An unusual case of femoral arteriovenous fistula associated with acute limb ischemia following femoral vein catheterization for hemodialysis / Um caso incomum de fístula arteriovenosa femoral associada a isquemia aguda de membro após cateterização da veia femoral para hemodiálise

Abstract Co-occurrence of acute limb ischemia (ALI) and arteriovenous fistula (AVF) as a manifestation of inadvertent arterial injury during percutaneous femoral vein dialysis catheter insertion is a rare and dangerous, but preventable complication. Iatrogenic femoral AVF commonly presents late, with leg swelling or high output cardiac failure. However, the co-occurrence of a femoral AVF with both progressive leg swelling, and acute thromboembolism has not been previously reported. We report the case of an iatrogenic femoral AVF with superficial femoral artery (SFA) thrombosis and distal embolism in a 53-year-old female who underwent percutaneous femoral access for temporary hemodialysis. Both the SFA and AVF were managed with open surgical repair.

Resumo A coocorrência de isquemia aguda de membro (IAM) e fístula arteriovenosa (FAV) como uma manifestação de lesão arterial inadvertida durante a inserção de cateter para hemodiálise por via femoral percutânea é uma complicação rara e perigosa, porém evitável. A FAV femoral iatrogênica geralmente tem apresentação tardia, com edema dos membros inferiores ou insuficiência cardíaca de alto débito. No entanto, a coocorrência de FAV femoral com edema progressivo dos membros inferiores e tromboembolismo agudo não foi previamente relatada. Relatamos o caso de uma FAV femoral iatrogênica com trombose da artéria femoral superficial (AFS) e embolia distal em uma paciente do sexo feminino, 53 anos, submetida à acesso femoral percutâneo para hemodiálise temporária. Tanto a AFS quanto a FAV foram manejadas com reparo cirúrgico aberto.

Anatomy of the Middle Meningeal Artery

Introduction The middle meningeal artery (MMA) is an important artery in neurosurgery. As the largest branch of the maxillary artery, it provides nutrition to the meninges and to the frontal and parietal regions. Diseases, including dural arteriovenous fistula (DAVF), pseudoaneurysm, true aneurysm, traumatic arteriovenous fistula (TAVF), Moya-Moya disease (MMD), recurrent chronic subdural hematoma (CSDH), migraine, and meningioma,may be related to the MMA. The aim of the present study is to describe the anatomy of the MMA and to correlate it with brain diseases. Methods A literature review was performed using the PubMed, Scielo, Scientific Direct, Ebsco, LILACS, TripDataBase and Cochrane databases, with the following descriptors: neurosurgery, neuroanatomy, meninges and blood supply. Discussion The MMA is embedded in a cranial groove, and traumatic or iatrogenic factors can result in MMA-associated pseudoaneurysms or arteriovenous fistulas (AVFs). In hemodynamic stress, true aneurysms can develop. Arteriovenous fistulas, pseudoaneurysms, and true aneurysms can be effectively treated by endovascular or surgical removal. In MMD, the MMA plays a role in the development and in the improvement of collateral circulation. Finally, in cases of CSDH, when standard surgery and drainage fail, MMA embolization can constitute a great alternative. Conclusion The MMA is a relevant structure for the understanding of neurosurgical diseases. In conclusion, every neurosurgeon must know the anatomy of the MMA sufficiently to correlate it with the diagnosed pathology, thus obtaining treatment effectiveness and preventing brain lesion.

Angioaccesos para hemodiálisis en el trasplante renal: implicaciones hemodinámicas sobre el corazón izquierdo / Angioaccess for hemodialysis in kidney transplantation: hemodynamic implications for the left heart

Las complicaciones cardiovasculares representan la principal causa de morbilidad y mortalidad en pacientes con enfermedad renal crónica, por lo que el objetivo de este artículo es demostrar la influencia de la permanencia de la fístula arteriovenosa sobre variables eco cardiográficamente mensuradas en el corazón izquierdo. Para ello, se definió un estudio multivariable, longitudinal, prospectivo y controlado de grupos independientes después de una intervención que incluyó 39 pacientes a los que se le cerró el angioacceso (grupo de estudio) y 42 que no fueron expuestos a la cirugía (grupo control). Ambos grupos exhibían trasplante renal funcionante. Los principales resultados surgenal comparar el predominio entre el grupo de estudio con el de control, la edad promedio; 45,6 y 44,1 años, el sexo masculino, 24 (60%) y 23 (53,5%) y el color de la piel blanca; 33 (82,5%) y 32 (74,4%). La etiología de la nefropatía originaria más frecuente fue la nefropatía vascular hipertensiva; 12 (30%) vs 14 (32,6%). Entre las manifestaciones clínicas, en el grupo de estudio se evidenció remisión de las palpitaciones y la disnea de esfuerzo. Respecto a la tensión arterial, para la sistólica oscilaba; de 123 ±13,4 a 120,5 ±9,2 vs de 125,6 ±8,4 a 128 ±8,3 mm Hg (p= 0,000), mientras la diastólica variaba de; 76,8 ±7,5 a 76,3 ±6,2 vs 78,6 ±4,9 a 82,4 ±3,9 mm Hg (p= 0,000). El hematocrito comportaba valores equivalentes; 0,43 ±0,06 y 0,45 ±0,06 vs 0,42 ±0,05 y 0,42 ±0,06 l/l (p= 0,035) y la creatinina sérica mostró descenso en los pacientes intervenidos de; 106,8 ± 26,2 hasta 99,8 ±23,9 µ Mol/l vs 114 ±27,8 a 120,3 ±31 µ Mol/l (p= 0,002). Las variables ecocardiográficas mensuradas comparativamente según la localización de los angioaccesos a nivel del codo izquierdo; diámetro del ventrículo izquierdo: 3,12 ±4,08 vs 1,48 ±3,46 mms (p=0,001), fracción de eyección del ventrículo izquierdo: 2,99 ±5,47 vs -1,98 ±6,23 % (p=0,018) y el volumen telediastólico: -23 ±33,41 vs 10,86 ±36,87 ml (p=0,006). El codo contralateral revelaba; para la fracción de eyección del ventrículo izquierdo: 3,32 ±3,42 vs -2,18 ±4,78 % (p=0,037) y para el gasto cardíaco: -1,29 ±0,88 vs -0,26 ±0,86 l/min (0,020). Las conclusiones demuestran que el cierre del angioacceso a pacientes con trasplante renal funcionante respecto a los no intervenidos, contribuye a la regresión de las alteraciones morfológicas y hemodinámicas constatadas por ecocardiografía transtorácica en el corazón izquierdo a nivel de las diferentes localizaciones de los accesos vasculares.

Cardiovascular complications represent the main cause of morbidity and mortality in patients with chronic renal disease, so the objective of this article is to demonstrate the influence of the patency of the arteriovenous fistula on echocardiographic variables measured in the left heart. For this, a multivariate study, longitudinal, prospective and controlled study of independent groups after an intervention that included 39 patients who had their angioaccess closed (study group) and 42 who were not exposed to surgery (control group). Both groups exhibited functional kidney transplantation. The main results emerge when comparing the prevalence between the study group and the control group, the average age; 45.6 and 44.1 years, the male sex, 24 (60%) and 23 (53.5%) and the white skin color; 33 (82.5%) and 32 (74.4%). The most frequent etiology of the original nephropathy was hypertensive vascular nephropathy; 12 (30%) vs 14 (32.6%). Among the clinical manifestations, remission of palpitations and dyspnea on exertion were evidenced in the study group. With regard to blood pressure, for the systolic it ranged from 123 ±13.4 to 120.5 ±9.2 vs. 125.6 ±8.4 to 128 ±8.3 mmHg (p= 0.000), while the diastolic varied from; 76.8 ±7.5 to 76.3 ±6.2 vs. 78.6 ±4.9 to 82.4 ±3.9 mmHg (p= 0.000). The hematocrit had equivalent values; 0.43 ±0.06 and 0.45 ±0.06 vs 0.42 ±0.05 and 0.42 ±0.06 l/l (p= 0.035) and the serum creatinine showed decrease in the operated patients from; 106.8 ±26.2 to 99.8 ±23.9 µMol/l vs 114 ±27.8 to 120.3 ±31 µMol/l (p= 0.002). The echocardiographic variables measured comparatively according to the location of the angioaccesses at the left elbow level; diameter of the left ventricle: 3.12 ±4.08 vs 1.48 ±3.46 mms (p=0.001), ejection fraction of the left ventricle: 2.99 ±5.47 vs -1.98 ±6.23 % (p=0.018) and the telediasolic volume: -23 ±33.41 vs 10.86 ±36.87 ml (p=0.006). The contralateral elbow revealed; for the left ventricular ejection fraction: 3.32 ±3.42 vs -2.18 ±4.78 % (p=0.037) and for cardiac output: -1.29 ±0.88 vs -0.26 ±0.86 l/min (0.020). The conclusions show that the our study has shown that closing the angioaccess to patients with functioning renal transplants with respect to those not operated, contributes to the regression of morphological and hemodynamic alterations observed by transthoracic echocardiography in the left heart at the different locations of the vascular accesses.

Fístula arteriovenosa traumática em região temporal: um desafio terapêutico / Traumatic arteriovenous fistula in the temporal region: a therapeutic challenge

Resumo As fistulas arteriovenosas podem ser congênitas ou traumáticas, sendo as primeiras mais comuns e diagnosticadas na infância e as últimas mais raras e com diagnóstico mais tardio. Ambas necessitam de tratamento intervencionista, que pode ser endovascular ou correção cirúrgica, sendo que cada caso deve ser estudado individualmente. Este artigo apresenta o caso de um paciente de 46 anos, com fístula arteriovenosa na artéria temporal superficial esquerda com suas veias correspondentes decorrente de trauma contuso na região temporal na infância. O diagnóstico foi confirmado por exame de imagem, e o paciente foi submetido a tratamento cirúrgico convencional, apresentando melhora dos sintomas. O caso chama atenção para uma afecção rara, sua investigação diagnóstica e condutas terapêuticas. As fistulas arteriovenosas traumáticas apresentam baixa incidência, ocorrem em variadas localizações e podem causar sintomas, requerendo tratamento, às vezes desafiador, com melhora da qualidade de vida do paciente.

Abstract Arteriovenous fistulas can be congenital or traumatic, the former being more common and diagnosed in childhood, and the latter being rarer and diagnosed later in life. Both require interventional treatment, which may be endovascular, or surgical repair and each case must be studied individually. This article presents the case of a 46-year-old patient with an arteriovenous fistula (AVF) between the left temporal artery and its corresponding veins resulting from a blunt trauma to the parietal region during childhood. The diagnosis was confirmed by imaging examination and he underwent conventional surgical treatment with improvement of symptoms. The case calls attention to a rare condition, its diagnostic investigation, and therapeutic approaches. The incidence of traumatic arteriovenous fistulas is low. They can occur in a variety of ways and can cause symptoms, requiring treatment, which is sometimes challenging, resulting in improvement in the patient's quality of life.

Avaliação clínica da maturação da fístula arteriovenosa para hemodiálise: revisão de escopo / Evaluación clínica de la maduración de la fístula arteriovenosa para hemodiálisis: revisión de alcance / Arteriovenous fistula maturation clinical assessment for hemodialysis: a scoping review

Resumo Objetivo: Mapear as evidências de pesquisa disponíveis para avaliação clínica da maturação da fístula arteriovenosa. Métodos: Estudo do tipo Scoping review, com busca realizada entre outubro a novembro de 2019 nas bases de dados JBI, Cochrane, Biblioteca Virtual em Saúde, PubMed, e CINAHL, sendo incluídos estudos com pacientes maiores de 18 anos, com doença renal crônica pré-dialítica ou já em hemodiálise, submetidos à cirurgia da fístula arteriovenosa; texto disponível; e idiomas inglês, espanhol ou português. Foram excluídos estudos relacionados a fase pós-operatória ou relacionados a cuidados com próteses/enxertos arteriovenosos. Resultados: Foram identificadas 1954 publicações elegíveis, dos quais 38 compuseram a amostra final. O estudo compreendeu publicações entre 1998 e 2018, com abrangência internacional do tema (94,7%). O profissional executor da avaliação foi predominantemente o enfermeiro ou equipe de enfermagem (47,4%), e a avaliação teve início no pós-cirúrgico imediato, até meses após a cirurgia. Dentre as técnicas de avaliação clínica, 23 estudos (60,5%) recomendaram o exame físico e 15 (39,5%) a combinação anamnese e exame físico. Conclusão: A presente revisão apresentou o mapeamento de evidências, nas quais a avaliação clínica da fístula arteriovenosa deve incluir anamnese e exame físico, sendo apresentados vários elementos ligados a permeabilidade e respostas vasculares do acesso. Houve a predominância do profissional enfermeiro como avaliador, sendo ressaltada a necessidade do treinamento para execução da avaliação, além de uma avaliação mais abrangente, com aplicação do Processo e Teorias de Enfermagem, e Linguagens Padronizadas, o que pode propiciar um novo campo de investigação e desenvolvimento na área.

Resumen Objetivo: Mapear las evidencias de investigación disponibles para evaluación clínica de la maduración de la fístula arteriovenosa. Métodos: Estudio tipo scoping review, cuya búsqueda fue realizada entre octubre y noviembre de 2019 en las bases de datos JBI, Cochrane, Biblioteca Virtual em Saúde, PubMed y CINAHL. Se incluyeron estudios con pacientes mayores de 18 años, con enfermedad renal crónica predialítica o ya en hemodiálisis, sometidos a cirugía de fístula arteriovenosa y textos disponibles en inglés, español o portugués. Se excluyeron estudios relacionados con la fase posoperatoria o relacionados con cuidados de prótesis/injertos. Resultados: Se identificaron 1.954 publicaciones elegibles, de las cuales 38 formaron parte de la muestra final. El estudio comprendió publicaciones entre 1998 y 2018, con alcance internacional del tema (94,7 %). El profesional que ejecutó la evaluación fue predominantemente el enfermero o el equipo de enfermería (47,4 %) y la evaluación comenzó en el posoperatorio inmediato, hasta meses después de la cirugía. Entre las técnicas de evaluación clínica, 23 estudios (60,5 %) recomendaron el examen físico y 15 (39,5 %) la combinación entre anamnesis y examen físico. Conclusión: La revisión presentó el mapeo de evidencias, en las cuales la evaluación clínica de la fístula arteriovenosa debe incluir anamnesis y examen físico. También se presentaron varios elementos relacionados con la permeabilidad y respuestas vasculares del acceso. Hubo una predominancia del profesional enfermero como evaluador y se destaca la necesidad de entrenamiento para llevar a cabo la evaluación, además de una evaluación más abarcadora, con aplicación del proceso y teorías de enfermería y un lenguaje estandarizado, lo que puede proporcionar un nuevo campo de investigación y desarrollo del área.

Abstract Objective: To map the available research evidence for arteriovenous fistula maturation clinical assessment. Methods: A scoping review, with a search conducted between October and November 2019 at JBI, Cochrane, Virtual Health Library, PubMed, and CINAHL. Studies with patients over 18 years old, with pre-dialysis chronic kidney disease or already under hemodialysis, who underwent arteriovenous fistula surgery were included; available text; and in English, Spanish, and Brazilian Portuguese. Studies related to the postoperative phase or related to care with prostheses/arteriovenous grafts were excluded. Results: One thousand nine hundred and fifty-four eligible studies were identified; 38 made up the final sample. The study comprised studies between 1998 and 2018, with an international scope of the theme (94.7%). The professional who performed the assessment was predominantly the nurse or nursing team (47.4%), and assessment started in the immediate post-surgical period, even months after surgery. Among the clinical assessment techniques, 23 studies (60.5%) recommended physical examination and 15 (39.5%) the combination of medical history and physical examination. Conclusion: This review presented the mapping of evidence, in which arteriovenous fistula clinical assessment must include medical history and physical examination. Several elements related to the permeability and vascular responses of the access were presented. There was a predominance of professional nurses as evaluators. There was need for training to carry out the assessment, in addition to a more comprehensive assessment, with the application of the Nursing Theory and Standardized Languages and Process, which may provide with a new field of research and development in the area.

Reparación endovascular de aneurisma de arteria ilíaca común asociado a fístula arterio-venosa ílio-ilíaca: reporte de caso / Endovascular repair of common iliac artery aneurysm associated with ilio-iliac arteriovenous fistula: case report

Resumen Introducción: Los aneurismas aislados de arteria ilíaca común son una patología infrecuente y habitualmente el diagnóstico es incidental. Su manejo solía ser por vía abierta, pero con el advenimiento de la cirugía endovascular, se han identificado mejores desenlaces en los pacientes llevados a este tipo de procedimientos, reservando la reparación abierta en los casos agudos y rupturas. La asociación entre estos aneurismas con fístulas ílio-ilíacas son infrecuentes y su manejo endovascular se ha reportado en solo una ocasión. Objetivo: Se presenta un caso de un paciente masculino de 82 años, con esta asociación, en el cual se decidió llevar de manera electiva a manejo endovascular de su patología. Discusión: En la literatura el manejo endovascular es ampliamente recomendado por su perfil de seguridad, sin embargo, no existe suficiente evidencia ante la presencia de una fístula ílio-ilíaca de manera concomitante, por ser una condición infrecuente. Conclusión: En el presente caso, abordamos de manera endovascular esta relación, obteniendo resultados favorables, con adecuado control de la patología, sin presentación de complicaciones.

Introduction: The isolated aneurysms of the common iliac artery correspond to an infrequent pathology; and the diagnosis of this entity is usually incidental. Its management is usually by open route, but with the advent of endovascular surgery, better outcomes have been identified in patients taken to this kind of procedure, reserving open repair for the urgent cases, like ruptures. The association between these aneurysms with ilio-iliac fistula is uncommon and their endovascular management has been reported only in one case in the literature. Aim: A case of an 82-year-old male patient will be presented, with this association, who was taken to an endovascular repair of his pathology, with good postoperative results. Discussion: In the literature, endovascular management is recommended by its safety profile, however there is insufficient evidence in the presence of an ilio-iliac fistula concomitantly, because it is an infrequent condition. Conclusion: In the present case, we address this relationship endovascularly, obtaining favorable results, with adequate control of the pathology, without presenting any complications.

Correção cirúrgica de fístula carotídeo-jugular traumática / Surgical repair of a traumatic carotid-jugular arteriovenous fistula

Resumo Traumatismos cervicais penetrantes podem ser potencialmente fatais. Em cerca de 25% dos casos, há lesão vascular associada, que pode evoluir para fístulas arteriovenosas. Os autores apresentam um caso de correção tardia, por cirurgia aberta, de uma fístula carotídeo-jugular e fazem uma breve revisão sobre o diagnóstico e opções de tratamento dessa condição.

Abstract Penetrating neck injuries can be life threatening. In about 25% of cases there are vascular injuries, which can progress to formation of arteriovenous fistulas. The authors present a case of delayed open surgery to repair a carotid-jugular fistula and briefly review the diagnosis and treatment options for this condition.

Tratamento endovascular da hipertensão portal e da hemorragia digestiva recorrente e secundária à síndrome da fístula arterioportal: complicação tardia de trauma abdominal penetrante / Endovascular treatment of portal hypertension and recurrent digestive hemorrhage secondary to arterioportal fistula syndrome: late complication of penetrating abdominal trauma

Resumo A síndrome da fístula artério-portal (FAP) é uma rara e reversível causa de hipertensão portal pré-sinusoidal, ocasionada pela comunicação de uma artéria visceral com o sistema venoso portal. A maioria dos pacientes é assintomática, mas quando desenvolvem sintomas, estes são mais relacionados com sangramento gastrointestinal, ascite, insuficiência cardíaca congestiva e diarreia. Este desafio terapêutico apresenta um caso de FAP decorrente de ferimento antigo por arma branca e subsequente evolução clínica desfavorável, com grave desnutrição e frequentes hemorragias digestivas. O caso foi solucionado através de oclusão da FAP por meio de tratamento endovascular.

Abstract The arterioportal fistula (APF) syndrome is a rare and reversible cause of pre-sinusoidal portal hypertension, caused by communication between a visceral artery and the portal venous system. Most patients are asymptomatic, but when they do develop symptoms, these are mainly related to gastrointestinal bleeding, ascites, congestive heart failure, and diarrhea. This therapeutic challenge presents a case of APF caused by a 20-year-old stabbing injury with unfavorable late clinical evolution, including significant malnutrition and severe digestive hemorrhages. The patient was treated using an endovascular procedure to occlude of the fistula.

Fístula arteriovenosa pós-cateterismo radial com repercussões cardiopulmonares / Arteriovenous fistula after radial catheterization with cardiopulmonary repercussions

O presente artigo relata o caso de um paciente coronariopata de 86 anos submetido a cateterismo cardíaco via acesso radial à esquerda. Cerca de 16 meses após o procedimento, manifestou dispneia sem relação com esforço, associada a hipóxia noturna. Apresentava frêmito à palpação do punho esquerdo e foi diagnosticado com fístula arteriovenosa radiocefálica no punho esquerdo. Ao duplex scan apresentava alteração de padrão de onda e aumento da velocidade diastólica compatível com fístula arteriovenosa. Foi submetido a correção cirúrgica da fístula, apresentando melhora clínica e laboratorial após o procedimento. O acesso radial para cateterismo cardíaco tem sido cada vez mais utilizado, principalmente por causar complicações menos frequentes e menos deletérias em comparação ao acesso femoral. Entretanto, complicações como fístula arteriovenosa ocorrem e podem ser especialmente prejudiciais em pacientes octogenários

This article describes the case of an 86-year-old coronary disease patient who underwent cardiac catheterization via a left radial access. Around 16 months after the procedure, he presented with dyspnea, unrelated to effort, but associated with nocturnal hypoxia. There was a palpable thrill in the left wrist and he was diagnosed with a radiocephalic arteriovenous fistula in the left wrist. A duplex scan revealed an abnormal wave pattern and increased diastolic velocity compatible with arteriovenous fistula. The fistula was repaired surgically and the patient exhibited improvement in clinical and laboratory parameters after the procedure. Radial access is increasingly being used for cardiac catheterization, primarily because it is associated with fewer and less harmful complications than femoral access. However, complications such as arteriovenous fistula occur and can be particularly harmful in octogenarian patients

Gradual treatment of arteriovenous fistula in femoral vessels as a complication of coronary angiography

Abstract Arteriovenous fistula due to coronary angiography intervention is rarely seen. Arteriovenous fistulas may be asymptomatic according to the size of the shunt, as well as to the heart failure. In this case report, we aimed to share gradual transition from endovascular methods to surgery and why surgical treatment is required for a patient who developed arteriovenous fistula after coronary angiography.

Endovascular treatment of acute gastrointestinal bleeding from a large splenic artery pseudoaneurysm: case report and literature review / Tratamento endovascular da hemorragia digestiva aguda por volumoso pseudoaneurisma esplênico: relato de caso e revisão da literatura

O pseudoaneurisma da artéria esplênica é uma entidade rara, com pouco mais de 150 casos descritos na literatura. A pancreatite é a etiologia mais comum, seguida do trauma. Em contraposição ao aneurisma verdadeiro, esse pseudoaneurisma é frequentemente sintomático, com risco de ruptura de 47% e mortalidade de 90%, quando não tratado. Descrevemos o caso de uma paciente de 48 anos que apresentou hemorragia gastrointestinal associada a pancreatite crônica agudizada. Durante investigação, a endoscopia evidenciou sinais de sangramento recente, e a angiorressonância de abdome observou volumoso pseudoaneurisma da artéria esplênica. Foi submetida a tratamento endovascular com embolização com micromolas, não apresentando novos episódios de sangramento. Atualmente, o tratamento endovascular é efetivo com baixa morbimortalidade e taxas de sucesso de 79-100%, sendo uma técnica viável para pacientes com processo inflamatório abdominal em franca atividade. Realizamos uma revisão das técnicas endovasculares e agentes embolizantes usados para o tratamento dessa patologia

Pseudoaneurysm of the splenic artery is a rare entity, with little more than 150 cases described in the literature. Pancreatitis is the most common etiology, followed by trauma. In contrast with true aneurysms, pseudoaneurysms are frequently symptomatic, with a 47% risk of rupture and 90% mortality if left untreated. We describe the case of a 48-year-old female patient who suffered a gastrointestinal hemorrhage associated with acute-on-chronic pancreatitis. During workup, endoscopy revealed signs of recent bleeding and magnetic resonance angiography of the abdomen showed a large pseudoaneurysm of the splenic artery. The patient underwent endovascular treatment with microcoil embolization and no further bleeding episodes occurred. Endovascular treatment is now an effective option with low morbidity and mortality and success rates in the range of 79-100%, making it a viable technique for patients with active abdominal inflammation. We conducted a review of endovascular techniques and embolization agents used to treat this pathology

Correção cirúrgica de pseudoaneurismas e fístula arteriovenosa complexa entre vasos poplíteos / Surgical repair of pseudoaneurysms and complex arteriovenous fistula between popliteal vessels

A fístula arteriovenosa (FAV) é uma comunicação anormal e permanente entre uma artéria e uma veia devido a traumas penetrantes e lesões iatrogênicas. O trauma penetrante na parede arterial pode levar à formação de pseudoaneurismas (PSA) e, se houver lesão venosa concomitante, à formação de uma FAV. Os autores apresentam o caso de um paciente portador de FAV complexa de vasos poplíteos associada a pseudoaneurisma de artéria poplítea, sugeridos a partir de exames clínicos e exames de imagem, e tratados por cirurgia convencional devido à indisponibilidade de um stent graft com diâmetro apropriado, além de a cirurgia endovascular não estar disponível no serviço em que o paciente foi operado

An arteriovenous fistula (AVF) is an abnormal and permanent communication between an artery and a vein caused by penetrating traumas or iatrogenic injuries. A penetrating trauma to the endothelial wall can lead to formation of pseudoaneurysms (PSA) and to formation of an AVF. Here, the authors present the case of a patient with a complex AVF of popliteal vessels, associated with popliteal artery pseudoaneurysm, suggested by clinical features and imaging exams, and treated with conventional surgery due to unavailability of a stent graft with appropriate diameter and because endovascular surgery isn't provided at the service where this patient was operated

Fístulas arterio-venosas trombosadas para hemodiálisis y su tratamiento / Thrombosed hemodyalisis arteriovenous fistulae and their treatment

Introducción: La trombosis constituye la principal causa de disfunción y pérdida de las fístulas arterio-venosas para hemodiálisis. Objetivo: actualizar los aspectos relacionados con los principales tratamientos de las fístulas arterio-venosas trombosadas. Fuente de los datos: Se realizó la búsqueda de artículos sobre el tema en la base de dato Medline, artículos publicados en páginas web y revistas líderes en la publicación de estudios sobre fístulas arterio-venosas para hemodiálisis. Síntesis de los datos: La trombosis es la complicación más frecuente de las fístulas arterio-venosas, su principal causa lo constituyen los errores técnicos en la trombosis precoz y las estenosis en las tardías. Conclusiones: La repermeabilización precoz de las fístulas arterio-venosas y tratar las estenosis en el mismo acto quirúrgico, es lo que se recomienda. Para tales fines se cuenta con las técnicas quirúrgicas identificadas como el gold standard y las endovasculares, con resultados alentadores(AU)

Introduction: Thrombosis is the most frequent cause of dysfunction and loss of hemodyalisis arteriovenous fistula. Objective: To update knowledge on the epidemiology, the characteristics and the main treatments of the thrombosed hemodyalisis arteriovenous fistulae. Data source: A literature research about the topic was made in Medline, in articles published in different web pages and in leading journals in the publication of studies about hemodialysis arteriovenous fistula. Data synthesis: Thrombosis is the most frequent complication of the arteriovenous fistula, being the technical errors the main cause of premature thrombosis and the stenosis in the late thrombosis. Conclusions: It is recommended to use early repermeabilization of the arteriovenuos fistulae and to treat stenosis in the same surgical act; for that purpose the surgical treatment identified as the "standard gold" and the endovascular technique achieve encouraging results(AU)

Coronary arteriovenous fistulas in adult patients: surgical management and outcomes

Abstract Objective: The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods: Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results: A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion: The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Trauma inguinal penetrante com formação de fístula arteriovenosa e pseudoaneurisma: relato de caso / Acquired arteriovenous fistula and pseudoaneurysm secondary to penetrating inguinal trauma: a case report

Os autores apresentam um relato de caso de vítima de acidente de trabalho com ferimento penetrante em região inguinal direita com peça metálica em espiral, que evoluiu com fístula arteriovenosa da artéria femoral profunda com a veia femoral profunda associado a pseudoaneurisma envolvendo essas estruturas e a veia femoral comum. As fístulas arteriovenosas ocorrem frequentemente após traumas e a associação com pseudoaneurisma é fato raro, devendo ser tratadas precocemente após seu diagnóstico. O ultrassom duplex é atualmente o exame mais utilizado para a avaliação inicial e a arteriografia, o padrão ouro para diagnóstico. No paciente em questão foi realizado tratamento convencional com abordagem cirúrgica direta, sutura arterial e ligaduras venosas. Entretanto, nos dias atuais a cirurgia endovascular e a compressão guiada por ultrassom são métodos terapêuticos que têm sido utilizados com sucesso. O paciente evoluiu sem intercorrência, recebendo alta para acompanhamento ambulatorial com preservação do membro.

This article describes the case of a work accident victim with a penetrating wound to the right inguinal region caused by a metal spiral. The patient developed an arteriovenous fistula between the deep femoral artery and deep femoral vein, combined with a pseudoaneurysm surrounding these structures and the common femoral vein. Arteriovenous fistulas frequently occur after traumas, but the combination of fistula and pseudoaneurysm is rare. It is recommended that they be treated immediately after diagnosis. Duplex ultrasound is the most widely used method for initial assessment and arteriography is the gold standard for diagnosis of arteriovenous fistulas. Endovascular surgery has recently been used successfully in such cases. However, this patient was treated conventionally using a direct surgical approach, arterial suture and venous ligatures, and the limb was saved. The patient developed no complications and was discharged to outpatients follow-up.

Alternative grafts for brachioaxillary hemodialysis access: 1-year comparative results

BACKGROUND: Many chronic renal patients lack autologous veins in the upper limbs suitable for construction of arteriovenous fistulas for hemodialysis. Alternative fistula options for these patients should be evaluated and compared.OBJECTIVE: To compare different types of grafts used for brachioaxillary access in hemodialysis patients in terms of their patency and complication rates.METHOD: Forty-nine patients free from arterial system abnormalities and with no venous options for creation of arteriovenous fistulae in the arm and/or forearm underwent brachioaxillary bypass with implantation of autologous saphenous vein, polytetrafluoroethylene (PTFE), or PROPATEN(r) grafts. Patients were assessed by Doppler ultrasonography at 3, 6, and 12 months after surgery. RESULTS: The four first saphenous vein grafts had failed by 3 or 6 months after surgery. The autologous saphenous vein group was discontinued at the beginning of the study because of extreme difficulty in achieving puncture and hematoma formation. Failure rates of PTFE and PROPATEN(r) grafts did not differ after 3 (p = 0.559), 6 (p = 0.920), or 12 months (p = 0.514). A log-rank test applied to cumulative survival of grafts at 1 year (0.69 for PTFE, 0.79 for PROPATEN(r)) detected no significant differences (p = 0.938). There were no differences in complications resulting in graft failure between the two types of prosthetic graft.CONCLUSION: Autologous saphenous vein grafts do not appear to be a good option for brachioaxillary hemodialysis access because of difficulties with achieving puncture. Brachioaxillary fistulae constructed using PTFE or PROPATEN(r) grafts exhibited similar patency and complication rates. Further studies with large samples size are warranted to confirm our findings.

CONTEXTO: Há inúmeros pacientes renais crônicos sem veias autólogas nos membros superiores para confecção de fístulas arteriovenosas para realização de hemodiálise. As opções de fístula nestes pacientes devem ser avaliadas e comparadas.OBJETIVO: Comparar diferentes enxertos para acesso braquioaxilar em pacientes hemodialíticos, em relação a permeabilidade e taxas de complicação. MÉTODO: Um grupo de 49 pacientes, sem alterações no sistema arterial e sem opções venosas para criação de fístula arteriovenosa no braço e/ou antebraço, foi submetido a procedimentos cirúrgicos para implante de diferentes enxertos: veia safena autóloga, enxertos de PTFE e PROPATEN(r).RESULTADOS: Os quatro primeiros implantes de veia safena falharam no terceiro e no sexto mês após a cirurgia. Interrompeu-se o uso de veia safena autóloga no início do estudo pela extrema dificuldade de punção e pela formação de hematoma. Não houve diferenças nas taxas de falha dos enxertos de PTFE e PROPATEN(r) após três (p = 0,559), seis (p = 0,920) e 12 meses (p = 0,514) de seguimento. O teste de Logrank aplicado à sobrevida cumulativa dos enxertos por um ano (0,68 para PTFE; 0,79 para PROPATEN(r)) não relevou diferenças (p = 0,938). Não foram encontradas diferenças entre os enxertos prostéticos em relação ao tipo de complicação que determinou as falhas.CONCLUSÃO: O enxerto de veia safena autóloga parece não ser é uma boa opção para acesso braquioaxilar em hemodialíticos, já que implica em dificuldade na punção. Os enxertos de PTFE e PROPATEN(r) em fistula braquioaxilar resultaram em permeabilidade e taxas de complicações similares. Estudos com amostras maiores são necessários para confirmar nossos achados.

Traumatic arteriovenous fistula associated to pseudoaneurysm of the superficial temporal artery in a child: case report and literature review / Fístula arteriovenosa traumática associada a pseudoaneurisma da artéria temporal superficial em uma criança: relato de caso e revisão da literatura

As fístulas arteriovenosas (FAVs) e os pseudoaneurismas traumáticos extracranianos são malformações incomuns e, em sua maioria, estão associadas a traumatismo craniano fechado com lesão contusa de forte intensidade. O diagnóstico em geral é clínico, porém o exame de escolha para o diagnóstico definitivo é a angiografia. Nos casos em que a lesão é pequena, é possível abordá-la com embolização via endovascular com sucesso. A excisão cirúrgica, no entanto, ainda é o método de escolha para o tratamento. É relatado um caso de um paciente do sexo masculino, com 9 anos de idade, diagnosticado com FAV, acometendo o ramo frontal da artéria temporal superficial, secundária a trauma craniano contundente ocorrido três anos antes do diagnóstico.

The arteriovenous fistulae (AVFs) and the extracranial traumatic pseudoaneurysms are uncommon malformations and in the majority of the cases are associated to closed head trauma with high intensity blunt lesion. The diagnosis is generally clinical, though the exam of choice for definitive diagnosis is an angiography. In minor lesion cases it's possible to successfully approach it with endovas-cular embolization. The surgical excision though, is the method of choice for the treatment. Here is reported a case of a 9-year-old male patient, diagnosed with AVF involving the frontal branch of the superficial temporal artery, secondary to blunt head trauma occurred three years before diagnosis.

Endovascular Recanalization of a Thrombosed Native Arteriovenous Fistula Complicated with an Aneurysm: Technical Aspects and Outcomes

OBJECTIVE: To evaluate the technical aspects and outcomes of endovascular recanalization of a thrombosed native arteriovenous fistula (AVF) complicated with an aneurysm. MATERIALS AND METHODS: Sixteen patients who had a thrombosed AVF complicated with an aneurysm (two radiocephalic and 14 brachiocephalic) were included in this study. Recanalization procedures were performed by mechanical thrombectomy using the Arrow-Trerotola percutaneous thrombectomy device and adjunctive treatments. We evaluated dose of thrombolytic agent, underlying stenosis, procedure time, technical and clinical success, and complications. The primary and secondary patency rates were calculated using the Kaplan-Meier analysis. RESULTS: The thrombolytic agents used were 100000 U urokinase mixed with 500 IU heparin (n = 10) or a double dose of the mixture (n = 6). The thrombi in aneurysms were removed in all but two patients with non-flow limiting residual thrombi. One recanalization failure occurred due to a device failure. Aspiration thrombectomy was performed in 87.5% of cases (n = 14). Underlying stenoses were found in the outflow draining vein (n = 16), arteriovenous anastomosis or juxtaanastomosis area (n = 5), and the central vein (n = 3). Balloon angioplasty was performed for all stenoses in 15 patients. Two patients with a symptomatic central vein stenosis underwent insertion of a stent after balloon angioplasty. Mean procedure time was 116.3 minutes. Minor extravasation (n = 1) was resolved by manual compression. Both technical and clinical success rates were 93.8% (n = 15). The primary patency rates at 3, 6, and 12 months were 70.5%, 54.8%, and 31.3%, respectively. The secondary patency rates at 3, 6, and 12 months were 70.5%, 70.5%, and 47.0%, respectively. CONCLUSION: Thrombosed AVF complicated with an aneurysm can be successfully recanalized, and secondary patency can be prolonged with endovascular treatment.

Hybrid treatment of arteriovenous fistula between popliteal vessels / Tratamento híbrido para fístula arteriovenosa entre vasos poplíteos

The authors describe treatment of a patient who presented an arteriovenous fistula between the popliteal vessels more than 20 years after a gunshot wound. The patient underwent endovascular treatment using Viabahn (Gore®) stent grafts, but, because of the large disparity in popliteal artery diameters proximal and distal of the fistula, the endovascular treatment was unsuccessful. The superficial femoral artery was then banded around the stent graft that was deployed previously. This improvised strategy allowed an open surgical approach to be performed far from the fistula site, reducing the risks of operating in a region with anatomic distortions and significant enlargement of the surrounding venous structures, which would certainly have increased the likelihood of iatrogenic injuries.

Os autores descrevem o tratamento de um paciente portador de fístula arteriovenosa entre vasos poplíteos com mais de 20 anos de evolução, após ferimento por projétil de arma de fogo. O paciente foi submetido a tratamento endovascular pelo implante de stents revestidos Viabahn (Gore®), porém o mesmo não foi bem sucedido devido à diferença de diâmetro entre a artéria poplítea proximal e a distal à fístula. A artéria femoral superficial foi submetida à cerclagem com fios de sutura ao redor do stentgraft previamente implantado. Esse recurso de improvisação permitiu uma abordagem distante do sítio da fístula, diminuindo os riscos do acesso cirúrgico em uma região com distorções anatômicas e vasos sanguíneos ectasiados, o que certamente acarretaria maior risco de lesões iatrogênicas.