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Case report: Transvenous embolization of a traumatic arteriovenous fistula
Clinical Radiology (1996) 51,886 889
Case Report: Transvenous Embolization of a Traumatic Arteriovenous Fistula J. C. L I T H E R L A N D and R. J. A S H L E I G H
Department of Diagnostic Radiology, South Manchester University Hospitals Trust, West Didsbury, Manchester, UK
Correspondence to: Dr R. Ashleigh, Department of Radiology, Withington Hospital, Nell Lane, Didsbury, Manchester M20 8LR, UK.
swollen and a thrill and a loud 'machinery' type bruit were detected in this region. Radiographic examination of the pelvis and femur were normal. Angiography confirmed the clinical suspicion of a traumatic AVF predominantly involving the lateral circumflex branch of the profunda femoris artery but the fistula was also fed from other collaterals. The main feeding vessel was embolized proximal to the fistula using steel coils and some decrease in flow was obtained. However, collateral filling persisted via the distal lateral circumflex femoral artery. The initial procedure was terminated at this stage. The patient was referred to our hospital because of persisting symptoms and signs. A repeat angiogram via a left femoral arterial approach confirmed occlusion of the main feeding artery of the AVF but collateral filling persisted from branches of the internal iliac artery and other branches of the profunda femoris (Fig. 1). Although bypass of the coils with a coaxial catheter was attempted this proved impossible. The right common femoral vein was therefore punctured and a catheter advanced into the lateral circumflex branch of the profunda femoral vein. The fistula entered the vein at an acute angle and although we were unable to pass a conventional catheter through to the arterial side a left internal mammary catheter could be placed at the orifice. This allowed a coaxial catheter (Tracker 18, Vascular Ltd) to be passed into the arterial side (Fig. 2). Fibred platinum microcoils (4mm) (Target, Vascular Ltd) were then placed in the feeding arteries, both proximal (Fig. 3) and distal to the site of the AV communication. Finally, three 8mm Gianturco coils (Cook, Europe) were placed in the vein to lie across the fistulous opening. A check angiogram showed satisfactory
(a)
(b)
A case of a post-traumatic arteriovenous fistula of the lateral circumflex femoral artery is presented which was successfully embolized by a transvenous approach. The importance of occluding the feeding artery both proximal to and distal to the fistula is emphasized. The treatment of arterio-venous fistulae (AVF) in various anatomical locations by embolization is now a well established procedure and is usually performed by an arterial approach. We report a case of a traumatic AVF in which arterial embolization was not possible because of previous occlusion of the main feeding vessel by steel coils. The lesion was therefore approached transvenously and treated successfully.
CASE REPORT A 25-year-old man presented to the Accident and Emergency department at another hospital after being thrown from his motorcycle in a road traffic accident. He complained of localized pain and bruising of the upper lateral aspect of his right thigh. On examination the thigh was
Fig. 1 (a) Early phase and (b) mid arterial phase profunda femoral arteriogram showing multiple collaterals reforming the transverse branch of the lateral circumflex femoral artery (broad arrow) and maintaining patency of the AVF (arrow). Coils from the previous attempt at embolization can be seen (arrowhead). The dilated draining vein can be seen in Fig. l(b) (small arrows). © 1996 The Royal College of Radiologists.
CASE REPORTS
(a)
887
(b)
Fig. 2 (a) A LIMA curved catheter has been placed transvenously so its tip lies at the site of the AVF. (b) A Tracker catheter has been advanced through the fistula to lie within the proximal artery distal to the previously sited coils.
closure of the fistula, although some arterial collaterals were still patent (Fig. 4). On review, one month later, the dilated veins and bruit had completely disappeared and the patient was asymptomatic.
DISCUSSION The recognition and prompt treatment of traumatic AVF is important if long term morbidity is to be avoided. Although AVF are usually the result of penetrating injury to the extremities they can also occur after blunt injury as in our case. They present initially with swelling, bruising and a thrill or bruit and if not recognized and treated promptly can become chronic leading to the deveiopment of local aneurysms, distal limb ischaemia and congestive cardiac failure. The use of transarterial embolization in the treatment of acute arterial injury is well established. Fisher and Ben Menachem [1] described their experiences with 14 patients and two of these involved successful treatment of traumatic AVF by embolization of the profunda femoris artery with coils. It is essential to occlude the artery on both sides of the fistula. If only the proximal artery is occluded the fistula will remain' open and retrograde flow through collaterals will © 1996 The Royal'College of Radiologists, Clinical Radiology, 51,886 889.
increase allowing the fistula to enlarge. This is the radiological equivalent of a Hunterian ligation which carries a serious risk of ischaemia to the distal limb because of the development of steal by the fistula [2]. If a standard catheter cannot be passed into the distal artery, success can often be achieved using a coaxial system such as the Tracker. It is important to treat the fistula adequately at the first attempt. Arterial embolization proximal to the fistula will only give temporary relief as collaterals will continue to feed the AVF via the 'back door'. Once the proximal feeding artery is occluded the easiest route of access is lost and a second, more complex, procedure will be necessary as in this case. It is also possible that the resulting anatomy will be unfavourable to an endovascular approach and surgical exploration may be required. As well as placing the patient at risk from the additional radiological or surgical procedure, hospital stay will be prolonged together with the increased cost of the extra procedure. The only technically feasible route to the fistula was via a transvenous approach. This enabled us to close the fistula by placing coils on both the arterial and venous sides. While coils or detachable balloons may be used to occlude AVF, depending on the site of the lesion, in this
888
CLINICAL RADIOLOGY
(a) Fig. 3 - Microcoils have been inserted to lie in the proximal artery adjacent to the fistula. The fistula is still fed from the distal artery via collaterals (arrow).
case we felt that coils were the agents of choice in view of the complex anatomy. The transvenous approach to AVF has been well described in the neuroradiological literature. It has been used to close carotico-cavernous [3], spinal and scalp AVF [4,5]. Its use in the general circulation has been less widely reported. Sclafini [6] performed transvenous catheterization of a distal posterior tibial artery which was contributing to a fistulous communication and could not be approached transarterially because of previous proximal occlusion. Patterson et al. [7] used temporary transvenous placement of a Fogarty balloon to occlude an innominate artery to vein fistula. Yakes et al. [8] used a combination of approaches, including the transvenous route, to occlude AVFs with ethanol. Direct percutaneous embolization of peripheral pseudoaneurysms and AVF has also been described [9,10]. We did not think that this lesion would be amenable to direct puncture, although this technique has been used for scalp and peripheral AVF [6,8]. We believe the transvenous approach to AVF is an important and effective technique when arterial access is impossible or has failed and can be used in cases which would otherwise require surgical intervention. When embolization of AVF is performed it is essential to occlude either the feeding artery both proximal and distal to the fistula or to occlude the vein across the neck of the fistula otherwise successful closure will not be achieved.
(b) Fig. 4 (a) and (b) Angiogram taken following placement of coils in the distal feeding artery and on the venous side of the AVF (see text). The fistula is now occluded. Some hypervascularity persists inferolaterally. © 1996 The Royal College of Radiologists, Clinical Radiology, 51,886-889.
CASE REPORTS
REFERENCES 1 Fisher RG, Ben-Menachem Y. Embolisation procedures in trauma: the extremities acute lesions. Seminars in Interventional Radiology 1985;2:118-124. 2 Kester RC. Arteriovenous fistulae and Microvascular surgery. In: Cuschieri A, Giles GR and Moosa AR, eds. Essential Surgical Practice. Bristol: Wright PSG, 1982:790 807. 3 Yamashita K, Taki W, Nishi S et al. Transvenous embolization of dural caroticocavernous fistulae: technical considerations. Neuroradiology 1993;35:475 479. 4 Willinsky R, terBrugge K, Monanera W e t al. Spinal epidural arteriovenous fistulas: Arterial and venous approaches to embolisation. American Journal qf Neuroradiology 1993;14:812 817. 5 Barnwell SL, Halbach VV, Dowd CF et al. Endovascular treatment of scalp arteriovenous fistulas associated with a large varix. Radiology 1989;173:533 539.
889
6 Sclafini SJA. Arteriographic treatment of chronic post-traumatic arteriovenous fistulas of the extremities. Seminars in Interventional Radilogy 1985;2:125 129. 7 Patterson RD, Tomsick TA, Wilson JH et al. Transvenous Fogarty balloon catheter occlusion of an iatrogenic innominate artery to innominate vein fistula. Cardiovascularand Interventional Radiology 1993;16:316-318. 8 Yakes WF, Leuthke JM, Merland JJ et al. Ethanol embolisation of arteriovenous fistulas: a primary mode of therapy. Journal of Vascular Interventional Radiology 1990; 1:89-96. 9 McIvor J, Treweeke PS. Case Report: Direct percutaneons embolisation of a false aneurysm with steel coils. Clinical Radiology 1988;39:205-207. t0 Sanchez FW, Bertozzi G. Direct percutaneous embolization of a postembolectomy pseudoaneurysm. Cardiovascular and Interventional Radiology 1994;17:155-157.
Clinical Radiology (1996) 51, 889 891
Case Report: Tumoral Pseudogout of the Hip Joint A. CORAL,
G. HARDY*,
A. HARVEY'~
a n d R. M . S M I T H S
Departments o f Radiology, *Pathology, t R h e u m a t o l o g y and +Academic Orthopaedic Surgery, S t James's University Hospital, Leeds, U K A c a s e o f t u m o r a l p s e u d o g o u t is d e s c r i b e d i n w h i c h imaging showed a faintly-calcified synovial mass on the anterior aspect of the neck of femur and ultrasoundguided Trucut biopsy provided a diagnostic sample, thereby excluding malignant neoplasm. The patient was unusual in being younger than any previously described case and unique in presenting at a stage when the lesion was undetectable on a plain radiograph.
CASE REPORT A 38-year-old woman presented with continuous right groin and anterior thigh pain, preceded by 2 years of increasingly frequent bouts of discomfort each of which had lasted around 7 days before resolving. The pain was worse on taking a stride but was not relieved by rest. There was no systemic upset, involvement of other joints, skin disease, previous illnesses of note or joint disease in the family. Examination showed that the movements of the right hip were painfully restricted in all planes. Movements of the spine were unlimited. Full blood count, serum calcium, phosphate and thyroxine, and plasma viscosity were normal. Rheumatoid factor was negative. A clinical diagnosis of right hip synovitis of undetermined cause was made. An anteroposterior radiograph of the hip joints was normal (Fig. 1). Ultrasound demonstrated severe hyperechoic thickening of the synovium lmeasuring 22 mm, compared to normal of 6 mm) (Fig. 2). A subsequent 9Tc-bone scintigram showed an area of increased tracer uptake in the region of, but not corresponding entirely to, the distal part of the neck of femur (Fig. 3). MRI was done to determine whether there was a lesion of bone at the site of increased uptake on the scintigram. T1 weighted spin-echo and short tau inversion recovery images confirmed a well-defined mass anterior to the femoral neck that corresponded in size and shape to the lesion demonstrated by ultrasound (Fig. 4). The mass was heterogeneous and intermediate signal on T1 weighting and uniform high signal on T2 weighting. The signal from bone was normal. Finally, CT showed the synovial thickening to contain a ring of fine calcification which corresponded to the ring of increased echogenicity on the ultrasonogram (Fig. 5). Percutaneous ultrasound-guided core biopsy with a 14g Trucut needle was then undertaken. Histological examination of the biopsy specimen revealed fibrous tissue with areas of hyaline change. There Correspondence to: Dr A. Coral, Department of Radiology, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
© 1996The Royal College of Radiologists, ClinicalRadiology, Sl, 889--891.
were deposits of granular material containing few multinucleate giant cells as well as rod-and tablet-shaped crystals exhibiting positive birefringence with polarized light (Fig. 6). The latter were typical of calcium pyrophosphate dihydrate (CPPD). Intra-articular corticosteroids had no effect and so the mass was removed surgically, resulting in remission of symptoms. The pathology of the resected specimen was identical to that of the core biopsy.
DISCUSSION The diagnosis of tumoral pseudogout was made on the basis of an episodic chronic disorder showing a gradual d e t e r i o r a t i o n o f s y m p t o m s w i t h time, o n t h e d e m o n s t r a t i o n of a faintly calcified synovial mass with imaging, and on finding calcium pyrophosphate dihydrate crystals at histological examination. The clinical and radiological manifestations of CPPD
Fig. 1
Radiograph of pelvis showing normal hip joints.
Case Report: Transvenous Embolization of a Traumatic Arteriovenous Fistula J. C. L I T H E R L A N D and R. J. A S H L E I G H
Department of Diagnostic Radiology, South Manchester University Hospitals Trust, West Didsbury, Manchester, UK
Correspondence to: Dr R. Ashleigh, Department of Radiology, Withington Hospital, Nell Lane, Didsbury, Manchester M20 8LR, UK.
swollen and a thrill and a loud 'machinery' type bruit were detected in this region. Radiographic examination of the pelvis and femur were normal. Angiography confirmed the clinical suspicion of a traumatic AVF predominantly involving the lateral circumflex branch of the profunda femoris artery but the fistula was also fed from other collaterals. The main feeding vessel was embolized proximal to the fistula using steel coils and some decrease in flow was obtained. However, collateral filling persisted via the distal lateral circumflex femoral artery. The initial procedure was terminated at this stage. The patient was referred to our hospital because of persisting symptoms and signs. A repeat angiogram via a left femoral arterial approach confirmed occlusion of the main feeding artery of the AVF but collateral filling persisted from branches of the internal iliac artery and other branches of the profunda femoris (Fig. 1). Although bypass of the coils with a coaxial catheter was attempted this proved impossible. The right common femoral vein was therefore punctured and a catheter advanced into the lateral circumflex branch of the profunda femoral vein. The fistula entered the vein at an acute angle and although we were unable to pass a conventional catheter through to the arterial side a left internal mammary catheter could be placed at the orifice. This allowed a coaxial catheter (Tracker 18, Vascular Ltd) to be passed into the arterial side (Fig. 2). Fibred platinum microcoils (4mm) (Target, Vascular Ltd) were then placed in the feeding arteries, both proximal (Fig. 3) and distal to the site of the AV communication. Finally, three 8mm Gianturco coils (Cook, Europe) were placed in the vein to lie across the fistulous opening. A check angiogram showed satisfactory
(a)
(b)
A case of a post-traumatic arteriovenous fistula of the lateral circumflex femoral artery is presented which was successfully embolized by a transvenous approach. The importance of occluding the feeding artery both proximal to and distal to the fistula is emphasized. The treatment of arterio-venous fistulae (AVF) in various anatomical locations by embolization is now a well established procedure and is usually performed by an arterial approach. We report a case of a traumatic AVF in which arterial embolization was not possible because of previous occlusion of the main feeding vessel by steel coils. The lesion was therefore approached transvenously and treated successfully.
CASE REPORT A 25-year-old man presented to the Accident and Emergency department at another hospital after being thrown from his motorcycle in a road traffic accident. He complained of localized pain and bruising of the upper lateral aspect of his right thigh. On examination the thigh was
Fig. 1 (a) Early phase and (b) mid arterial phase profunda femoral arteriogram showing multiple collaterals reforming the transverse branch of the lateral circumflex femoral artery (broad arrow) and maintaining patency of the AVF (arrow). Coils from the previous attempt at embolization can be seen (arrowhead). The dilated draining vein can be seen in Fig. l(b) (small arrows). © 1996 The Royal College of Radiologists.
CASE REPORTS
(a)
887
(b)
Fig. 2 (a) A LIMA curved catheter has been placed transvenously so its tip lies at the site of the AVF. (b) A Tracker catheter has been advanced through the fistula to lie within the proximal artery distal to the previously sited coils.
closure of the fistula, although some arterial collaterals were still patent (Fig. 4). On review, one month later, the dilated veins and bruit had completely disappeared and the patient was asymptomatic.
DISCUSSION The recognition and prompt treatment of traumatic AVF is important if long term morbidity is to be avoided. Although AVF are usually the result of penetrating injury to the extremities they can also occur after blunt injury as in our case. They present initially with swelling, bruising and a thrill or bruit and if not recognized and treated promptly can become chronic leading to the deveiopment of local aneurysms, distal limb ischaemia and congestive cardiac failure. The use of transarterial embolization in the treatment of acute arterial injury is well established. Fisher and Ben Menachem [1] described their experiences with 14 patients and two of these involved successful treatment of traumatic AVF by embolization of the profunda femoris artery with coils. It is essential to occlude the artery on both sides of the fistula. If only the proximal artery is occluded the fistula will remain' open and retrograde flow through collaterals will © 1996 The Royal'College of Radiologists, Clinical Radiology, 51,886 889.
increase allowing the fistula to enlarge. This is the radiological equivalent of a Hunterian ligation which carries a serious risk of ischaemia to the distal limb because of the development of steal by the fistula [2]. If a standard catheter cannot be passed into the distal artery, success can often be achieved using a coaxial system such as the Tracker. It is important to treat the fistula adequately at the first attempt. Arterial embolization proximal to the fistula will only give temporary relief as collaterals will continue to feed the AVF via the 'back door'. Once the proximal feeding artery is occluded the easiest route of access is lost and a second, more complex, procedure will be necessary as in this case. It is also possible that the resulting anatomy will be unfavourable to an endovascular approach and surgical exploration may be required. As well as placing the patient at risk from the additional radiological or surgical procedure, hospital stay will be prolonged together with the increased cost of the extra procedure. The only technically feasible route to the fistula was via a transvenous approach. This enabled us to close the fistula by placing coils on both the arterial and venous sides. While coils or detachable balloons may be used to occlude AVF, depending on the site of the lesion, in this
888
CLINICAL RADIOLOGY
(a) Fig. 3 - Microcoils have been inserted to lie in the proximal artery adjacent to the fistula. The fistula is still fed from the distal artery via collaterals (arrow).
case we felt that coils were the agents of choice in view of the complex anatomy. The transvenous approach to AVF has been well described in the neuroradiological literature. It has been used to close carotico-cavernous [3], spinal and scalp AVF [4,5]. Its use in the general circulation has been less widely reported. Sclafini [6] performed transvenous catheterization of a distal posterior tibial artery which was contributing to a fistulous communication and could not be approached transarterially because of previous proximal occlusion. Patterson et al. [7] used temporary transvenous placement of a Fogarty balloon to occlude an innominate artery to vein fistula. Yakes et al. [8] used a combination of approaches, including the transvenous route, to occlude AVFs with ethanol. Direct percutaneous embolization of peripheral pseudoaneurysms and AVF has also been described [9,10]. We did not think that this lesion would be amenable to direct puncture, although this technique has been used for scalp and peripheral AVF [6,8]. We believe the transvenous approach to AVF is an important and effective technique when arterial access is impossible or has failed and can be used in cases which would otherwise require surgical intervention. When embolization of AVF is performed it is essential to occlude either the feeding artery both proximal and distal to the fistula or to occlude the vein across the neck of the fistula otherwise successful closure will not be achieved.
(b) Fig. 4 (a) and (b) Angiogram taken following placement of coils in the distal feeding artery and on the venous side of the AVF (see text). The fistula is now occluded. Some hypervascularity persists inferolaterally. © 1996 The Royal College of Radiologists, Clinical Radiology, 51,886-889.
CASE REPORTS
REFERENCES 1 Fisher RG, Ben-Menachem Y. Embolisation procedures in trauma: the extremities acute lesions. Seminars in Interventional Radiology 1985;2:118-124. 2 Kester RC. Arteriovenous fistulae and Microvascular surgery. In: Cuschieri A, Giles GR and Moosa AR, eds. Essential Surgical Practice. Bristol: Wright PSG, 1982:790 807. 3 Yamashita K, Taki W, Nishi S et al. Transvenous embolization of dural caroticocavernous fistulae: technical considerations. Neuroradiology 1993;35:475 479. 4 Willinsky R, terBrugge K, Monanera W e t al. Spinal epidural arteriovenous fistulas: Arterial and venous approaches to embolisation. American Journal qf Neuroradiology 1993;14:812 817. 5 Barnwell SL, Halbach VV, Dowd CF et al. Endovascular treatment of scalp arteriovenous fistulas associated with a large varix. Radiology 1989;173:533 539.
889
6 Sclafini SJA. Arteriographic treatment of chronic post-traumatic arteriovenous fistulas of the extremities. Seminars in Interventional Radilogy 1985;2:125 129. 7 Patterson RD, Tomsick TA, Wilson JH et al. Transvenous Fogarty balloon catheter occlusion of an iatrogenic innominate artery to innominate vein fistula. Cardiovascularand Interventional Radiology 1993;16:316-318. 8 Yakes WF, Leuthke JM, Merland JJ et al. Ethanol embolisation of arteriovenous fistulas: a primary mode of therapy. Journal of Vascular Interventional Radiology 1990; 1:89-96. 9 McIvor J, Treweeke PS. Case Report: Direct percutaneons embolisation of a false aneurysm with steel coils. Clinical Radiology 1988;39:205-207. t0 Sanchez FW, Bertozzi G. Direct percutaneous embolization of a postembolectomy pseudoaneurysm. Cardiovascular and Interventional Radiology 1994;17:155-157.
Clinical Radiology (1996) 51, 889 891
Case Report: Tumoral Pseudogout of the Hip Joint A. CORAL,
G. HARDY*,
A. HARVEY'~
a n d R. M . S M I T H S
Departments o f Radiology, *Pathology, t R h e u m a t o l o g y and +Academic Orthopaedic Surgery, S t James's University Hospital, Leeds, U K A c a s e o f t u m o r a l p s e u d o g o u t is d e s c r i b e d i n w h i c h imaging showed a faintly-calcified synovial mass on the anterior aspect of the neck of femur and ultrasoundguided Trucut biopsy provided a diagnostic sample, thereby excluding malignant neoplasm. The patient was unusual in being younger than any previously described case and unique in presenting at a stage when the lesion was undetectable on a plain radiograph.
CASE REPORT A 38-year-old woman presented with continuous right groin and anterior thigh pain, preceded by 2 years of increasingly frequent bouts of discomfort each of which had lasted around 7 days before resolving. The pain was worse on taking a stride but was not relieved by rest. There was no systemic upset, involvement of other joints, skin disease, previous illnesses of note or joint disease in the family. Examination showed that the movements of the right hip were painfully restricted in all planes. Movements of the spine were unlimited. Full blood count, serum calcium, phosphate and thyroxine, and plasma viscosity were normal. Rheumatoid factor was negative. A clinical diagnosis of right hip synovitis of undetermined cause was made. An anteroposterior radiograph of the hip joints was normal (Fig. 1). Ultrasound demonstrated severe hyperechoic thickening of the synovium lmeasuring 22 mm, compared to normal of 6 mm) (Fig. 2). A subsequent 9Tc-bone scintigram showed an area of increased tracer uptake in the region of, but not corresponding entirely to, the distal part of the neck of femur (Fig. 3). MRI was done to determine whether there was a lesion of bone at the site of increased uptake on the scintigram. T1 weighted spin-echo and short tau inversion recovery images confirmed a well-defined mass anterior to the femoral neck that corresponded in size and shape to the lesion demonstrated by ultrasound (Fig. 4). The mass was heterogeneous and intermediate signal on T1 weighting and uniform high signal on T2 weighting. The signal from bone was normal. Finally, CT showed the synovial thickening to contain a ring of fine calcification which corresponded to the ring of increased echogenicity on the ultrasonogram (Fig. 5). Percutaneous ultrasound-guided core biopsy with a 14g Trucut needle was then undertaken. Histological examination of the biopsy specimen revealed fibrous tissue with areas of hyaline change. There Correspondence to: Dr A. Coral, Department of Radiology, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
© 1996The Royal College of Radiologists, ClinicalRadiology, Sl, 889--891.
were deposits of granular material containing few multinucleate giant cells as well as rod-and tablet-shaped crystals exhibiting positive birefringence with polarized light (Fig. 6). The latter were typical of calcium pyrophosphate dihydrate (CPPD). Intra-articular corticosteroids had no effect and so the mass was removed surgically, resulting in remission of symptoms. The pathology of the resected specimen was identical to that of the core biopsy.
DISCUSSION The diagnosis of tumoral pseudogout was made on the basis of an episodic chronic disorder showing a gradual d e t e r i o r a t i o n o f s y m p t o m s w i t h time, o n t h e d e m o n s t r a t i o n of a faintly calcified synovial mass with imaging, and on finding calcium pyrophosphate dihydrate crystals at histological examination. The clinical and radiological manifestations of CPPD
Fig. 1
Radiograph of pelvis showing normal hip joints.