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Use of an AMPLATZER Duct Occluder Device to Treat a Recurrent Arteriovenous Fistula following Endovenous Laser Treatment
1082
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Letters to the Editor
Woodley-Cook et al
’
JVIR
From: Joel Woodley-Cook, MSc, MD, FRCPC Maxime Noël-Lamy, MD, FRCPC Kong Teng Tan, MD, FRCS, FRCPC Thomas Lindsay, MD, MSc, FRCSC Department of Medical Imaging (J.W.-C., M.N.-L., K.T.T.) Department of Vascular Surgery (T.L.) University Health Network University of Toronto 585 University Avenue, Peter Munk Building, 1-298 Toronto, Ontario M5G 2C4, Canada
Figure 4. Coronal CT image obtained 6 weeks after CERAB shows a decrease in size of the aneurysm with a concomitant decrease in the size of the phlegmon. Glue fragmentation was noted. Vessels with stents were widely patent, and the aneurysm was completely thrombosed with no endoleak (compare with Fig 1).
excluding the aneurysm (Fig 2c). This technique presents an alternative endovascular technique, especially in patients with small native aortic dimensions.
REFERENCES 1. Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg 2007; 46:906–912. 2. Kan CD, Lee HL, Luo CY, Yang YJ. The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm—institute case management with systemic literature comparison. Ann Vasc Surg 2010; 24:433–440. 3. Goverde PC, Grimme FA, Verbruggen PJ, Reijnen MM. Covered endovascular reconstruction of aortic bifurcation (CERAB) technique: a new approach in treating extensive aortoiliac occlusive disease. J Cardiovasc Surg (Torino) 2013; 54:383–387. 4. Grimme FA, Goverde PA, Van Oostayen JA, Zeebregts CJ, Reijnen MM. Covered stents for aortoiliac reconstruction of chronic occlusive lesions. J Cardiovasc Surg (Torino) 2012; 53:279–289.
Use of an AMPLATZER Duct Occluder Device to Treat a Recurrent Arteriovenous Fistula following Endovenous Laser Treatment
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.02.015
Editor: We present a case of an arteriovenous fistula (AVF) of the external iliac vessels following endovenous laser treatment (EVLT) of varicose veins that was successfully treated with an AMPLATZER Duct Occluder II (St. Jude Medical, Inc, St. Paul, Minnesota) after an unsuccessful attempt at surgical ligation. Our institution does not require institutional review board approval for case reports. A 62-year-old man presented to his family physician with a 4-year history of gradually worsening dyspnea. He had undergone EVLT for greater saphenous vein varicosities 4 years before presentation, at which time a venous ultrasound scan did not demonstrate a fistula. Computed tomography angiography revealed a 12-mmwide AVF between the left external iliac artery and vein with associated dilatation of the common femoral vein and IVC (Figs 1, 2). Echocardiography confirmed left ventricular hypertrophy likely secondary to high-output cardiac failure from the AVF. Because of the width of the AVF (12 mm), the patient underwent surgical repair and began a course of warfarin to prevent thrombus development in the dilated veins, which would no longer be exposed to high-flow blood. The patientʼs dyspnea returned 12 months after surgery, and repeat computed tomography angiography showed the AVF had reopened. Because of the difficult initial surgery and failure of surgical ligation, it was decided to perform an endovascular approach. The width of the AVF measured 3 mm, the external iliac vein measured 20 mm, and the external iliac artery measured 10 mm at the level of the fistula. These measurements were compatible with an AMPLATZER Duct Occluder II device. The procedure was performed under local anesthesia and conscious sedation. Venous and arterial access was obtained to deploy the device over a secure wire using the “body floss” technique for through-and-through access. The distal left common femoral artery was accessed retrogradely followed by insertion of a 6-F vascular sheath, and the right femoral vein was accessed retrogradely followed by insertion of a 7-F vascular sheath. A 0.035-inch angled hydrophilic guidewire was advanced from the arterial side into the inferior vena cava through the fistula and snared for through-and-through access with an Ensnare device (Merit Medical; South Jordan, Utah). Through the venous access site, the AMPLATZER Duct Occluder II (diameter
Volume 26
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Number 7
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July
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2015
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Figure 1. Computed tomography angiography demonstrating a 12-mm-wide AVF (arrowhead) of the left external iliac artery (a) and early filling external iliac vein (v). Figure 3. Digital subtraction angiography image at the level of the external iliac artery AVF demonstrates the AMPLATZER Occluder II device crossing the fistula into the left external iliac artery via the external iliac vein (arrowhead).
Figure 2. Three-dimensional reformat of computed tomography angiography demonstrating a markedly dilated venous system (arrow).
9 mm, waist 3 mm, and length 4 mm) was advanced through the fistula (Fig 3). An arteriogram confirmed satisfactory placement, and the device was released. A completion arteriogram demonstrated no residual AVF (Fig 4). At 18 months after the procedure, the patient was asymptomatic, and vascular ultrasound demonstrated trace AVF flow (Fig 5) with no dilated veins and no palpable bruit. AVF formation is a rare complication of EVLT for varicose veins (1,2). We believed that an external iliac artery stent graft not only would be at increased risk of migration, thrombosis, and fracture but also would likely
Figure 4. The AMPLATZER device is released (arrowhead) with a final arteriogram demonstrating no evidence of a fistulous connection or early venous drainage.
require a surgical cutdown for deployment. Chaudry et al (3) described deployment of an AMPLATZER II plug via a surgical cutdown for a posttraumatic AVF between the profunda femoris artery and vein 30 years after a gunshot injury, but the low profiling of the AMPLATZER Duct Occluder II was thought to be a more suitable option to reduce the likelihood of thrombosis. Ultrasound-guided compression was also discussed, but given the paucity of
1084
’
Letters to the Editor
Cui et al
’
JVIR
From: Yue Cui, MD Jie Yu, MD Zhuang Nie, MD Heshui Shi, MD Department of Radiology Union Hospital Tongji Medical College Huazhong University of Science and Technology No. 1277, Jiefang Road Wuhan, Hubei 43002, China
Figure 5. Follow-up Doppler ultrasound scan obtained 18 months after deployment of the AMPLATZER Duct Occluder II device demonstrates a trace fistula between the left external iliac artery and vein (arrowhead).
data in the literature supporting this method, it was decided to proceed with an endovascular option. We describe successful treatment of an external iliac AVF with a ductus arteriosus occluder device traditionally used to treat patent ductus arteriosus, and this experience presents an interesting solution to a rare complication of EVLT. Given the low profiling of the device within the vessels, the risk of potential thrombosis was thought to be minimal. Finally, given its low migration rate (4), the AMPLATZER Duct Occluder II was viewed as a safe option for treating this fistula.
Editor: This report meets criteria for institutional review board exemption at our institute. We present a case of type I aortic dissection (DeBakey classification) with concomitant pulmonary artery (PA) dissection extending through a patent ductus arteriosus (PDA), which was definitively diagnosed by multidetector computed tomography (CT). A 42-year-old woman presented with episodic dyspnea, coughing, shortness of breath, and nocturnal orthopnea. The patient denied a history of trauma or surgery. However, she reported a past medical history of PDA, which was detected by transthoracic echocardiography 5 years ago and was not treated. The physical examination showed a systemic arterial pressure of 126/ 59 mm Hg. A grade 3/6 systolic murmur was heard in the precordial region. Transthoracic echocardiography showed the aorta and PA dissection, left atrium, and left ventricular enlargement. A PDA that connected the main PA with the descending aorta was detected (Fig 1). Chest radiography demonstrated superior mediastinum broadening, severe cardiomegaly,
REFERENCES 1. Timperman PE. Arteriovenous fistula after endovenous laser treatment of the short saphenous vein. J Vasc Interv Radiol 2004; 15:625–627. 2. Wheatcroft M, Lindsay T, Lossing A. Two cases of arteriovenous fistula formation between the external iliac vessels following endovenous laser therapy. Vascular 2014; 22:464–467. 3. Chaudry M, Flinn WR, Kim K, Neschis DG. Traumatic arteriovenous fistula 52 years after injury. J Vasc Surg 2010; 51:1265–1267. 4. Thanopoulos BV, Eleftherakis N, Tzannos K, Stefanadis C, Giannopoulos A. Further experience with catheter closure of patent ductus arteriosus using the new Amplatzer duct occluder in children. Am J Cardiol 2010; 105:1005–1009.
A Rare Case of Aortic Dissection with Concomitant Pulmonary Artery Dissection Extending through a Patent Ductus Arteriosus None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.03.010
Figure 1. PDA (arrow) that connected the main PA with the descending aorta was detected by transthoracic echocardiography. ARCH ¼ aortic arch, LPA ¼ left pulmonary artery.
’
Letters to the Editor
Woodley-Cook et al
’
JVIR
From: Joel Woodley-Cook, MSc, MD, FRCPC Maxime Noël-Lamy, MD, FRCPC Kong Teng Tan, MD, FRCS, FRCPC Thomas Lindsay, MD, MSc, FRCSC Department of Medical Imaging (J.W.-C., M.N.-L., K.T.T.) Department of Vascular Surgery (T.L.) University Health Network University of Toronto 585 University Avenue, Peter Munk Building, 1-298 Toronto, Ontario M5G 2C4, Canada
Figure 4. Coronal CT image obtained 6 weeks after CERAB shows a decrease in size of the aneurysm with a concomitant decrease in the size of the phlegmon. Glue fragmentation was noted. Vessels with stents were widely patent, and the aneurysm was completely thrombosed with no endoleak (compare with Fig 1).
excluding the aneurysm (Fig 2c). This technique presents an alternative endovascular technique, especially in patients with small native aortic dimensions.
REFERENCES 1. Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg 2007; 46:906–912. 2. Kan CD, Lee HL, Luo CY, Yang YJ. The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm—institute case management with systemic literature comparison. Ann Vasc Surg 2010; 24:433–440. 3. Goverde PC, Grimme FA, Verbruggen PJ, Reijnen MM. Covered endovascular reconstruction of aortic bifurcation (CERAB) technique: a new approach in treating extensive aortoiliac occlusive disease. J Cardiovasc Surg (Torino) 2013; 54:383–387. 4. Grimme FA, Goverde PA, Van Oostayen JA, Zeebregts CJ, Reijnen MM. Covered stents for aortoiliac reconstruction of chronic occlusive lesions. J Cardiovasc Surg (Torino) 2012; 53:279–289.
Use of an AMPLATZER Duct Occluder Device to Treat a Recurrent Arteriovenous Fistula following Endovenous Laser Treatment
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.02.015
Editor: We present a case of an arteriovenous fistula (AVF) of the external iliac vessels following endovenous laser treatment (EVLT) of varicose veins that was successfully treated with an AMPLATZER Duct Occluder II (St. Jude Medical, Inc, St. Paul, Minnesota) after an unsuccessful attempt at surgical ligation. Our institution does not require institutional review board approval for case reports. A 62-year-old man presented to his family physician with a 4-year history of gradually worsening dyspnea. He had undergone EVLT for greater saphenous vein varicosities 4 years before presentation, at which time a venous ultrasound scan did not demonstrate a fistula. Computed tomography angiography revealed a 12-mmwide AVF between the left external iliac artery and vein with associated dilatation of the common femoral vein and IVC (Figs 1, 2). Echocardiography confirmed left ventricular hypertrophy likely secondary to high-output cardiac failure from the AVF. Because of the width of the AVF (12 mm), the patient underwent surgical repair and began a course of warfarin to prevent thrombus development in the dilated veins, which would no longer be exposed to high-flow blood. The patientʼs dyspnea returned 12 months after surgery, and repeat computed tomography angiography showed the AVF had reopened. Because of the difficult initial surgery and failure of surgical ligation, it was decided to perform an endovascular approach. The width of the AVF measured 3 mm, the external iliac vein measured 20 mm, and the external iliac artery measured 10 mm at the level of the fistula. These measurements were compatible with an AMPLATZER Duct Occluder II device. The procedure was performed under local anesthesia and conscious sedation. Venous and arterial access was obtained to deploy the device over a secure wire using the “body floss” technique for through-and-through access. The distal left common femoral artery was accessed retrogradely followed by insertion of a 6-F vascular sheath, and the right femoral vein was accessed retrogradely followed by insertion of a 7-F vascular sheath. A 0.035-inch angled hydrophilic guidewire was advanced from the arterial side into the inferior vena cava through the fistula and snared for through-and-through access with an Ensnare device (Merit Medical; South Jordan, Utah). Through the venous access site, the AMPLATZER Duct Occluder II (diameter
Volume 26
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Number 7
’
July
’
2015
1083
Figure 1. Computed tomography angiography demonstrating a 12-mm-wide AVF (arrowhead) of the left external iliac artery (a) and early filling external iliac vein (v). Figure 3. Digital subtraction angiography image at the level of the external iliac artery AVF demonstrates the AMPLATZER Occluder II device crossing the fistula into the left external iliac artery via the external iliac vein (arrowhead).
Figure 2. Three-dimensional reformat of computed tomography angiography demonstrating a markedly dilated venous system (arrow).
9 mm, waist 3 mm, and length 4 mm) was advanced through the fistula (Fig 3). An arteriogram confirmed satisfactory placement, and the device was released. A completion arteriogram demonstrated no residual AVF (Fig 4). At 18 months after the procedure, the patient was asymptomatic, and vascular ultrasound demonstrated trace AVF flow (Fig 5) with no dilated veins and no palpable bruit. AVF formation is a rare complication of EVLT for varicose veins (1,2). We believed that an external iliac artery stent graft not only would be at increased risk of migration, thrombosis, and fracture but also would likely
Figure 4. The AMPLATZER device is released (arrowhead) with a final arteriogram demonstrating no evidence of a fistulous connection or early venous drainage.
require a surgical cutdown for deployment. Chaudry et al (3) described deployment of an AMPLATZER II plug via a surgical cutdown for a posttraumatic AVF between the profunda femoris artery and vein 30 years after a gunshot injury, but the low profiling of the AMPLATZER Duct Occluder II was thought to be a more suitable option to reduce the likelihood of thrombosis. Ultrasound-guided compression was also discussed, but given the paucity of
1084
’
Letters to the Editor
Cui et al
’
JVIR
From: Yue Cui, MD Jie Yu, MD Zhuang Nie, MD Heshui Shi, MD Department of Radiology Union Hospital Tongji Medical College Huazhong University of Science and Technology No. 1277, Jiefang Road Wuhan, Hubei 43002, China
Figure 5. Follow-up Doppler ultrasound scan obtained 18 months after deployment of the AMPLATZER Duct Occluder II device demonstrates a trace fistula between the left external iliac artery and vein (arrowhead).
data in the literature supporting this method, it was decided to proceed with an endovascular option. We describe successful treatment of an external iliac AVF with a ductus arteriosus occluder device traditionally used to treat patent ductus arteriosus, and this experience presents an interesting solution to a rare complication of EVLT. Given the low profiling of the device within the vessels, the risk of potential thrombosis was thought to be minimal. Finally, given its low migration rate (4), the AMPLATZER Duct Occluder II was viewed as a safe option for treating this fistula.
Editor: This report meets criteria for institutional review board exemption at our institute. We present a case of type I aortic dissection (DeBakey classification) with concomitant pulmonary artery (PA) dissection extending through a patent ductus arteriosus (PDA), which was definitively diagnosed by multidetector computed tomography (CT). A 42-year-old woman presented with episodic dyspnea, coughing, shortness of breath, and nocturnal orthopnea. The patient denied a history of trauma or surgery. However, she reported a past medical history of PDA, which was detected by transthoracic echocardiography 5 years ago and was not treated. The physical examination showed a systemic arterial pressure of 126/ 59 mm Hg. A grade 3/6 systolic murmur was heard in the precordial region. Transthoracic echocardiography showed the aorta and PA dissection, left atrium, and left ventricular enlargement. A PDA that connected the main PA with the descending aorta was detected (Fig 1). Chest radiography demonstrated superior mediastinum broadening, severe cardiomegaly,
REFERENCES 1. Timperman PE. Arteriovenous fistula after endovenous laser treatment of the short saphenous vein. J Vasc Interv Radiol 2004; 15:625–627. 2. Wheatcroft M, Lindsay T, Lossing A. Two cases of arteriovenous fistula formation between the external iliac vessels following endovenous laser therapy. Vascular 2014; 22:464–467. 3. Chaudry M, Flinn WR, Kim K, Neschis DG. Traumatic arteriovenous fistula 52 years after injury. J Vasc Surg 2010; 51:1265–1267. 4. Thanopoulos BV, Eleftherakis N, Tzannos K, Stefanadis C, Giannopoulos A. Further experience with catheter closure of patent ductus arteriosus using the new Amplatzer duct occluder in children. Am J Cardiol 2010; 105:1005–1009.
A Rare Case of Aortic Dissection with Concomitant Pulmonary Artery Dissection Extending through a Patent Ductus Arteriosus None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.03.010
Figure 1. PDA (arrow) that connected the main PA with the descending aorta was detected by transthoracic echocardiography. ARCH ¼ aortic arch, LPA ¼ left pulmonary artery.