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Inferior mesenteric arteriovenous fistula treated by percutaneous arterial embolization: A breathtaking story!
Diagnostic and Interventional Imaging (2014) 95, 85—86
LETTER / Gastrointestinal imaging Inferior mesenteric arteriovenous fistula treated by percutaneous arterial embolization: A breathtaking story! Keywords: Arteriovenous fistula; Inferior mesenteric; Percutaneous arterial embolization An arteriovenous fistula (AVF) is an abnormal high flow communication between an artery and a vein. In the splanchnic network, these may be either congenital (25%) or acquired, usually as a result of penetrating abdominal injuries due to a bullet or knife or as a complication of arterial catheterization or surgery [1]. Splanchnic AVF are rare (approximately 200 cases are reported in the literature). In decreasing order the sites involved are hepatic (45%), splenic (30%), superior mesenteric, gastroduodenal and inferior mesenteric [1—3]. Inferior mesenteric AVF are extremely rare, with only 15 reported cases [1,4—8]. Case report
of the increased risk of extensive arterial thrombosis and the resultant ischemia [9—11]. Migration of the coils into the portal system has also been described for blood vessels of diameter over 8 mm at high flow rates [11]. Surgery would appear preferable in these situations. In this patient, the IMA was catheterized from a right femoral approach and a long (45 cm) straight 6F Cordis® introducer was inserted. The CT angiography findings were confirmed by selective angiography with a dilatation of the proximal IMA and one of its dividing branches from which the fistula had developed. The other branch supplying the left colonic artery was spindly and of normal diameter. A type 4 Amplatzer Plug® approximately 30% larger than the feeder artery, the diameter of which had been measured on the reference CT, was deployed at the fistula site to occlude it. This was chosen because of the size and flow rate in the artery, to avoid migration of embolus. Plug 4 passes through the lumen of the 5F catheter, which avoids advancing the introducer into the artery being embellished, causing less trauma. Deployment is controlled by a detachment system. The left colonic artery remained patent on the check angiogram (Fig. 2).
A 59-year-old man was being followed up for poorly differentiated intramucosal sigmoid adenocarcinoma. Clinically, the patient was in very good general health and his only complaint was of some constricting abdominal pain on exertion. Examination revealed an abdominal bruit and CT showed a large AVF between the proximal portion of the inferior mesenteric artery (IMA), which was aneurysmal in appearance and the inferior mesenteric vein (Fig. 1). Following a multidisciplinary discussion, and with the patient’s agreement, the decision was taken to treat him because of his abdominal pain and the size of the fistula, together with the aneurysmal dilatation of the proximal IMA. Other signs that may be present and lead to patients being treated are portal hypertension and colonic ischemia. The additional symptoms described are mesenteric claudication, diarrhea, malabsorption, melena and rectal bleeding [2—4,6]. Discussion Alternative treatments are available. Percutaneous endovascular arterial embolization of the feeder artery at the artery-venous junction is the technique of choice as it is extremely effective and because of the low risk of complications in moderate flow fistulae [9,10]. On the other hand, this is not recommended in large vessel AVF because
Figure 1. Abdominal CT before treatment with intravenous injection of contrast medium in the arterial phase. Coronal multiplanar reconstruction (MPR). Solid arrow (VMI): inferior mesenteric vein; arrowhead (ACG): left colonic artery; arrow (AR): Riolan arcade.
2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.09.004
86
Letter Conclusion Mesenteric system AVF are rare, and usually acquired postoperatively following colonic surgery. In similar situations, which require low or moderate flow AVF and optimal technical conditions to precisely position materials, percutaneous endovascular arterial embolization appears to be an effective treatment with a low complication rate [6] and an alternative to surgery. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References
Figure 2. Angiography and selective catheterization of the IMA with deployment of a Plug (asterisk). Arrow (AMI): inferior mesenteric artery. Solid arrow (ACG): left colonic artery.
In the following week, the patient complained of paroxysmal abdominal pain, developing in spasms and resolving spontaneously over a few days. The abdominal murmur disappeared and at 8 months the patient is entirely asymptomatic with a WHO score of 0. A repeat CT angiogram at 6 months showed total occlusion of the fistula with complete thrombosis of the inferior mesenteric vein ectasia and partial thrombosis of the IMA, which remained dilated. The left colonic artery was patent. No CT signs of colonic ischemia, portal hypertension or early portal opacification were seen (Fig. 3). A one-year review was organized.
[1] Van Way III CW, Crane JM, Riddell DH, Foster JH. Arteriovenous fistula in the portal circulation. Surgery 1971;70:876—90. [2] Sabatier JC, Bruneton JN, Drouillard J, Elie G, Tavernier J. Inferior mesenteric arteriovenous fistula of congenital origin. A report on one case and review of the published literature. J Radiol Electrol Med Nucl 1978;59:727—9. [3] Okada K. Inferior mesenteric arteriovenous fistula eight years after sigmoidectomy. Intern Med 2002;41(7):543—8. [4] Türkvatan A. Inferior mesenteric arteriovenous fistula with ischemic colitis: multidetector computed tomographic angiography for diagnosis. Turk J Gastroenterol 2009;20(1):67—70. [5] Metcalf DR. Ischemic colitis: an unusual case of inferior mesenteric arteriovenous fistula causing venous hypertension. Report of a case. Dis Colon Rectum 2008;51(9):1422—4. [6] Oyama K, Hayashi S, Kogure T, Kirakawa K, Akaike A. Inferior mesenteric arteriovenous fistula. Report of a case and review of the literature. Nippon Igaku Hoshasen Gakkai Zasshi 1980;40:944—50. [7] Capron JP, Gineston JL, Remond A, Lallement PY, Delamarre J, Revert R, et al. Inferior mesenteric arteriovenous fistula. Transcatheter occlusion of inferior mesenteric arteriovenous fistula: a case report. Cardiovasc Intervent Radiol 1989;12:35—7. [8] Nemcek Jr AA, Yakes W. SIR 2005 Annual meeting film panel case: inferior mesenteric artery to inferior mesenteric vein fistulous connection. J Vasc Intervent Radiol 2005;16:1179—82. [9] Shih MC, Angle JF, Leung DA, Cherry KJ, Harthun NL, Matsumoto AH, et al. CTA and MRA in mesenteric ischemia: part 2, normal findings and complications after surgical and endovascular treatment. AJR Am J Roentgenol 2007;188:462—71. [10] Fabre A, Abita T, Lachachi F, Rudelli P, Carlier M, Bocquel JB, et al. Inferior mesenteric arteriovenous fistulas. Report of a case. Ann Chir 2005;130:417—20. [11] Isik FF, Greenfield AJ, Desmond B, et al. Fistule artérioportale iatrogène : diagnostic et traitement. Ann Chir Vasc 1989;3:55—8.
N. Brucher a,∗ , G. Moskovitch a , P. Otal a , X. Chaufour b , H. Rousseau a
Figure 3. Repeat abdominal CT 6 months after treatment with intravenous injection of contrast medium in the arterial phase. Coronal multiplanar reconstruction (MPR). AMI: inferior mesenteric artery (arrow); ACG: left colonic artery (solid arrow). Plug (asterisk).
a Department of diagnostic and interventional imaging, Toulouse-Rangueil University Hospitals, Rangueil Hospital, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex, France b Department of vascular surgery and angiology, Toulouse-Rangueil University Hospitals, Rangueil Hospital, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex, France ∗ Corresponding author. E-mail address: [email protected] (N. Brucher)
LETTER / Gastrointestinal imaging Inferior mesenteric arteriovenous fistula treated by percutaneous arterial embolization: A breathtaking story! Keywords: Arteriovenous fistula; Inferior mesenteric; Percutaneous arterial embolization An arteriovenous fistula (AVF) is an abnormal high flow communication between an artery and a vein. In the splanchnic network, these may be either congenital (25%) or acquired, usually as a result of penetrating abdominal injuries due to a bullet or knife or as a complication of arterial catheterization or surgery [1]. Splanchnic AVF are rare (approximately 200 cases are reported in the literature). In decreasing order the sites involved are hepatic (45%), splenic (30%), superior mesenteric, gastroduodenal and inferior mesenteric [1—3]. Inferior mesenteric AVF are extremely rare, with only 15 reported cases [1,4—8]. Case report
of the increased risk of extensive arterial thrombosis and the resultant ischemia [9—11]. Migration of the coils into the portal system has also been described for blood vessels of diameter over 8 mm at high flow rates [11]. Surgery would appear preferable in these situations. In this patient, the IMA was catheterized from a right femoral approach and a long (45 cm) straight 6F Cordis® introducer was inserted. The CT angiography findings were confirmed by selective angiography with a dilatation of the proximal IMA and one of its dividing branches from which the fistula had developed. The other branch supplying the left colonic artery was spindly and of normal diameter. A type 4 Amplatzer Plug® approximately 30% larger than the feeder artery, the diameter of which had been measured on the reference CT, was deployed at the fistula site to occlude it. This was chosen because of the size and flow rate in the artery, to avoid migration of embolus. Plug 4 passes through the lumen of the 5F catheter, which avoids advancing the introducer into the artery being embellished, causing less trauma. Deployment is controlled by a detachment system. The left colonic artery remained patent on the check angiogram (Fig. 2).
A 59-year-old man was being followed up for poorly differentiated intramucosal sigmoid adenocarcinoma. Clinically, the patient was in very good general health and his only complaint was of some constricting abdominal pain on exertion. Examination revealed an abdominal bruit and CT showed a large AVF between the proximal portion of the inferior mesenteric artery (IMA), which was aneurysmal in appearance and the inferior mesenteric vein (Fig. 1). Following a multidisciplinary discussion, and with the patient’s agreement, the decision was taken to treat him because of his abdominal pain and the size of the fistula, together with the aneurysmal dilatation of the proximal IMA. Other signs that may be present and lead to patients being treated are portal hypertension and colonic ischemia. The additional symptoms described are mesenteric claudication, diarrhea, malabsorption, melena and rectal bleeding [2—4,6]. Discussion Alternative treatments are available. Percutaneous endovascular arterial embolization of the feeder artery at the artery-venous junction is the technique of choice as it is extremely effective and because of the low risk of complications in moderate flow fistulae [9,10]. On the other hand, this is not recommended in large vessel AVF because
Figure 1. Abdominal CT before treatment with intravenous injection of contrast medium in the arterial phase. Coronal multiplanar reconstruction (MPR). Solid arrow (VMI): inferior mesenteric vein; arrowhead (ACG): left colonic artery; arrow (AR): Riolan arcade.
2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.09.004
86
Letter Conclusion Mesenteric system AVF are rare, and usually acquired postoperatively following colonic surgery. In similar situations, which require low or moderate flow AVF and optimal technical conditions to precisely position materials, percutaneous endovascular arterial embolization appears to be an effective treatment with a low complication rate [6] and an alternative to surgery. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References
Figure 2. Angiography and selective catheterization of the IMA with deployment of a Plug (asterisk). Arrow (AMI): inferior mesenteric artery. Solid arrow (ACG): left colonic artery.
In the following week, the patient complained of paroxysmal abdominal pain, developing in spasms and resolving spontaneously over a few days. The abdominal murmur disappeared and at 8 months the patient is entirely asymptomatic with a WHO score of 0. A repeat CT angiogram at 6 months showed total occlusion of the fistula with complete thrombosis of the inferior mesenteric vein ectasia and partial thrombosis of the IMA, which remained dilated. The left colonic artery was patent. No CT signs of colonic ischemia, portal hypertension or early portal opacification were seen (Fig. 3). A one-year review was organized.
[1] Van Way III CW, Crane JM, Riddell DH, Foster JH. Arteriovenous fistula in the portal circulation. Surgery 1971;70:876—90. [2] Sabatier JC, Bruneton JN, Drouillard J, Elie G, Tavernier J. Inferior mesenteric arteriovenous fistula of congenital origin. A report on one case and review of the published literature. J Radiol Electrol Med Nucl 1978;59:727—9. [3] Okada K. Inferior mesenteric arteriovenous fistula eight years after sigmoidectomy. Intern Med 2002;41(7):543—8. [4] Türkvatan A. Inferior mesenteric arteriovenous fistula with ischemic colitis: multidetector computed tomographic angiography for diagnosis. Turk J Gastroenterol 2009;20(1):67—70. [5] Metcalf DR. Ischemic colitis: an unusual case of inferior mesenteric arteriovenous fistula causing venous hypertension. Report of a case. Dis Colon Rectum 2008;51(9):1422—4. [6] Oyama K, Hayashi S, Kogure T, Kirakawa K, Akaike A. Inferior mesenteric arteriovenous fistula. Report of a case and review of the literature. Nippon Igaku Hoshasen Gakkai Zasshi 1980;40:944—50. [7] Capron JP, Gineston JL, Remond A, Lallement PY, Delamarre J, Revert R, et al. Inferior mesenteric arteriovenous fistula. Transcatheter occlusion of inferior mesenteric arteriovenous fistula: a case report. Cardiovasc Intervent Radiol 1989;12:35—7. [8] Nemcek Jr AA, Yakes W. SIR 2005 Annual meeting film panel case: inferior mesenteric artery to inferior mesenteric vein fistulous connection. J Vasc Intervent Radiol 2005;16:1179—82. [9] Shih MC, Angle JF, Leung DA, Cherry KJ, Harthun NL, Matsumoto AH, et al. CTA and MRA in mesenteric ischemia: part 2, normal findings and complications after surgical and endovascular treatment. AJR Am J Roentgenol 2007;188:462—71. [10] Fabre A, Abita T, Lachachi F, Rudelli P, Carlier M, Bocquel JB, et al. Inferior mesenteric arteriovenous fistulas. Report of a case. Ann Chir 2005;130:417—20. [11] Isik FF, Greenfield AJ, Desmond B, et al. Fistule artérioportale iatrogène : diagnostic et traitement. Ann Chir Vasc 1989;3:55—8.
N. Brucher a,∗ , G. Moskovitch a , P. Otal a , X. Chaufour b , H. Rousseau a
Figure 3. Repeat abdominal CT 6 months after treatment with intravenous injection of contrast medium in the arterial phase. Coronal multiplanar reconstruction (MPR). AMI: inferior mesenteric artery (arrow); ACG: left colonic artery (solid arrow). Plug (asterisk).
a Department of diagnostic and interventional imaging, Toulouse-Rangueil University Hospitals, Rangueil Hospital, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex, France b Department of vascular surgery and angiology, Toulouse-Rangueil University Hospitals, Rangueil Hospital, 1, avenue du Pr-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex, France ∗ Corresponding author. E-mail address: [email protected] (N. Brucher)