com eficiência por meio de procedimentos minimamente invasivos. Nós descrevemos quatro casos de trauma arterial dos membros que foram tratados por técnicas endovasculares num centro de referência. Todos os pacientes evoluíram satisfatoriamente durante o seguimento de 15 meses. Nós sugerimos que o tratamento endovascular é uma alternativa promissora em relação à cirurgia para pacientes selecionados com trauma arterial dos membros.

Endovascular Treatment of a “Fishy” Ulcer Caused by a Traumatic Arteriovenous Fistula

Arteriovenous fistula secondary to trauma is an uncommon cause of leg ulcers. In this article, an unusual case of a nonhealing leg ulcer caused by a stingray is described. This case highlights the difficulty in diagnosing and treating nonhealing ulcers secondary to arteriovenous fistula.

Endovascular Repair of Hemodialysis Graft-Related Pseudoaneurysm: An Alternative Treatment Strategy in Salvaging Failing Dialysis Access

Introduction Hemodialysis access—related pseudoaneurysm is a known complication in patients requiring hemodialysis via prosthetic arteriovenous grafts (AVGs). The traditional treatment strategy of AVG-related pseudoaneurysms is either AVG ligation or interposition replacement with another prosthetic graft segment or autogenous veins.

Patients and methods From June 2002 to August 2007, 32 self-expanding stent grafts were implanted in 26 patients with AVG pseudoaneurysms. Indications for treatment consisted of large AVG pseudoaneurysm size, localized pain at pseudoaneurysm site, enlarging pseudoaneurysm, and skin site breakdown. AVG pseudoaneurysm exclusion was accomplished with Wallgrafts, Viabahn endoprosthesis, and Fluency endograft. Technical success was achieved in all patients. Nineteen patients experienced a marked decrease in the size of their pseudoaneurysm following endograft exclusion. Successful hemodialysis was resumed through endograft-excluded AVG in all patients within 48 hours.

Conclusions Endoluminal exclusion of AVG pseudoaneurysms using endografts is a safe and effective treatment strategy in patients with hemodialysis-related pseudoaneurysm.

Endovascular repair of a left axillary-left pulmonary artery fistula: report of a case

An abnormal communication between an artery of the systemic circulation and a pulmonary artery represents a rare clinical condition. A 76-year-old man presented with nocturnal dyspnea and retrosternal pain caused by a non-ST-elevation acute coronary syndrome. He had a history of a coronary artery bypass grafting operation 17 years previously, which required a repeat procedure 7 years later with a construction of an anastomosis of the left internal thoracic artery to the left anterior descending artery. Coronary angiography revealed an abnormal fistulous communication between the left axillary and the left pulmonary artery. Pressure measurements revealed pulmonary hypertension. An endovascular repair of the fistula was performed during repeat coronary angiography with an implantation of two self-expandable covered polytetrafluoroethylene stent grafts measuring 9 and 10 mm in diameter respectively, and thus resulting in a complete obstruction of the abnormal communication. During a follow-up period of 2 months the patient showed a significant improvement in his clinical condition.

Endovascular treatment of lower limb penetrating arterial traumas

PURPOSE

The purpose of this study was to evaluate the effectiveness of percutaneous arterial embolization in patients with penetrating peripheral arterial trauma.

MATERIALS AND METHODS

Twelve patients with penetrating peripheral arterial trauma were treated with percutaneous arterial embolization between 2002 and 2007. All injuries were secondary to penetrating stab wounds. Active bleeding (eight patients), recurrent bleeding episodes (one patient), persistent pain and mass (one patient), leg edema, claudication, swelling (one patient), local hyperemia, and pain (one patient) were the presenting symptoms. Microcatheter systems were used for catheterization. We used n-butyl cyanoacrylate mixture as the embolizing agent in all patients.

RESULTS

On angiograms the inferior gluteal artery (one patient), internal pudendal artery (one patient), perforating branch of the profundal femoral artery (six patients), superficial femoral artery (one patient), peroneal artery (two patients), and anterior tibial artery (one patient) were found to be injured. In all patients, the source of arterial bleeding could be reached, and a safe embolization was achieved. Nontarget embolization due to backflow of n-butyl cyanoacrylate mixture was detected in two patients and inguinal hematoma at the puncture site occurred in one patient.

CONCLUSIONS

We conclude that embolization-particularly n-butyl cyanoacrylate embolization-is technically feasible in patients with penetrating peripheral arterial trauma.

Endovascular PTFE-Covered Stent for Treatment of an External Iliac Artery Pseudoaneurysm in the Presence of Chronic Infection

A 75-year-old woman with an external iliac artery pseudoaneurysm, thought to have resulted from a chronic loosening and infection of a total hip replacement, was successfully treated by placement of a covered endoluminal stent.

Traumatic pseudoaneurysm of the popliteal artery after blunt trauma: case report and a review of the literature

Pseudoaneurysms of the popliteal artery following trauma are rare lesions. We present 3 cases of pseudoaneurysms of the popliteal artery (4, 20, and 45 years old respectively) with a delayed presentation, following blunt trauma, presenting over a 3-year period, and a short review of the relevant literature. A delayed pattern of presentation, over 2 years after blunt popliteal trauma, was observed in all patients. They presented with a painful pulsatile mass in the popliteal fossa, and their peripheral pulses were normal. Orthopedic and rheumatologic evaluation findings were negative. Diagnostic evaluation included triplex, arteriography, and computed tomography angiography. A posterior popliteal approach was used, and after aneurysmal excision, reversed great saphenous vein and lesser saphenous vein (1 patient) grafts were used. After 2 to 4 years of follow-up, all grafts remain patent and the patients have fully functional limbs. A literature search revealed 70 cases of pseudoaneurysms of the popliteal artery reported in civilian settings. These lesions should be repaired shortly because their complications (rupture, thromboembolic episodes) carry a high risk for limb dysfunction and amputation. Penetrating or blunt trauma is the main causative factor (62.5%), but iatrogenic trauma accounts for an increasing number of reports (37.5%). Strict follow-up of popliteal trauma is essential. A high level of suspicion and awareness can lead to early diagnosis and treatment of pseudoaneurysms of the popliteal artery and prevent the serious complications associated with these lesions.