Endovascular repair of post-traumatic, concomitant popliteal artery pseudoaneurysm and arteriovenous fistula

A Central Venous Catheter Line Misadventure: "Doctor why do I have a humming sound in my ear?"

We report a 32-year-old female patient who was referred to a tertiary care hospital in Muscat, Oman, in 2021 with an iatrogenic arteriovenous fistula (AVF) that presented as a neck swelling which developed few weeks after an attempt of central venous catheterisation through the right internal jugular vein. The fistula was corrected surgically with a successful outcome. AVF is an abnormal communication between an artery and vein which can occur as a congenital anomaly, after trauma or iatrogenic following central venous catheter or endovenous thermal ablation.

Peroneal/posterior tibial nerves delayed dysfunction due to traumatic popliteal artery pseudoaneurysm resulting from trivial stab wound: A case report

Background:

Popliteal artery pseudoaneurysms due to stab wounds are extremely rate. Even more infrequently, they can contribute to the compression of multiple peripheral nerves.

Case Description:

A 23-year-old male, following a trivial stab wound, developed the delayed occurrence of a pseudoaneurysm of the popliteal artery. This resulted in the delayed onset of a compressive popliteal/posterior tibial neuropathy. Following restoration of blood flow through the popliteal artery utilizing saphenous vein grafting, additional neurolysis resulted in resolution of the compressive neuropathy.

Conclusion:

A 23-year-old male developed a pseudoaneurysm following minor trauma that resulted in peripheral nerve dysfunction.

Management of dual traumatic arterial-venous fistula from a single shotgun injury: a case report and literature review

Background

Traumatic arteriovenous fistula (TAVF) is an uncommon vascular entity that arises in various locations, often from penetrating injuries, with a wide spectrum of signs and symptoms. This case report highlights the importance of suspecting multiple TAVFs after a single gunshot wound, especially if it involves pellets. It also sheds light on adapting treatment, whether endovascular or open repair, to the location and characteristics of each fistula.

Case presentation

A 35-year-old male, with history of shotgun wound 5 months earlier, presented to our clinic with right lower extremity (RLE) edema and pain. Arterial duplex scan and subsequent angiogram showed two TAVFs at the popliteal and posterior tibial (PT) arteries, both of which could not be exactly localized with a computed tomography angiography (CTA) due to artifacts. The fistula connecting the posterior tibial artery (PTA) and vein was repaired endovascularly using a covered-stent, while the fistula between the popliteal artery and vein was repaired surgically. Postoperative follow-up at 3 months showed no arteriovenous fistula (AVF), patent vessels and distal stent stenosis at the PTA.

Conclusions

Patients who sustain gunshot injuries with shrapnel or pellets and develop TAVF consequentially need to be followed up with the possibility of multiple AVFs in mind. Arterial duplex scan is highly sensitive to detect those AVFs, yet angiography remains gold standard, particularly with extensive metal artefacts. Endovascular repair, when feasible, should be considered first, unless the patient is unstable or has anatomical constraints that increase the risk of complications. Lastly, surgeons should be weary of deep venous thrombosis (DVT), the Branham effect and arterial aneurysmal dilation postoperatively.

[False aneurysm of external carotid artery diagnosed after thyroidectomy]

The patient 58-year-old with nodular goiter grade 2 was hospitalized to the surgical clinic. Thyroidectomy was performed. Postoperative period was complicated by hiccups and pulsation in the right half of the neck. According to angiography and CT data, there were a hematoma within thyroid bed and arteriovenous fistula between superior thyroid artery and right facial vein. Surgical repair of the fistula and false aneurysm drainage were carried out. This case report demonstrates a rare complication of thyroidectomy - arteriovenous fistula between superior thyroid artery and facial vein followed by pulsatile false aneurysm.

Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature

Objective:

To review the current use of endovascular techniques in trauma.

Summary Background Data:

Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma.

Methods:

The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines.

Results:

Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability.

Conclusions:

The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.

Retrograde embolization of anterior tibial artery for an iatrogenic arterio-venous fistula causing left lower extremity claudication

Lower extremity angiogram is generally a safe and effective procedure with a low rate of vascular complications. We report here a unique case of a 33-year-old female with anterior tibial artery (ATA) to anterior tibial vein fistula formation after lower extremity endovascular intervention. This was initially treated with open repair of the fistula and ligation of ATA. However, patient continued to complain of claudication like symptoms. Patient subsequently had an endovascular embolization of ATA in a retrograde fashion. Recovery was unremarkable; patient was discharged home same day. Three months postoperatively patient denies leg pain, a follow-up arterial duplex failed to show presence of arterio-venous fistula. This case illustrates the effectiveness of an endovascular approach as a minimally invasive treatment for this uncommon complication that occurs after lower extremity endovascular intervention.

Pseudoaneurysm and Arteriovenous Fistula in a Rhesus Macaque (Macaca mulatta)

An 8-y-old female rhesus macaque (Macaca mulatta) presented for swelling of the left lower limb distal to the inguinal region and associated with the femoral artery. Physical and ultrasound examinations suggested an arteriovenous fistula combined with a pseudoaneurysm. After review of possible treatment options, we determined that open surgical repair was the best course of action. The pseudoaneurysm and arteriovenous fistula were surgically resected, and the macaque recovered without complication.

[Post-traumatic concomitant popliteal artery pseudoaneurysm and arteriovenous fistula]

Popliteal injuries are well known to be serious with a high rate of mortality due to damage caused to popliteal vessels. Pseudoaneurysm formation and arteriovenous fistulas are well-known complications of arterial injury, but are rarely concomitant. Diagnosis is usually done by computed tomography (CT) angiography. Treatment strategies consist of surgery or endovascular management. We report the surgical treatment of two cases of popliteal arteriovenous fistula associated with pseudoaneurysm complicating stab wounds.

[Management of popliteal artery pseudoaneurysms as a result of limb trauma and orthopedic surgery or associated with osteochondromas]

Most published articles regarding popliteal artery pseudoaneurysms (PAPs) are case reports and in English language literature. In this context, no study with robust data was previously published. The exact epidemiology of these APs is not well-known and their management is not yet codified. We wanted to summarize the current knowledge on diagnostic and therapeutic features of PAPs as a result of limb trauma and orthopedic surgery or associated with osteochondromas. An electronic research on MEDLINE and EMBASE between 1953 and March 2015 was performed; using the key words "popliteal pseudoaneurysm". The referenced articles were selectively read and this systematic review included 116 articles. Patient demographics; clinical presentations; diagnostic and therapeutic features were reviewed. In sum, 122 cases were analyzed. Overall young adult (average age=30.48±21.25 years old) represented the majority of the affected population with a masculine preponderance (79%). The main etiologies included femoral exostosis (63%), followed by the orthopedic surgery (25%) and direct trauma into the knee (10%). Painful swelling (44%) and/or pulsatile mass (39%) represented the most commonly presenting symptoms. The commonest radiological investigations used included arteriography (49%) and CTA (27%). The treatment was open surgical repair (85%) or endovascular stenting graft (14%). Post-therapeutic courses were often uneventful (98%). The morbidity rate was low at about 2%. The treatment of direct post-traumatic PAPs was usually open surgical repair (83%) with saphenous vein grafting. Endovascular stenting may be an ideal option for managing PAPs following orthopedic surgery (88%). Open surgery for vascular repair and maximum exostectomy must be undertaken concomitantly in the setting of APs associated with osteochondromas.

Popliteal artery pseudoaneurysm associated with solitary osteochondromatosis

Osteochondroma is the most common benign tumor of the bone, seen mostly during adolescence. In the current study, we report a 19-year-old male patient with a two-week history of pain and swelling of the medial side of his right thigh just above the knee without any trauma. CT angiography revealed a popliteal artery pseudoaneurysm and its close relationship with a femoral osteochondroma. Surgical repair consisted of repair of pseudoaneurysm and removal of osteochondroma. In young patients, a non-traumatic pseudoaneurysm of distal femoral artery may be a complication of an osteochondroma and this treatable pathology should be looked for to prevent recurrence.

Leg ulcer as a complication of a posttraumatic tibial arteriovenous fistula treated by endovascular approach with stent-graft placement

Endovascular treatment of posttraumatic arteriovenous fistulae (AVFs) in the lower extremities by means of covered stent-grafts is widely accepted, and many cases have been reported in the iliac-femoral region. However, few reports exist on the treatment of infrapopliteal AVFs, with or without a pseudoaneurysm, using this method. The authors present this case report dealing with a patient who had undergone a tibial and peroneal open fracture in his left limb 34 years ago. He developed a leg ulcer as a consequence of AVF between the tibialis posterior artery and vein, which resulted in venous insufficiency, which was treated by the endovascular approach with the placement of a stent-graft. Total healing was achieved over a period of 3 months. Angio-CT was performed, showing stent-graft patency 6 months after the endovascular procedure.