Iatrogenic vertebrojugular arteriovenous fistula

Iatrogenic Vertebral Arteriovenous Fistula Involving Brachiocephalic Vein Due to Central Venous Catheterization: A Case Report

PURPOSE

To report a case of vertebral arteriovenous fistula (VAVF) caused by iatrogenic trauma of central venous catheterization (CVC) involving brachiocephalic vein (BCV).

CASE REPORT

A 79-year-old female was referred for assessment of a vertebral artery (VA) aneurysm at the V1 segment. The patient had no signs other than a vascular murmur on the right neck and was diagnosed 20 years after undergoing CVC. Right vertebral angiography revealed a high-flow shunt from the V1 segment of the right VA and draining into the right BCV. The fistula had a single communication between a pseudoaneurysm and large varix. We diagnosed the patient with CVCinduced VAVF (CIVAVF) involving BCV and obliterated the shunt by selective transarterial and transvenous embolization of the pseudoaneurysm under flow control using a balloon catheter with no complications.

CONCLUSION

This case highlights the point that CIVAVF involving BCV is rare but possible. In addition, there is a possibility that CIVAVF involving BCV does not demonstrate the findings of arterial steal or retrograde venous drainage and is undiagnosed for a long term due to lack of neurological manifestation and other subjective symptoms. We also showed that endovascular treatment can be feasible and useful for CIVAVF involving BCV.

Vertebral Arteriovenous Fistula: A Review Article

OBJECTIVE

Vertebrovertebral fistulas (VVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities, outcome, and complications associated with treatment.

METHODS

A literature search was performed by a reference librarian and after screening, 128 case reports and 16 case series were left for inclusion in the review. All possible data were abstracted by 3 authors, results were tabulated, and descriptive statistics (mean, range, and proportions) were reported. No formal statistical analysis was performed as part of this study.

RESULTS

A total of 280 patients were analyzed. VVFs can be categorized in 3 subgroups (iatrogenic, spontaneous, and traumatic), based on the mechanism of formation, and these different causes share different underlying demographics that bear important treatment considerations. Traumatic VVFs are more commonly seen in young men; the spontaneous form is more commonly seen in young women. Iatrogenic VVFs are more commonly seen in elderly people. Spontaneous VVFs are most commonly located between C1 and C2. Most iatrogenic (n = 39; 57%), spontaneous (n = 106; 82%), and traumatic (n = 53; 73%) VVFs were treated with deconstructive (defined as occlusion of fistula and feeding vessels) endovascular therapy. Overall treatment-related permanent morbidity was 3.3% (9/270) and mortality was 1.5% (4/270).

CONCLUSIONS

VVFs are uncommon lesions, and treatment is often indicated, even in patients without retrograde venous drainage. When treatment is undertaken, the cause of presentation and associated patient demographics should be considered when planning the treatment strategy.

A rare case of a vertebrojugular arteriovenous fistula: A case report and review of literature

Vertebrojugular fistulas have been described in the literature associated with blunt or penetrating injury and iatrogenic or spontaneous development. Its presentation may be broad and may include symptoms of radiculopathy, vertebrobasilar insufficiency, tinnitus, and bruit. However, so far, no direct cardiac complications had been reported. Here, we describe a case of an 86-year-old female who suffered a C5 vertebral fracture secondary to a ground-level fall that was initially treated conservatively due to the onset of new severe atrial fibrillation. However, the patient was later on taken to surgery due to progressive neurologic deterioration. Intraoperative complications led to the diagnosis of a vertebral-jugular fistula that was successfully embolized. The effective obliteration of the fistulae led to the recovery of both neurologic and cardiac symptoms.

Stent graft repair of traumatic vertebral pseudoaneurysm with arteriovenous fistula

Traumatic vertebral pseudoaneurysm is a rare occurrence. Such case with an enlarging symptomatic vertebral arteriovenous (AV) fistula was successfully treated with a covered endostent. Presentation, diagnosis and different acceptable treatment plans to this condition are further discussed. Stentgrafts can play an important and effective role in therapy of traumatic vertebral pseudoaneurysm with a concomitant AV fistula.

Iatrogenic vertebral artery injury

Iatrogenic vertebral artery injury (VAI) results from various diagnostic and therapeutic procedures. The objective of this article is to provide an update on the mechanism of injury and management of this potentially devastating complication. A literature search was conducted using PubMed. The iatrogenic VAIs were categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., central venous catheterization, cervical spine surgery, chiropractic manipulation, diagnostic cerebral angiography, percutaneous nerve block, and radiation therapy. The incidence, mechanisms of injury, and reparative procedures were discussed for each type of procedure. The type of VAI depends largely on the type of procedure. Laceration was the dominant type of acute injury in central venous catheterization and cervical spine surgery. Arteriovenous fistulae and pseudoaneurysms were the delayed complications. Arterial dissection was the dominant injury type in chiropractic manipulation and diagnostic cerebral angiography. Inadvertent arterial injection caused seizures or stroke in percutaneous nerve block. Radiation therapy was responsible for endothelial injury which in turn resulted in delayed stenosis and occlusion of the vertebral artery (VA). The proximal VA was the most vulnerable portion of the artery. Although iatrogenic VAIs are rare, they may actually be more prevalent than had previously been thought. Diagnosis of iatrogenic VAI may not always be easy because of its rarity and deep location, and a high level of suspicion is necessary for its early detection. A precise knowledge of the surgical anatomy of the VA is essential prior to each procedure to prevent its iatrogenic injury.

Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report

BACKGROUND

Vertebrojugular fistulas after penetrating cervical trauma (gunshot or stab wounds) are rarely reported. Successful endovascular coil embolization of an acute fistulizing vertebral artery pseudoaneurysm involving an obstructed internal jugular vein is presented and the various treatment strategies for such a lesion are described.

CASE DESCRIPTION

A 23-year-old man presented from an outside institution after sustaining 2 gunshot wounds in a civilian conflict. Neuroimaging revealed a right vertebral artery pseudoaneurysm, which formed a fistulous connection with the internal jugular vein. Because venous outflow obstruction was present just below the fistula, a high-flow shunt was directed intracranially. Both the pseudoaneurysm and arteriovenous fistula were accessed percutaneously via a transfemoral route and coil embolization was performed. Perfusion of the basilar artery circulation was assumed by the contralateral vertebral artery. The ipsilateral posteroinferior cerebellar artery filled through retrograde flow down the vertebral confluence.

CONCLUSIONS

Coil embolization is a safe and reliable strategy by which to obliterate an acute traumatic vertebrojugular fistula as well as pseudoaneurysm. Serial angiographic follow-up is mandatory to document a persistent cure.

Imaging the vertebral artery

Although conventional intraarterial digital subtraction angiography remains the gold standard method for imaging the vertebral artery, noninvasive modalities such as ultrasound, multislice computed tomographic angiography and magnetic resonance angiography are constantly improving and are playing an increasingly important role in diagnosing vertebral artery pathology in clinical practice. This paper reviews the current state of vertebral artery imaging from an evidence-based perspective. Normal anatomy, normal variants and a number of pathological entities such as vertebral atherosclerosis, arterial dissection, arteriovenous fistula, subclavian steal syndrome and vertebrobasilar dolichoectasia are discussed.

Iatrogenic vertebral arteriovenous fistula treated with a hemobahn stent-graft

PURPOSE

To illustrate the utility of color flow duplex ultrasound (CFDU) in the diagnosis and stent-graft treatment of a rare arteriovenous fistula (AVF) involving the vertebral artery and vein.

CASE REPORT

An iatrogenic AVF involving the right vertebral artery and vein was diagnosed in a 45-year-old man using CFDU. Treatment was recommended due to the large volume of blood shunted through the fistula and the associated loud bruit. Endoluminal treatment involved deployment of a covered stent within the vertebral artery to exclude the fistula. Postoperative CFDU confirmed the success of the treatment.

CONCLUSIONS

CFDU can be utilized to accurately diagnose unusual lesions, such as AVFs involving the vertebral artery. The technique is also useful in planning treatment and monitoring the durability of stent-grafts implanted to obliterate this type of defect.

Venous pseudo-aneurysm as a late complication of short-term central venous catheterisation

Complications following central venous catheterisation abound in the medical literature. This reflects the under-estimated potential hazards associated with this procedure as well as an increase in the number of such procedures performed in high-risk patients. We report on a case where a venous pseudo-aneurysm developed four months after the removal of a short-term central venous catheter in a moderately high-risk patient.

Recurrent vertebral arteriovenous fistula after surgical repair: treatment with a self-expanding stent-graft

PURPOSE

To describe successful endovascular repair of a recurrent vertebral arteriovenous fistula (AVF) after surgical correction.

CASE REPORT

A 42-year-old woman presented with recurrent dizziness, nausea, and headaches. A loud bruit in the right neck was present. Central venous catheter insertion had been done 1 year previously, creating an angiographically documented right-sided vertebral AVF that was successfully excluded by a surgical procedure. Four weeks later, the AVF reappeared. Successful endovascular repair with a self-expanding stent-graft was performed. Follow-up over 12 months was uneventful, with a patent vertebral artery and no recurrence of symptoms.

CONCLUSIONS

Endovascular stent-graft repair is feasible and offers a therapeutic alternative in the treatment of vertebral AVF, in particular for recurrence after initial surgery. This minimally invasive method may become the treatment of choice in the management of such lesions, preserving patency of the vertebral artery.