Postcatheterization pseudoaneurysms and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents

Closure of patent Potts shunt with aortic endoluminal stent graft

Pulmonary hypertension secondary to residual Potts shunt is not an uncommon phenomenon. A 59-year-old male with a history of tetralogy of Fallot was noted, on a full heart study, to have persistent pulmonary hypertension, normal left ventricular function, severe aortic regurgitation, and a residual Potts shunt. A previous surgical attempt at closure of the shunt during definitive repair was unsuccessful. An aortic endoluminal stent graft was deployed to definitively close the shunt. There was a subsequent normalization of pulmonary pressures following Potts shunt closure. The patient will now proceed with surgical aortic root repair and aortic valve replacement.

True and false aneurysms of the femoral artery

True aneurysms of the femoral artery are uncommon. They are most often identified in elderly males and are frequently associated with aneurysms at other locations. Femoral artery aneurysms that are symptomatic or larger than 2.5 cm should be repaired in order to prevent limb-threatening complications, such as rupture, thrombosis, or embolization. Open repair is the standard method of treatment and should be preceded by evaluation for coexisting aortoiliac or popliteal aneurysms, assessment of superficial femoral artery patency, and determination of the point of origin of the deep femoral artery relative to the aneurysm sac. Femoral artery pseudoaneurysms are most often seen in the setting of previous femoral artery catheterization but may also be associated with trauma, anastomotic leakage, or infection. The majority of femoral pseudoaneurysms less than 3 cm in diameter will spontaneously thrombose and may be observed with serial duplex ultrasound exams in asymptomatic patients. Symptomatic pseudoaneurysms, pseudoaneurysms with a diameter greater than 3 cm, and those found in patients who are anticoagulated should usually be treated. Ultrasound-guided thrombin injection is our preferred method for treating femoral pseudoaneurysm because of its low risk, high success rate, and efficacy in the setting of anticoagulation. Ultrasound-guided compression is an alternative method that may be considered when thrombin products are contraindicated. Open pseudoaneurysm repair should be undertaken in the setting of infection, rapid expansion, or if less-invasive methods are not technically feasible.

Pseudoaneurysms and the role of minimally invasive techniques in their management

Pseudoaneurysms are common vascular abnormalities that represent a disruption in arterial wall continuity. Some complications associated with pseudoaneurysms develop unpredictably and carry high morbidity and mortality rates. The advent of new radiologic techniques with a greater sensitivity for asymptomatic disease has allowed more frequent diagnosis of pseudoaneurysms. Conventional angiography remains the standard of reference for diagnosis but is an invasive procedure, and noninvasive diagnostic modalities (eg, ultrasonography [US], computed tomographic angiography, magnetic resonance angiography) should be included in the initial work-up if possible. A complete work-up will help in determining the cause, location, morphologic features, rupture risk, and clinical setting of the pseudoaneurysm; identifying any patient comorbidities; and evaluating surrounding structures and relevant vascular anatomy, information that is essential for treatment planning. Therapeutic options have evolved in recent years from the traditional surgical option toward a less invasive approach and include radiologic procedures such as US-guided compression, US-guided percutaneous thrombin injection, and endovascular management (embolization, stent-graft placement). The use of noninvasive treatment has led to a marked decrease in the morbidity and mortality rates for pseudoaneurysms.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs

PURPOSE

To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries.

MATERIAL AND METHODS

From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate.

RESULTS

There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67 +/- 0.91 days.

CONCLUSION

PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

Postcatheterization femoral arteriovenous fistula: endovascular treatment with N-butyl-cyanoacrylate embolization

We report a case of an iatrogenic femoral arteriovenous fistula (AVF) in a 67-year-old man presenting with right femoral bruit on the day after sheath removal for cardiac catheterization. This was successfully treated with embolization using N-butyl-cynoacrylate (NBCA) through a coaxial microcatheter. Transcatheter embolization of iatrogenic femoral AVFs with NBCA in selected cases may be a safe and effective treatment in the presence of long fistula tracts. It is then easy to perform in experienced hands and relatively inexpensive.

Endovascular treatment of obstructive iliac artery dissections

PURPOSE

To report our results from a study of the endovascular treatment of flow restricting chronic atherosclerotic or catheter-induced segmental iliac artery dissections with bare stents.

MATERIAL AND METHODS

Thirty symptomatic patients with 32 lesions, including chronic atherosclerotic (n = 21) and catheter-induced (n = 11) segmental arterial dissections, were treated with primary stenting. The common iliac artery was involved in 19 lesions and the external iliac artery in the remaining 13. Two patients had two lesions in the same vessel. Technical success was defined as restoration of the smooth contoured luminal patency with no more than 20% residual stenosis in diameter in atherosclerotic dissections associated with plaque formation or total obliteration of the false lumen in catheter-induced dissections. Complete relief of, or marked improvements in, presenting symptoms, or at least single category improvement, was assessed for clinical success.

RESULTS

Technical success rate was 100%. No procedure-related complications such as distal emboli or early occlusions were observed. Complete symptom relief was achieved in all patients with catheter-induced dissection and in all but three cases with chronic spontaneous atherosclerotic dissection. In two cases, occlusion of the stents occurred during the follow-up period. Clinical and radiological mean follow-up for 24 months (range 3-55) revealed patency of all other stented segments. Cumulative primary patency rate was 97% over 12 months and 90% over 24 months.

CONCLUSION

Endovascular treatment of chronic atherosclerotic and catheter-induced short obstructive iliac arterial dissections with bare stents is safe and effective. Patency of the diseased arterial segment with a smooth lumen can be sustained for an extensive period.

Stent-Graft Treatment of Patients with Acute Bleeding from Hepatic Artery Branches

PURPOSE

To present a new treatment option in patients with acute bleeding from the hepatic artery branches.

METHODS

Four male patients, 23-49 years old (mean 36.3 years), were treated for acute bleeding and subsequent transient hypotension. Bleeding episodes were secondary to hepatic artery pseudoaneurysms in two patients and surgical suture insufficiency in one patient. In the remaining patient, anastomotic leakage occurred following thrombolysis for hepatic artery thrombosis. Patients were treated by endovascular placement of one or two balloon-expandable stent-grafts, ranging from 17 to 28 mm in length.

RESULTS

All procedures were carried out without serious complications. All stent-grafts were deployed in the intended position with immediate cessation of bleeding and initial preservation of satisfactory blood flow.

CONCLUSIONS

Bleeding from the hepatic artery can be treated by insertion of balloon-expandable stent-grafts in the acute setting.

Surgical Repair of a Post-traumatic Arteriovenous Fistula Complicated by Stent-Graft Misplacement

An arteriovenous fistula (AVF) is an abnormal connection between an artery and a vein which may result from a traumatic injury or occur as a congenital abnormality. It may be asymptomatic or may present with a variety of symptoms. Surgical or endovascular treatment can be preferred. We present a case of unsuccessful percutaneous treatment of a femoral AVF due to misplacement of the stent-grafts, necessitating surgical correction.

Stent-Graft Treatment of Extracranial Carotid and Vertebral Arterial Lesions

Five patients with pseudoaneurysms of the carotid artery (n = 4) and an arteriovenous fistula of the vertebral artery (n = 1) were treated with stent-grafts. Commercially made devices were used in all but one of the patients. In four of the five patients, the pathology was successfully excluded. One patient had a small type-I endoleak. There were no immediate procedure-related complications or neurologic sequalae. All experienced immediate resolution of symptoms. One patient was lost to follow-up after discharge and another died 2 weeks after intervention. The remaining patients remained asymptomatic with patent stent-grafts after follow-up periods of 14, 16, and 46 months, respectively.

An Audit of Vascular Surgical Intervention for Complications of Cardiovascular Angiography in 2324 Patients from a Single Center

This study examines the incidence and outcome of complications requiring surgical intervention in a major vascular unit serving interventional radiology and interventional cardiology. Between April 2000 and March 2001, 2324 patients underwent angiographic examinations (male/female = 1579:745, mean age = 68 years, range 45-88). In non-stent patients, a 4-or 5-mm French (4-mm F, 5-mm F) guage nonheparinized arterial catheter was used, and in patients requiring stents a 6- or 7-mm French guage catheter was used. Pressure was applied to the puncture site for up to 6 min. Fifteen complications requiring vascular surgical procedure were recorded during in-hospital follow-up (9 males, 6 females). Our early operative (30-day) mortality rate was 0.086%. Although the number of major complications requiring surgical intervention after interventional or diagnostic cardiovascular radiology is diminishing, vigilance in these cases is still required. Where possible, a small catheter with a J-shaped guidewire should be used and prolonged compression should be brought to bear on the puncture site.

Gadolinium-enhanced Three-dimensional MR Angiography of Takayasu Arteritis

Takayasu arteritis is a form of large vessel vasculitis with a possible autoimmune origin that may cause stenosis of the aorta and its major branches. Six types of Takayasu arteritis are recognized; the type depends on whether the ascending aorta, descending thoracic aorta, abdominal aorta, aortic cervicobrachial branches, or renal arteries are affected. The coronary and pulmonary arteries are also sometimes involved. Clinical features of the disease include diminished or absent pulses, claudication, hypertension, and mesenteric angina. Conventional angiography has been the standard imaging tool for diagnosis and evaluation of Takayasu arteritis, although it demonstrates only the lumen of the vessel. Less invasive cross-sectional methods such as computed tomographic angiography and, more recently, three-dimensional magnetic resonance (MR) angiography can effectively demonstrate thickening of the vessel wall, which may be the earliest manifestation of the disease, occurring before stenosis and dilatation. MR imaging in particular allows better soft-tissue differentiation and can show other signs of inflammation, including mural edema and increased mural vascularity. Other advantages of MR imaging are the lack of iodinated contrast material or ionizing radiation.

Current treatment methods for postcatheterization pseudoaneurysms

Pseudoaneurysms are a recognized complication of arterial catheterization. Until recently, the standard method of treatment has been surgical. The past decade has seen the introduction of several minimally invasive techniques that have largely replaced surgical treatment of pseudoaneurysms. The most commonly used methods are ultrasound-guided compression and percutaneous injection of thrombin into the pseudoaneurysm. This review article describes all the methods available for the treatment of postcatheterization pseudoaneurysms, presents results from the largest published series, and discusses the relative merits of each technique.

Large vertebral arteriovenous fistula treated with stent-grafts--case report

A 24-year-old woman presented with neck bruit and thrill. Neurological examination revealed no focal abnormality. Angiography and magnetic resonance imaging showed an arteriovenous fistula (AVF) at the C4-5 levels of the right vertebral artery (VA). The fistula had a single orifice that drained into the epidural veins via the C4-5 intervertebral foramen. A stent-graft was made of a 3.9 cm balloon-expandable stent and an expandable polytetrafluoroethylene graft sutured outside the stent. The stent-graft was advanced through the femoral artery up to the VA but did not pass far enough distally to seal the entire fistula because of the high friction between the bulky device and the small vessel. Another 2 cm stent-graft was delivered and successfully positioned across the fistula. The AVF completely disappeared and the right VA was well preserved. Follow-up angiography at 3 weeks and 5 months after the treatment showed no fistula and no stenosis inside the stent-grafts. Stent-grafts are useful to treat AVF with a large orifice. The stent-graft is a promising technology to treat neurovascular diseases, although improvement is required for use in smaller vessels.

Iatrogenic Femoral Artery Pseudoaneurysm

A small (< 6 cm(3) in volume or 1.8 cm in diameter), uncomplicated iatrogenic femoral artery pseudoaneurysm in a reliable patient not requiring anticoagulation can be safely observed with weekly physical examinations and ultrasound evaluations until full thrombosis is documented. The patient should be informed that any symptoms or complications should be reported to a physician immediately. A pseudoaneurysm associated with limb ischemia, severe infection, neurologic deficit, skin necrosis, rapid expansion, or hemorrhage should be treated surgically. Also, surgery is recommended if less invasive treatment strategies have failed, or if a planned surgical procedure involving the groin is anticipated. Given its high success rate, low complication rate, and cost-effectiveness, ultrasound-guided thrombin injection should be considered as first-line treatment for uncomplicated iatrogenic femoral pseudoaneurysm. Ultrasound-guided compression repair is an effective alternative to thrombin injection, especially in institutions that have little or no experience with thrombin injection. Alternative treatment strategies, such as percutaneous endovascular stenting and perfusion ballooning, are generally not recommended as first-line treatment options, because they have not been studied as extensively as ultrasound-guided compression repair or thrombin injection. If no other options are available, however, these alternative approaches may be appropriate in certain clinical situations.

Percutaneous management of access site complications

Percutaneous cardiac catheterization and endovascular procedures are associated with complications at the vascular access site. While surgery has been the traditional treatment for vascular access complications, the current state of the art permits percutaneous management of many access site complications. Surgical repair may be required only when percutaneous methods fail, are not available, or are unsuitable.

Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment

OBJECTIVES

We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF.

BACKGROUND

Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment.

METHODS

A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography.

RESULTS

The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence.

CONCLUSIONS

Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.

Embolization of profunda femoris artery branch pseudoaneurysms with ethylene vinyl alcohol copolymer (onyx)

This report describes the use of a new embolic agent, Onyx, which is composed of ethylene vinyl alcohol copolymer dissolved in 8% dimethyl sulfoxide, in the endovascular transcatheter embolization of traumatic profunda femoris artery branch pseudoaneurysms in three cases. Two of the cases involved massive thigh swelling after penetrating injury and the other involved massive hemorrhage at the site of a surgical fixator pin. Diagnostic angiography revealed pseudoaneurysm formation of the profunda femoris artery branches in all cases. Immediate control angiography after the embolization procedures demonstrated complete closure of the pseudoaneurysms. During the follow-up period there was no recurrent bleeding. The advantages of Onyx over conventional liquid embolic agents and coils are discussed.

Covered stent-graft repair of the brachiocephalic arteries: technical note

OBJECTIVE

The use of a covered stent-graft to repair disruptions of the cervical carotid and vertebral arteries is described. This device maintains vessel patency while effectively excluding pseudoaneurysms, arteriovenous fistulae, and other breaches in the integrity of the arterial wall.

METHODS

Patient 1 bled from a large rent in the proximal common carotid artery as a result of tumor invasion. Patient 2 developed a vertebral arteriovenous fistula after a stab injury to the neck. Patient 3 developed cerebral infarction and an enlarging pseudoaneurysm of the internal carotid artery, also after a stab wound to the neck.

RESULTS

All three patients were treated with the Wallgraft endoprosthesis (Boston Scientific, Watertown, MA). In each case, the vessel wall defect was repaired while antegrade flow through the artery was preserved or restored. No neurological complications occurred as a result of stent-graft deployment.

CONCLUSION

Covered stent-grafts offer an alternative to endovascular occlusion of the parent vessel, thereby expanding the therapeutic options for patients with extracranial cerebrovascular disease. These three cases highlight the usefulness and versatility of these devices for endoluminal reconstruction of the brachiocephalic vasculature.

Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneurysm by biodegradable collagen injection

OBJECTIVES; The goal of this study was to assess the safety and efficacy of femoral artery pseudoaneurysm (FAP) closure by collagen injection. BACKGROUND; The FAP is an infrequent but troublesome complication after percutaneous transfemoral catheter procedures. If ultrasound-guided compression repair (UGCR) fails, vascular surgery is indicated. We have developed a less invasive method to close FAPs percutaneously by injecting collagen and, thus, inducing clotting within the aneurysm.

METHODS

Via a 9F needle or 11F sheath, a biodegradable adhesive bovine collagen is injected percutaneously into the FAP, guided by angiography from the contralateral site.

RESULTS

From 1993 to 2000, compression and UGCR had failed to obliterate 110 FAPs. These patients have been treated by collagen injection. Mean age of the patients was 65.6 +/- 10.2 years (range: 32 to 85 years), and 50% were women. Immediate closure of the FAP was achieved in 107/110 patients (97.3%) without any complication or adverse effect. In one patient the collagen could not be applied due to unfavorable anatomy. One patient needed a second session of collagen injection. In one patient too much collagen was inserted, which resulted in external compression of the artery, and surgical intervention was required. The overall success rate was 108/110 (98%, 95% confidence interval: 93.5% to 99.8%). Among the patients with successful procedures, there were no recurrences during six months follow-up.

CONCLUSIONS

The percutaneous treatment of iatrogenic FAP, by injection with collagen, is an effective and safe strategy. This method provides an excellent therapeutic alternative to the traditional surgical management.

Superior mesenteric artery pseudoaneurysm successfully treated with polytetrafluoroethylene covered stent

A postoperative superior mesenteric artery pseudoaneurysm that communicates with a pancreatic pseudocyst after aortic surgery is a difficult management problem. Untreated, this condition can lead to exsanguination. Traditional surgical treatment has many potential complications. Endovascular repair has the potential for avoidance of surgical complications. We present the first superior mesenteric artery pseudoaneurysm successfully treated with A polytetrafluorethylene covered stent.

Treatment of an iatrogenic petrous carotid artery pseudoaneurysm with a Symbiot covered stent: technical case report

OBJECTIVE AND IMPORTANCE

Surgery involving the middle ear or the temporal bone may cause an injury to the petrous carotid artery resulting in a pseudoaneurysm. Conventional treatment of such pseudoaneurysms has ranged from carotid occlusion to conservative management. The use of a balloon-expandable stent and/or Guglielmi detachable coils may be effective in a partially healed pseudoaneurysm. This report details the case of an acute petrous carotid pseudoaneurysm after a myringotomy procedure that was effectively treated with an expanded polytetrafluoroethylene-covered stent.

CLINICAL PRESENTATION

During a right myringotomy procedure, pulsatile blood was encountered in a 42-year-old woman with a history of repeated ear infections and bilateral middle ear ventilation tube placement. The blood was adequately tamponaded with gauze packing. Computed tomography of the temporal bone demonstrated a dehiscent carotid artery, and cerebral angiography revealed a 6-mm right petrous carotid pseudoaneurysm.

INTERVENTION/TECHNIQUE

An 8-French guide catheter was positioned via a transfemoral approach into the cervical right internal carotid artery, and the patient was systemically heparinized. A 4- x 31-mm Symbiot covered stent (Boston Scientific/Scimed, Maple Grove, MN) was passed over a Choice PT exchange wire (Boston Scientific/Scimed) to cover the neck of the pseudoaneurysm, obliterating the pseudoaneurysm. The patient was given aspirin and clopidogrel after stenting, and ear exploration was possible later the same day. Follow-up computed tomographic angiography performed 6 weeks later verified patency of the stent.

CONCLUSION

The use of an expanded polytetrafluoroethylene-covered stent may effectively treat intracranial internal carotid artery pseudoaneurysms in an acute setting. This treatment allows preservation of the parent artery and immediate treatment by reconstruction of the incompetent arterial wall to prevent potentially life-threatening hemorrhagic complications.

Percutaneous treatment of iatrogenic iliocaval fistula related to endograft placement for abdominal aortic aneurysm

The authors report a case of iatrogenic dissection occurring during endovascular treatment of an abdominal aortic aneurysm. The dissection was related to catheterization maneuvers that led to the development of a symptomatic arteriovenous fistula, which was successfully closed by coil embolization.

Successful stent-graft repair of a vertebrojugular arteriovenous fistula

PURPOSE

To describe an apparently unreported endovascular means of treating a vertebral arteriovenous fistula (AVF) using a small-caliber stent-graft to permanently reconstruct the involved vessels.

CASE REPORT

A 13-year-old girl presented with tinnitus caused by a high-flow AVF between the right extracranial vertebral artery and deep jugular vein arising from repeated internal jugular vein catheterization. A 4-mm-diameter balloon-expandable Jostent coronary stent-graft was placed in the vertebral artery via a percutaneous femoral access, with immediate and complete obliteration of the AVF and resolution of the tinnitus. Follow-up duplex ultrasonography at 15 months demonstrated patency and luminal integrity of the vertebral artery.

CONCLUSIONS

Vertebrojugular AVFs are rare and usually treated with transcatheter embolization techniques, but percutaneous repair using a small-caliber stent-graft appears feasible. This minimally invasive treatment might become the method of choice for AVFs in other small-bore vessels.

Femoral artery thrombosis after percutaneous thrombin injection of an external iliac artery pseudoaneurysm

Ultrasound-guided percutaneous thrombin injection has been developed as a less invasive and highly successful treatment of iatrogenic femoral pseudoaneurysms. Most of these lesions have been the result of catheterization procedures. This method has proved to be highly effective, and few complications have been reported. Specifically, native arterial thrombosis, although recognized as a severe complication, has been mentioned only briefly in the literature. We present a case of the successful management of native arterial thrombosis after attempted percutaneous thrombin injection of a chronic external iliac artery pseudoaneurysm. This case serves to illustrate the risk factors for this complication and the treatment options once it occurs. The success of this treatment with acute iatrogenic femoral pseudoaneurysms may not necessarily translate into similar success in other anatomic locations and clinical situations.

Treating complex nervous system vascular disorders through a "needle stick": origins, evolution, and future of neuroendovascular therapy

In the past few decades, dramatic improvements have occurred in the field of neuroendovascular surgery. Endovascular therapy today is a well-established treatment modality for a variety of cerebrovascular and nonvascular central nervous system diseases. The foundation of this spectacular evolution was laid by the efforts of pioneering visionaries who often worked alone and under difficult, almost impossible, conditions. Ongoing device development and refinement have revolutionized the field at a dizzying, exhilarating pace. With a better understanding of the molecular basis of diseases and further advancements in gene therapy, neuroendovascular techniques have an enormous potential for application to the entire spectrum of central nervous system diseases as a minimally invasive vehicle for the delivery of biological factors.