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Repair of a high-flow iliac arteriovenous fistula using a thoracic endograft

2009; Elsevier BV; Volume: 49; Issue: 3 Linguagem: Inglês

10.1016/j.jvs.2008.10.062

1097-6809

Brett Cronin, Justin T. Kane, William Lee, Jabi E. Shriki, Fred A. Weaver,

Central Venous Catheters and Hemodialysis

Open surgical repair of iliac arteriovenous fistulas is associated with significant morbidity and mortality, making endovascular repair an attractive alternative. This report describes a 39-year-old man who was admitted with two-pillow orthopnea, edema, and fatigue. He had sustained a gunshot wound to the pelvis 13 years previously. Six years after the gunshot wound, he was diagnosed with cardiomegaly and high-output congestive heart failure. A magnetic resonance angiography documented a large pelvic arteriovenous fistula. A diagnostic contrast angiogram confirmed a high-flow fistula between the left distal main internal iliac artery and left common iliac vein. A Gore TAG thoracic endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz) was used to repair this large, high-flow internal iliac artery–common iliac vein arteriovenous fistula. Open surgical repair of iliac arteriovenous fistulas is associated with significant morbidity and mortality, making endovascular repair an attractive alternative. This report describes a 39-year-old man who was admitted with two-pillow orthopnea, edema, and fatigue. He had sustained a gunshot wound to the pelvis 13 years previously. Six years after the gunshot wound, he was diagnosed with cardiomegaly and high-output congestive heart failure. A magnetic resonance angiography documented a large pelvic arteriovenous fistula. A diagnostic contrast angiogram confirmed a high-flow fistula between the left distal main internal iliac artery and left common iliac vein. A Gore TAG thoracic endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz) was used to repair this large, high-flow internal iliac artery–common iliac vein arteriovenous fistula. Penetrating traumatic injury is the most common cause of abdominal and pelvic arteriovenous fistulas. Owing to the location and size of the vessels that may be involved, open surgical repair is attended by significant morbidity and mortality. As endovascular technology has evolved, it has been increasingly used to treat selected arteriovenous fistulas and traumatic vascular injuries. This report describes the novel use of thoracic endograft technology to repair a traumatic high-flow pelvic arteriovenous fistula. A 39-year-old man was admitted with two-pillow orthopnea, edema, and fatigue. His medical history was remarkable for a gunshot wound to the pelvis sustained 13 years previously that required an exploratory laparotomy and left nephrectomy. According to the patient, he was diagnosed with cardiomegaly and high-output congestive heart failure 6 years after the gunshot wound. Six months before this admission, worsening of the symptoms related to the patient's congestive heart failure prompted a magnetic resonance angiography (Fig 1), which identified a large pelvic arteriovenous fistula. The physical examination showed the patient weighed 296 lbs and had upper and lower extremity pulses that were within the normal range. A grade 3/6 systolic ejection murmur was identified over the apex of the heart in addition to a "machine-like" bruit in the left lower quadrant of the abdomen. A diagnostic contrast angiogram was first performed as part of procedure planning. This revealed a high-flow fistula between the left distal main internal iliac artery and left common iliac vein (Fig 2, A). The left internal iliac artery was 24 mm in maximum diameter (Fig 2, B). Owing to the size of the internal iliac artery and common iliac vein, the large fistulous connection, and the pelvic location of the arteriovenous fistula, open surgical repair was deemed hazardous. With this information, it was elected to effect closure of the arteriovenous fistula with a Gore TAG thoracic endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz). Alternative methods such as internal iliac embolization and stent graft coverage of the origin of the internal iliac were not used due to concern that the large size and flow of the fistulous connection would result in embolization of coils into the vena cava and right atrium. Through a contralateral right femoral artery cutdown, the left internal iliac artery was cannulated with a floppy (Bentsen, Cook Medical Inc, Bloomington, Ind) wire with the assistance of an angled (Kumpe, Cook Medical) catheter. The left common femoral artery was then percutaneously accessed and a diagnostic flush pigtail catheter was placed in the aorta for procedural angiography as well as to secure ipsilateral access during TAG placement. With internal iliac wire access achieved, the wire was exchanged for a stiff wire (Amplatz Super Stiff, Boston Scientific, Natick, Mass), and a 20F TAG introducer sheath was placed over the wire to the aortic bifurcation. Through this access, a 28-mm × 10-cm TAG was delivered distally into the left internal iliac artery and deployed (Fig 2, C). After postdeployment balloon expansion of the TAG, flow in the arteriovenous fistula was reduced but still present. A second TAG device, also 28 mm × 10 cm, was then deployed, with device overlap >5 cm, distal to the first device in the internal iliac artery. After placement of the second TAG, the arteriovenous fistula was faintly visualized, and flow through the left internal iliac artery was markedly reduced. Postoperatively, the patient's symptoms of orthopnea resolved and he slept supine for the first time in several years. On physical examination, the machine-like murmur in the left lower quadrant was no longer present. A computed tomography (CT) scan completed 2 days postoperatively confirmed complete closure of the arteriovenous fistula (Fig 3). The patient was seen and examined 6 months after the intervention. He continued to exhibit symptomatic relief, with absence of symptoms of congestive heart failure. The left lower quadrant bruit was absent. A CT scan performed at this point demonstrated continued closure of the internal iliac–common iliac vein fistula by the TAG device. Also demonstrated was a marked reduction in the diameter of the common iliac vein compared with the initial postoperative CT scan (Fig 4, Fig 5).Fig 5A three-dimensional computed tomography reconstruction shows the TAG repair of the pelvic arteriovenous fistula at 6 months.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Arteriovenous fistulas involving the iliac arteries commonly occur secondary to trauma. In fact, trauma is the cause in approximately 80% of all iliac arteriovenous fistulas.1Davidovic L. Kostic D. Cvetkovic S. Lotina S.I. Kostic D.M. Cinara I.S. et al.Aortocaval fistulas.Cardiovasc Surgery. 2002; 10: 555-560Crossref PubMed Scopus (43) Google Scholar, 2Rutherford R.B. Vascular surgery.6th ed. W. B. Saunders, Philadelphia2005Google Scholar Initial descriptions of iliac vessel trauma gathered from World War II and the Korean and Vietnam wars estimated iliac vessel damage to account for 1.7% to 2.6% of all arterial injuries.2Rutherford R.B. Vascular surgery.6th ed. W. B. Saunders, Philadelphia2005Google Scholar Recent increases in urban violence in addition to the rising number of invasive pelvic procedures (eg, lumbar diskectomy) performed annually has led to an increased incidence.3Feliaciano D. Bitondo C. Mattox K. Burch J.M. Jordan Jr, G.L. Beall Jr, A.C. et al.Civilian trauma in the 1980s: a one year experience with 456 vascular and cardiac injuries.Ann Surg. 1984; 199: 717-724Crossref PubMed Scopus (131) Google Scholar, 4Parodi J. Schonholz C. Ferreira L. Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions.Ann Vasc Surg. 1999; 13: 121-129Abstract Full Text PDF PubMed Scopus (218) Google Scholar, 5Reber P. Patel A. Kniemeyer H. Surgical implications of failed endovascular therapy for posttraumatic femoral arteriovenous fistula repair.J Trauma. 1999; 46: 352-354Crossref PubMed Scopus (7) Google Scholar Even though some low-flow arteriovenous fistulas may resolve spontaneously, larger arteriovenous fistulas located in the pelvis, such as in this case, typically require intervention.5Reber P. Patel A. Kniemeyer H. Surgical implications of failed endovascular therapy for posttraumatic femoral arteriovenous fistula repair.J Trauma. 1999; 46: 352-354Crossref PubMed Scopus (7) Google Scholar In the past, these pelvic arteriovenous fistulas have been treated through open surgical interventions, including ligation of the arterial supply, quadruple ligation-excision, and complex reconstruction. However, all of these methods are associated with considerable morbidity and occasional mortality.2Rutherford R.B. Vascular surgery.6th ed. W. B. Saunders, Philadelphia2005Google Scholar After a review of the literature, Brewster et al6Brewster D. Cambria R. Moncure A. Darling R. LaMuraglia G. Geller S. et al.Aortocaval and iliac arteriovenous fistulas: recognition and treatment.J Vasc Surg. 1991; 13 (discussion 264-5): 253-264Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar reported the operative mortality of iliac arteriovenous fistula repair to be 5% to 10%, and Davidovic et al1Davidovic L. Kostic D. Cvetkovic S. Lotina S.I. Kostic D.M. Cinara I.S. et al.Aortocaval fistulas.Cardiovasc Surgery. 2002; 10: 555-560Crossref PubMed Scopus (43) Google Scholar found that the mortality rate of arteriovenous surgical repair can be as high as 66%.7Waldrop J. Dart B. Barker D. Endovascular stent graft treatment of a traumatic aortocaval fistula.Ann Vasc Surg. 2005; 19: 562-565Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Davis et al8Davis P. Gloviczki P. Cherry K. Toomey B.J. Stanson A.W. Bower T.C. et al.Aorto-caval and ilio-iliac arteriovenous fistulae.Am J Surg. 1998; 176: 115-118Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar documented that significant morbidities occur in 11% to 39% of surgical corrections of iliac arteriovenous fistulas. Associated morbidities can include limb ischemia, gangrene, limb loss, caval thrombosis, pulmonary embolus, venous stasis, and severe-uncontrollable bleeding, among others.9Quinn S. Sheley R. Semonsen K. Sanchez R. Hallin R. Endovascular stents covered with pre-expanded polytetrafluoroethylene for treatment of iliac artery aneurysms and fistulas.J Vasc Intervent Radiol. 1997; 8: 1057-1063Abstract Full Text PDF PubMed Scopus (27) Google Scholar In particular, late presentation of chronic arteriovenous fistulas, such as in this patient, are prone to significant intraoperative bleeding due to the fibrosis, robust collaterals, dilated vasculature, and the complex venous anatomy encountered during surgical dissection and repair.4Parodi J. Schonholz C. Ferreira L. Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions.Ann Vasc Surg. 1999; 13: 121-129Abstract Full Text PDF PubMed Scopus (218) Google Scholar The large physical size of our patient and the deep pelvic location of his fistula added additional factors that would have complicated any approach to surgical repair. In an effort to avoid the morbidity and mortality associated with an open approach to traumatic arterial injuries and arteriovenous fistulas, the focus has shifted to endovascular techniques, including the use of stent grafts and coil embolization. The first recorded repair of an arteriovenous fistula using an endovascular stent occurred in 1992 by Parodi et al,10Parodi J. Barone H. Transluminal treatment of abdominal aortic aneurysms and peripheral arteriovenous fistulas.1992Google Scholar during which a stent was deployed to treat a post-traumatic arteriovenous fistula located in the subclavian artery. Many authors since then, including Sanchez et al,11Sanchez L. Veith F. Ohki T. Suggs W. Bakal C. Cynamon J. Rosenblitt G. Lyon R. Early experience with the Corvita endoluminal graft for the treatment of arterial injuries.Ann Vasc Surg. 1999; 13: 151-157Abstract Full Text PDF PubMed Scopus (24) Google Scholar Marin et al,12Marin M. Veith F. Panetta T. Cynamon J. Sanchez L.A. Schwartz M.L. et al.Transluminally placed endovascular stented graft repair for arterial trauma.J Vasc Surg. 1994; 20: 466-472Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar McCarter et al,13McCarter D. Johnstone R. McInnes G. Reid D. Pollock J. Reid A. Iliac arteriovenous fistula following lumbar disc surgery treated by percutaneous endoluminal stent grafting.Br J Surg. 1996; 83: 796-797Crossref PubMed Scopus (33) Google Scholar and Zajko et al14Zajko A. Little A. Steed D. Curtiss E. Endovascular stent-graft repair of common iliac artery-to-inferior vena cava fistula.J Vasc Intervent Radiol. 1995; 6: 803-806Abstract Full Text PDF PubMed Scopus (39) Google Scholar have demonstrated that endoluminal grafts are effective in the treatment of a variety of arterial injuries, including arteriovenous fistulas. Recognized advantages of endovascular repair for traumatic arteriovenous fistulas compared with open surgical repair include diminished pain, decreased disability, rapid recovery, and lower cost.4Parodi J. Schonholz C. Ferreira L. Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions.Ann Vasc Surg. 1999; 13: 121-129Abstract Full Text PDF PubMed Scopus (218) Google Scholar Although data do not exist for a direct comparison of open and endovascular approaches to iliac arteriovenous fistulas, it would seem intuitively reasonable to presume the endovascular approach lowers the expected morbidity and mortality. Endoluminal grafts and coil embolization are anecdotally reported to be effective, but endovascular repair of pelvic arteriovenous fistulas is limited by the existing catheters, delivery systems, and devices.5Reber P. Patel A. Kniemeyer H. Surgical implications of failed endovascular therapy for posttraumatic femoral arteriovenous fistula repair.J Trauma. 1999; 46: 352-354Crossref PubMed Scopus (7) Google Scholar, 7Waldrop J. Dart B. Barker D. Endovascular stent graft treatment of a traumatic aortocaval fistula.Ann Vasc Surg. 2005; 19: 562-565Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar In our patient, most available endografts were not of sufficient diameter to treat an internal iliac artery of 24 mm. One consideration was to use a series of aortic extender cuffs to close the fistula; however, the shaft length of existing aortic endografts would not have been long enough in this patient to deliver cuffs to the distal internal iliac artery from a contralateral femoral approach. Another possibility would have been to use coils to embolize the fistula; however, the high-flow, short fistulous neck and large vessel size, coupled with the inability to precisely measure the size of the fistulous connection, dissuaded us from this option. The use of the TAG device solved these limitations by providing sufficient shaft length and endograft diameter to exclude the arteriovenous fistula. Furthermore, the 30-cm delivery sheath permitted access and support to the aortic bifurcation, which allowed for a relatively simple contralateral delivery. Endovascular techniques are an effective and possibly a preferred alternative to open surgical approaches for traumatic chronic arteriovenous fistulas. To our knowledge, this is the first reported case of a TAG endograft being deployed to repair an iliac arteriovenous fistula and provides an example of another treatment option for the endovascular surgeon.