Urinary tract reconstruction for iatrogenic fistula secondary to radical hysterectomy: Cases from Malawi's Fistula Care Center

Complications from radical hysterectomy in low-income countries (LICs) are largely unreported in the medical literature. We report on three cases of urinary tract reconstruction performed at the Fistula Care Center (FCC) in Lilongwe, Malawi for iatrogenic fistula following radical hysterectomy. These cases demonstrate the diversity and complexity of reconstruction techniques required and emphasize the need for careful tracking of surgical outcomes of radical hysterectomy.

Renal-inferior vena cava fistula complicating laparoscopic cholecystectomy causing heart failure repaired endovascularly, a case report and literature review

INTRODUCTION

Renal-caval Arterio-venous fistulas are rare entity which can be acquired, idiopathic or congenital. Laparoscopic cholecystectomy complicated by arteriovenous fistula formation is extremely rare and often go unnoticed. High output heart failure can occur as a consequence of such high flow fistulas. Repair can be done through open or endovascular approach with the latter being effective and less invasive. Repair can result in resolution of symptoms and improvement of heart function.

CASE PRESENTATION

We report a 43-year old female who developed an iatrogenic renal-caval fistula following laparoscopic cholecystectomy, that was complicated by intraoperative bleeding. She presented with worsening high output cardiac failure a year post-operative. Due to past history of Cor-triatriatum surgical repair -a congenital heart disease-, the diagnosis of renal arteriovenous fistula remained insidious. The fistula was diagnosed during cardiac catheterization in an attempt to diagnose her rapidly decompensating heart failure, and repaired successfully by endovascular repair.

DISCUSSION

To our knowledge, there are only a few reports in literature describing iatrogenic renal artery-caval fistulas in association with laparoscopic cholecystectomy. Such high flow fistulas can result in a significant, potentially life threatening physiologic impairment. The case was managed by endovascular approach resulting in return to baseline cardiac function and resolution of symptoms.

CONCLUSIONS

Renocaval arteriovenous fistulas are extremely rare to complicate laparoscopic cholecystectomy. It might go unnoticed, but may present with decompensated heart failure. It can be reversed by early recognition of symptoms, and diagnosis. High index of suspicion is a key, and endovascular modality is excellent treatment approach.

Delayed presentation of a traumatic scalp arteriovenous fistula

Background:

Arteriovenous (AV) fistulas of the scalp are extracranial vascular malformations commonly caused by trauma and typically present within 3 years. Although they follow a benign course, they can be esthetically displeasing.

Case Description:

We present an atypical onset of scalp AV fistula in a patient with a 1-year history of the left-sided pulsatile tinnitus and scalp swelling 7 years after a traumatic epidural hematoma evacuation. Our patient was found to have an 8 mm AV fistula supplied by the deep temporal artery. Endovascular embolization was performed using eight coils. There was no complication from the procedure, and the patient’s pulsatile tinnitus and swelling resolved immediately after embolization. Follow-up angiogram demonstrated complete obliteration of the AV fistula.

Conclusion:

Delayed presentation of traumatic scalp AV fistula is very rare, and it is important to keep this in the differential in patients with scalp swelling after head trauma.

Iatrogenic fistula between the aorta and the right ventricular outflow tract after Melody valve implantation: Case report and literature review

We present the first case of an iatrogenic aorta to right ventricular outflow tract fistula after Melody valve implantation. A 11-year-old girl, born with tetralogy of Fallot with absent pulmonary valve, underwent surgical repair at three years old with a 15-mm homograft. At five years old, calcification and stenosis of the homograft prompted successful balloon angioplasty and five years later she underwent Melody valve implantation. During follow-up, she began to suffer fatigue on moderate exertion. Echocardiography, cardiac catheterization and computed tomography were performed and showed a significant fistula between the right coronary ostium and the right ventricular outflow tract proximal to the implanted valve. The patient underwent surgical repair and in long-term follow-up there is no evidence of the fistula. Iatrogenic fistula between the ascending aorta and the right ventricular outflow tract after percutaneous pulmonary valve implantation is an uncommon complication, and may grow over time. A high level of suspicion is required for this rare complication and a final aortography may be necessary for the diagnosis.

Rising trends in iatrogenic urogenital fistula: A new challenge

Objective

To analyze trends in iatrogenic urogenital fistula among patients admitted for fistula repair at the Pakistan Institute of Medical Sciences, Islamabad.

Methods

In this longitudinal study, all patients who presented for fistula repair between 2006 and 2018 were included in the study. Patient data were collected on age, parity, and type and etiology of fistula, which was classified as ischemic or iatrogenic.

Results

Of 634 fistula patients, 371 (58.5%) had iatrogenic fistula, while 263 (41.5%) patients developed ischemic fistula due to obstructed labor. Mean age of patients was 31.6 years. Yearly trends showed an increase in iatrogenic fistula from 43.2% in 2006–2008 to 71.4% in 2017–2018. The major etiological contributor to iatrogenic fistula was hysterectomy (52.5%), followed by cesarean hysterectomy (26.4%), and cesarean delivery (19.9%).

Conclusion

A rising trend in iatrogenic fistula was observed. This emphasizes the need for optimization of surgical approaches and surgical skills. Moreover, gynecologic surgeries should be restricted to authorized gynecologic surgeons.

A rising yearly trend in iatrogenic fistula was observed over a 12‐year period in Pakistan.

Dual-balloon assisted super-selective embolisation of high flow arterial venous fistula within a transplant kidney

Background

In this case report, we describe a novel application of the technique of ‘dual-balloon assisted’ cannulation and embolisation of a high flow arterial venous fistula (AVF) in transplant kidney, where attempts at standard and previously described embolisation techniques were proving difficult to achieve.

Case presentation

Seventy year old gentleman with renal transplant presenting with high output cardiac failure and deteriorating renal function. Angiography demonstrated high flow traumatic AV fistula within transplanted kidney, secondary to multiple biopsies. Attempts at guidewire and guiding sheath placement and stability for occlusion plug deployment were failing due to combination of very high back-flow pressures within the AVF and challenging vascular anatomy; with an aneurysmal, tortuous iliac artery as well as intra renal transplanted vessels. A combination of angioplasty and remodeling aortic balloons in the transplant artery and the host external iliac vein respectively, facilitated stabilization of guiding sheath and hence controlled delivery of an occlusion plug from the venous side of the fistula. The fistula was successfully embolised, leading to complete resolution of patient symptoms and improvement of renal function beyond his previous baseline.

Conclusions

Percutaneous embolisation is an established technique to treat iatrogenic AVF in transplant kidneys. High flow pressure through an AVF, as demonstrated in this case, can cause difficulty and raise safety issues in accessing and embolising the AVF using previously described techniques. This case report describes an effective and novel application of the technique of using a second balloon in the host common iliac vein to; lower flow pressure, stabilise the guidewires during plug deployment and prevent displacement of wires and/or plug into the common iliac vein.