Percutaneous treatment of a large superior mesenteric artery pseudoaneurysm and arteriovenous fistula: A case report

Transarterial embolization of secondary inferior and superior mesenteric artery arteriovenous fistulas: a systematic review

Background

Acquired arteriovenous fistula are rare complications of a piercing injury, including a gunshot or knife injury, the rupture of a preexisting aneurysm into a neighboring vein, or a complication of arterial catheterization or abdominal surgical techniques, most often colonic resection. Our aim was to develop an online systematic review of the literature to determine all documented incidents of endovascular embolization of secondary mesenteric Arteriovenous Fistula, spanning key databases as well as pertinent publications, from 1982 to 2019. Our case was included as well. The primary objectives were technical success and death; the secondary outcomes were the frequency of complications and the advice of the operators.

Main body

Forty articles, comprising 41 patients, including our own, were reviewed. The superior mesenteric vessels are the most commonly affected by fistulas. Endovascularembolization was used in 80% of the cases. 100% of the patients had technical success. The intraoperative death rate was 0%, with a 90-day mortality rate of 8%, half of which was unrelated to the original pathology. More than 60% of patients who underwent successful treatments had no severe problems. All others had uneventful recoveries, with only 12% experiencing mild problems that were managed conservatively.

Conclusions

The majority of authors supported this therapeutic approach thereby making endovascular glue embolization the treatment of choice for superior mesenteric arteriovenous fistula and inferior mesenteric arteriovenous fistula in high risk patients and in patients with multiple co-morbidities.

Endovascular treatment of iatrogenic superior mesenteric arteriovenous fistula resulting in recurrent abdominal ascites

Superior mesenteric arteriovenous fistulas (AVFs) are rare and are usually caused by previous bowel surgery or blunt abdominal trauma. Patients may be asymptomatic, have non-specific symptoms of abdominal pain, nausea and vomiting or present with symptoms of portal hypertension; some patients may present years after initial surgery or trauma. Traditionally, superior mesenteric AVFs are treated by surgical ligation. However, percutaneous endovascular treatment has become increasingly popular in recent years. Different options of endovascular treatment include coil embolisation, covered stent and vascular plugs. There is a risk of coil migration with coil embolisation and covered stents may cause abnormal vessel straightening. Vascular plugs allow the fistula to be treated with fewer devices and have minimal risk of migration. Newer devices such as microvascular plugs have the added advantage of being able to be delivered through microcatheters or diagnostic catheters. The smaller profile of the microvascular plug also allows it to navigate through tortuous vessels. We report a case of a 77-year-old patient presenting with recurrent abdominal ascites three years after small bowel resection. CT and angiogram demonstrated a superior mesenteric AVF, which was successfully treated with a combination of microvascular plug and coil. He remained relatively asymptomatic four months after treatment.

Traumatic penetrating arteriovenous fistulas: a collective review

INTRODUCTION

Traumatic penetrating arteriovenous fistulas (AVFs) are very rare. The majority of these injuries occur secondary to penetrating trauma. Objectives of this study: review their incidence, clinical presentation, radiologic identification, management, complications and outcomes.

METHODS

A literature search was performed on MEDLINE Complete-Pubmed from 1829-2019. PRISMA guidelines were utilized. Of 305 potentially eligible articles, 201 articles were selected.

INCLUSION CRITERIA

patients age ≥ 18, articles with title and abstract in English, AVFs secondary to penetrating trauma, articles which specified vessels involved in AVFs, and those reporting complete information on patient presentation, diagnosis, imaging, surgical and/or endovascular surgical management, and outcomes of penetrating AVF's.

EXCLUSION CRITERIA

articles reporting blunt or iatrogenic AVFs, pediatric patients, fistulas used for dialysis and their complications, articles lacking complete information, cranial/spinal AVFs or cardiac AVFs, and duplicate articles. Mechanism of injury (MOI), diagnosis, involved vessels, management and outcomes of patients with AVFs secondary to penetrating trauma were recorded.

RESULTS

There were a total of 291 patients with AVFs secondary to penetrating injuries. Mechanism of injury (MOI): stab wounds (SW)-126 (43.3%), Gunshot wounds (GSW)-94 (32.3%), miscellaneous-35 (12%), mechanism unspecified-36 (12.4%). Anatomic area: neck-69 (23.7%) patients, thorax-46 (15.8%), abdomen-87 (30%), upper and lower extremities-89 (30.6%). Most commonly involved vessels-vertebral artery-38 (13%), popliteal vein-32 (11.7%). Angiography was diagnostic-265 patients (91.1%).

INTERVENTIONS

Surgical- 202 (59.6%), Endovascular-118 (34.8%). Associated: aneurysms/pseudoaneurysms-129 (44.3%).

CONCLUSION

Most AVFs occur secondary to penetrating injuries. Stab wounds account for the majority of these injuries. Most frequently injured vessels are vertebral artery and superficial femoral vein. Surgical interventions are the most common mode of management followed by endovascular surgical techniques.

Ruptured pancreaticoduodenal pseudoaneurysm causing arterioportal fistula: combined transarterial and transportal embolization

Background

Arterioportal fistulas are rare vascular disorders of the abdominal viscera. They are arteriovenous communications between the splanchnic arteries and the portal vein or its tributaries. We herein report a case of an extrahepatic arterioportal fistula that was caused by rupture of a pseudoaneurysm of the pancreaticoduodenal artery and successfully treated with embolization using a combination of the arterial and percutaneous transhepatic portal venous approaches.

Case presentation

A 79-year-old man was transferred to our hospital because of the sudden appearance of a hematoma containing a large pseudoaneurysm in the mesentery of the duodenum. Emergency abdominal angiography revealed that a pseudoaneurysm of the anterior inferior pancreaticoduodenal arterial branch had perforated into the portal system (arterioportal fistula). We performed coil embolization via the inflow artery and portal vein using a percutaneous transhepatic approach. The patient recovered without complications and was discharged.

Conclusion

This rare vascular disorder was successfully treated with an unplanned combination therapy. We believe that flexible strategy changes led to the successful treatment in this case.

Outcomes and complications for portal vein or superior mesenteric vein injury: No improvement in the era of damage control resuscitation

INTRODUCTION

Portal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care.

METHODS

We reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes.

RESULTS

Twenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting.

CONCLUSION

Despite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality.

Pseudoaneurysm associated with arteriovenous fistula involving a superficial breast arteriole after vacuum-assisted removal of a benign mass: A case report

RATIONALE

Pseudoaneurysm (PA) with associated arteriovenous fistula (AVF) is most often secondary to vascular catheterization, percutaneous biopsy, surgery, or trauma. PA-AVF occurs mainly in large or median arterial territories but rarely in the superficial arterioles of the breast.

PATIENT CONCERNS

A 30-year-old woman underwent vacuum-assisted removal of breast fibroadenomas under ultrasonic guidance. On the follow-up visit, the patient complained of a painful enlarging lump in her left breast.

DIAGNOSES

An iatrogenic breast PA-AVF was diagnosed.

INTERVENTIONS

The patient was treated with surgical excision and ligation under local anesthesia.

OUTCOMES

At the 1-month follow-up, the wound was found to have healed well, and breast PA-AVF was eradicated.

LESSONS

Vacuum-assisted removal has been the first-line intervention for benign mass resection because of minimal invasion, but the risk of serious vascular complications remains. Careful duplex ultrasound examination prior to the procedure is highly recommended.

Endovascular Repair of Superior Mesenteric Arteriovenous Fistula Causing Early Mesenteric Steal Syndrome Following Abdominal Gunshot Injury

Introduction

Superior mesenteric arteriovenous fistulae (SMAVF) are rare, usually secondary to trauma or iatrogenic injury and typically present sometime after the initial insult.

Report

A 30 year old male underwent immediate laparotomy for abdominal gunshot injury. The small bowel mesentery contained a large haematoma and a palpable thrill. CT demonstrated a large SMAVF. At re-look laparotomy, small bowel ischaemia was noted and following this endovascular SMA stent graft insertion was performed, with excellent angiographic and clinical results.

Conclusion

The first report of immediate traumatic SMAVF leading to acute mesenteric steal syndrome and successful management with endovascular stent insertion is presented.

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Traumatic superior mesenteric arteriovenous fistulae (SMAVF) are rare.

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They often have a delayed presentation following initial insult.

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Early SMAVF causing acute mesenteric steal syndrome is previously unreported.

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This can be managed by a combination of surgery and endovascular intervention.

Endovascular Treatment of Post-traumatic Superior Mesenteric Arteriovenous Fistula: A Case Report

Superior mesenteric arteriovenous fistulae (SMAVFs) are extremely rare with no consensus about therapeutic indications and optimal approach. Here, we present a case of a symptomatic SMAVF found in a young patient a few years after a penetrating abdominal injury. Following a complex clinical management of the acute status, we successfully managed the fistula with 3 covered stents in 2 consecutive endovascular procedures. Technical details of the performed procedures, including the main pitfalls and chosen solutions, have been explored and discussed.

Superior mesenteric arteriovenous fistula presenting as gastrointestinal bleeding: case report and literature review

Superior mesenteric arteriovenous fistula (SMAVF) is a rare vascular disorder usually following penetrating abdominal trauma or gastrointestinal surgery. Percutaneous endovascular treatment such as embolization, has been widely used to treat this disease. We report a patient, who was presented with melena at the onset of his symptoms, then an acute hematemesis in shock. A SMAVF was diagnosed on an angiogram after a large mesenteric vein was seen on CT. The patient had a successful emergency endoscopic variceal ligation (EVL) to stop bleeding. Then the patient received fistula embolization with covered stent.

Endovascular treatment of superior mesenteric artery pseudoaneurysms using covered stents in six patients

OBJECTIVE

The objective of our study was to evaluate our experience with the use of endovascular treatments for superior mesenteric artery (SMA) pseudoaneurysms using covered stents.

MATERIALS AND METHODS

Between 2002 and 2011, six patients (mean age, 41.7 years; range, 23-65 years) with SMA pseudoaneurysms were treated percutaneously with the placement of covered stents at our institution. The causes of SMA pseudoaneurysms were penetrating trauma (n = 2), blunt trauma (n = 1), and previous surgical procedures (n = 3). The mean diameter of the SMA pseudoaneurysms was 16 mm (range, 4-24 mm). Technical success and clinical success were retrospectively analyzed.

RESULTS

Immediate technical success, defined as exclusion of the pseudoaneurysm and lack of active extravasation, was achieved in all six patients. Secondary balloon angioplasty was needed in one patient with residual narrowing. There was a small dissection of the proximal SMA necessitating placement of a second bare stent across the dissection. A second covered stent (Fluency stent, 8 mm) was placed in the same patient because of recurrent bleeding due to a type II endoleak 5 days after the first covered stent had been placed. This patient had no subsequent episodes of bleeding or bowel ischemia. Follow-up CT in the remaining five patients (mean, 21 months; range, 1-58 months) confirmed stent patency and preserved distal arterial flow to the bowel without episodes of bleeding or bowel ischemia during follow-up (mean, 27 months; range, 11-58 months).

CONCLUSION

Percutaneous endovascular treatment using a covered stent may be a safe and feasible tool for SMA pseudoaneurysms.

Superior mesenteric arteriovenous fistula embolisation complicated by bowel ischaemia

Superior mesenteric arteriovenous fistulas are rare, especially when iatrogenic in origin. Management of these fistulas can be surgical or endovascular. Endovascular embolisation is the preferred modality with a low rate of complications. Among the reported complications, bowel ischaemia is considered an unlikely occurrence. We report a case of a complex iatrogenic arterioportal fistula that was managed by endovascular embolisation and controlled through both its inflow and outflow, and was later complicated by bowel ischaemia.

Gastrointestinal bleeding caused by extrahepatic arterioportal fistula associated with portal vein thrombosis

An extrahepatic arterioportal fistula (APF) involving the gastroduodenal artery and superior mesenteric vein is rare and mostly results from iatrogenic injuries. The clinical symptoms associated with APFs may include abdominal pain, gastrointestinal bleeding, ascites, nausea, vomiting, diarrhea, or even congestive heart failure. We present the case of a 70-year-old man who presented with chronic abdominal pain and gastrointestinal bleeding secondary to APF and portal vein thrombosis. The endovascular embolization of APF was accomplished successfully, and symptoms of portal hypertension resolved immediately after intervention. Unfortunately, the patient did not respond well to anticoagulation therapy with warfarin. Therefore, the patient underwent implantation of a transjugular intrahepatic portosystemic shunt, and the complications of portal hypertension resolved. In conclusion, the embolization of APF is technically feasible and effective and can be considered the first-choice therapy in selected patients.

Superior mesenteric arteriovenous fistula: imaging findings and endovascular treatment

Arteriovenous fistulae (AVF) of the superior mesenteric vasculature are rarely encountered. We present a case of an iatrogenic superior mesenteric AVF following subtotal colectomy, which was successfully treated with coil embolization. Cross-sectional imaging and angiographic findings are reviewed along with the options for endovascular therapy.

The use of balloon-expandable stent grafts for the management of acute arterial bleeding

PURPOSE

To evaluate the efficacy and safety of balloon-expandable stent grafts in the emergency treatment of acute arterial hemorrhage.

MATERIALS AND METHODS

Between July 2008 and December 2009, 15 patients with acute arterial hemorrhage from inflammatory vessel erosion or pseudoaneurysms (n = 9), noninflammatory pseudoaneurysms (n = 3), or iatrogenic vessel injury (n = 3) were treated with emergency stent graft implants. The primary study endpoints to determine treatment efficacy and safety were survival, complication rates, and freedom from recurrent hemorrhaging or reintervention. The secondary study endpoints were technical and clinical success.

RESULTS

The survival rate was 73% with a mean follow-up of 119 days ± 220. The complication rate was 20%. The procedure was technically successful in 13 of 15 (87%) patients. One endoleak persisted and led to a reintervention rate of 7%. The bleeding ceased immediately after stent graft implantation in 14 patients.

CONCLUSIONS

Implantation of balloon-expandable stent grafts is a safe and effective emergency treatment for acute arterial hemorrhage from visceral and peripheral vessels.

Tratamento endovascular de pseudoaneurisma de artéria mesentérica superior: relato de caso

O pseudoaneurisma de artéria mesentérica superior é uma doença rara, porém com alta taxa de ruptura e mortalidade. Sua etiologia geralmente é infecciosa e comumente o diagnóstico é feito por meio de achado nos exames de imagem. Historicamente, seu tratamento de eleição tem sido o reparo cirúrgico aberto; entretanto, é associado a inúmeras complicações e dificuldades técnicas. Relatamos um caso de pseudoaneurisma de artéria mesentérica superior em um paciente portador de abscesso hepático no qual, após resolução do processo infeccioso, foi empregado, com sucesso, um tratamento minimamente invasivo endovascular, com implante de micromolas e stent não-recoberto.

Transarterial thrombin injection secured with an embolic protection device as a treatment for a superior mesenteric artery pseudoaneurysm

A pseudoaneurysm of the superior mesenteric artery (SMA) is a rare and life-threatening condition of various etiology. Even unruptured it can cause severe health problems or death. We report a 71-year-old male with a SMA pseudoaneurysm who was successfully treated with a transarterial thrombin injection secured with an embolic protection device used in carotid angioplasty. To our knowledge, this is the first case of a SMA pseudoaneurysm treated by this method.

Arteriovenous fistula of a colic branch of the superior mesenteric artery: endovascular therapy

Arteriovenous fistulae (AVF) of the superior mesenteric artery and its branches are exceedingly rare. We report an unusual case of a patient who was found to be symptomatic from such an AVF, with diarrhea and terminal ileal thickening. We describe the findings from magnetic resonance imaging, computed tomography and catheter angiography and discuss the endovascular management.