Diagnostic difficulties in differentiating of arteriovenous fistula -- case report

Arteriovenous carotid-cavernous fistula is an abnormal connection between the dural branches of carotid artery or vertebral artery and the dural sinuses. Its clinical manifestations can resemble the crucial signs of thyroid orbitopathy, an inflammatory disorder of the orbit associated with Graves' disease. Therefore, differential diagnosis of thyroid orbitopathy and the congestion of the orbit seen in arteriovenous fistula is often clinically and radiologically confused. This is the case report of the simultaneous occurrence of dural arteriovenous fistula in 59 years old woman. The first manifestation was unilateral exophthalmia. After Computer Tomography and Magnetic Resonance Imaging were performed, the preliminary diagnosis of thyroid orbitopathy was established. The response of eye disorder to corticosteroid treatment resulted in evident deterioration. This prompted a reconsideration of the diagnosis and a new evaluation of the patient with sensitive techniques, leading to the final diagnosis of arteriovenous fistula.     

Monophasic synovial sarcoma presenting as a primary ileal mass: a case report and review of the literature

Introduction

Iliocaval fistulas can complicate an iliac artery aneurysm. The clinical presentation is classically a triad of hypotension, a pulsatile mass and heart failure. In this instance, following presentation with multiorgan failure, management included the immediate use of an endovascular stent graft on discovery of the fistula.

Case presentation

A 62-year-old Caucasian man presented to our tertiary hospital for management of iatrogenic trauma due to the insertion of a central venous line into his right common carotid artery, causing transient ischemic attack. Our patient presented to a peripheral hospital with fever, nausea, vomiting, acute renal failure, acute hepatic dysfunction and congestive heart failure. A provisional diagnosis of sepsis of unknown origin was made. There was a 6.5 cm×6.5 cm right iliac artery aneurysm present on a non-contrast computed tomography scan. An unexpected intra-operative diagnosis of an iliocaval fistula was made following the successful angiographic removal of the central line to his right common carotid artery. Closure of the iliocaval fistula and repair of the iliac aneurysm using a three-piece endovascular aortic stent graft was then undertaken as part of the same procedure. This was an unexpected presentation of an iliocaval fistula.

Conclusion

Our case demonstrates that endovascular repair of a large iliac artery aneurysm associated with a caval fistula is safe and effective and can be performed at the time of the diagnostic angiography. The presentation of an iliocaval fistula in this case was unusual which made the diagnosis difficult and unexpected at the time of surgery. The benefit of immediate repair, despite hemodynamic instability during anesthesia, is clear. Our patient had two coronary angiograms through his right femoral artery decades ago. Unusual iatrogenic causes of iliocaval fistulas secondary to previous coronary angiograms with wire and/or catheter manipulation should be considered in patients such as ours.     

SUCCESSFUL CLOSURE OF POST-TRAUMATIC CAROTID-JUGULAR ARTERIOVENOUS FISTULA COMPLICATED BY CONGESTIVE HEART FAILURE AND CEREBROVASCULAR INSUFFICIENCY

This report describes a patient who received a traumatic injury of the neck 28 years prior to admission to this institution. He had required multiple hospitalizations, along with medications for congestive heart failure. After ligation of a large arteriovenous fistula and replacement of a 3 cm segment of the left common carotid artery with an 8 mm double-velour graft, the patient was greatly improved.     

Thermoregulatory anatomy of pronghorn (Antilocapra americana)

We have found that pronghorn (Antilocapra americana) use external heat exchange with the environment and internal heat exchange between the carotid artery rete and cavernous venous sinus blood to regulate body temperature. Now we have investigated the relationship between the histological structure of the skin, cephalic veins, and carotid rete–cavernous sinus system and the physiological mechanisms pronghorn use, and whether their thermoregulatory anatomy has adaptive advantages. We harvested tissue samples of skin, three veins (i.e., angularis oculi vein, dorsal nasal vein, and facial vein), and the carotid rete–cavernous sinus system from four pronghorn, two culled in summer and two in winter, and examined each histologically. The three veins had the typical structure of veins with large lumina and thin walls. The carotid rete consisted of small (0.1–0.5 mm) arterioles with a density of ~10/mm², intertwined with veins (~2/mm²), enclosed within the cavernous sinus; a structure ideal for heat exchange. We concluded that the main function of the dorsal nasal and facial veins is to return cold blood to the body to effect whole body cooling. The cavernous sinus is supplied with warm blood by the palatine veins in winter and cold blood by the deep facial veins in summer, an arrangement different to that in other ungulates, such as sheep, in which the angularis oculi vein supplies the cavernous sinus. Pronghorn skin is richly supplied with blood vessels that facilitate convective heat loss in summer. In winter, the number of coarse and fine hairs per square millimeter increases more than in European deer to form a thick pelage that minimizes heat loss. In summer, the pelage is shed because hair follicles involute. Unlike in other ungulates, pronghorn skin has little adipose tissue. The number of apocrine glands increases in winter rather than in summer. We concluded that the glands have a reproductive/social function rather than a thermoregulatory one. In summary, our study shows that the thermoregulatory anatomy is consistent with our physiological data and has adaptive advantages that help explain the survival of pronghorn in an arid habitat characterized by extreme temperature variation and sparse vegetation.     

Clinical anatomy of the blood spaces and blood vessels surrounding the siphon of the internal carotid artery

The anterior blood space of the cavernous sinus is situated anterolateral to the carotid siphon in 70%, anterior to it in 15%, and lateral to it in 15%. Its height, depth, and mediolateral breadth were measured. The mean distance between the carotid siphon and the skin at the supraorbital foramen was measured with 63 (52.4-71.4) mm. The drainage of the orbital veins was studied and described as well as the area of origin and first course of the ophthalmic artery and its clinical importance.     

Critical oropharyngocutaneous fistulas after microsurgical head and neck reconstruction: indications for management using the "tissue-plug" technique

Despite advances in head and neck reconstruction with free-tissue transfer techniques, oropharyngocutaneous fistulas continue to present challenging and potentially lethal complications. The authors present a system for prioritizing these fistulas and the surgical management of nine patients in whom critical fistulas developed after microsurgical head and neck reconstruction. The indications for aggressive management of these fistulas were primarily dependent on their location. Three peristomal and six midneck fistulas were considered critical because of the risk of aspiration pneumonia and carotid artery blowout, respectively. Fistulas located in the submental and/or submandibular region were considered noncritical and were managed conservatively. Using the concept of a "tissue plug" for fistula repair, a dermal component (i.e., a deltopectoral or pectoralis major pedicled flap) is guided through the fistula, and with external traction the tissue "plugs" the tract. No sutures are placed directly in the surrounding friable tissue. There were no partial or total flap losses. There were two fistula recurrences in patients who had received postoperative radiation therapy. One of these recurrences was due to tumor recurrence within the previous fistula and was managed with palliative measures. The other fistula recurrence was closed with a local-flap procedure on an outpatient basis. All patients resumed oral feeding, except for the patient in whom tumor recurrence was suspected. This tissue-plug technique can be used in the management of critical peristomal and/or midneck oropharyngocutaneous fistulas not only to obliterate the tract but also to augment volume and vascularity in already damaged, ischemic, and deficient tissue.     

鞍旁海绵状血管瘤的MRI诊断及误诊分析

目的:分析鞍旁海绵状血管瘤MR影像特点及误诊原因,提高对该疾病的诊断及鉴别诊断水平。方法:收集我院经手术病理证实的13例鞍旁海绵状血管瘤,术前均行MRI平扫及增强扫描,5例行3D-ASL检查,分析其影像学资料。结果:9例表现为横向哑铃状,鞍旁大,鞍内小,病灶主体位于颈内动脉外侧,颈内动脉海绵窦段被病灶包绕;1例鞍旁与鞍内病灶大小相似,1例病灶主体位于颈内动脉内侧,2例病灶完全位于颈内动脉外侧;7例垂体显示不清,6例垂体受推移;6例T2W I表现为类似脑脊液的极高信号;仅5例行3D-ASL检查,病灶均呈低灌注。误诊9例,其中4例误诊垂体腺瘤,5例误诊脑膜瘤。结论:横向哑铃状、病灶主体位于颈内动脉外侧及T2W I类似脑脊液的极高信号是鞍旁海绵状血管瘤的典型影像特征。对于不典型病变,借助3D-ASL可以减少误诊,充分掌握MRI影像特征及鉴别诊断的要点,对提高临床术前诊断水平具有重要价值。     

A Case of Adrenal Cavernous Hemangioma Presenting with Progressive Enlargement and Apparent Hormonal Hypersecretion

ObjectiveTo report the case of a man with an adrenal cavernous hemangioma presenting as a progressively enlarging adrenal mass with apparent hormonal hyper-secretion.MethodsWe report the clinical, laboratory, imaging findings, and clinical course of this patient, and we highlight the important atypical features of this case. The literature is reviewed for the typical presentations of adrenal cavernous hemangiomas.ResultsA 59-year-old man presented with an adrenal incidentaloma that had an imaging phenotype suggestive of a pheochromocytoma or an adrenal carcinoma. The hormonal profile also suggested a state of aldosterone and catecholamine hypersecretion. Surgery, however, proved the diagnosis to be an adrenal cavernous hemangioma.ConclusionAlthough adrenal cavernous hemangioma is a rare entity, it should be considered in the differential diagnosis of an adrenal incidentaloma. Its radiologic features are not specific, and the presence of hormonal hypersecretion does not exclude the diagnosis. (Endocr Pract. 2008;14:104-108)     

Carotid artery injury with cerebral infarction following head and neck blunt trauma: report of a case

Blunt injury to the carotid artery is rare but may produce a devastating outcome with longterm morbidity. Initial recognition by clinicians is often difficult because of the diverse clinical manifestations, the delay in presentation of symptoms, and the associated multi-organ system injuries that accompany carotid injury. Early diagnosis and successful management of traumatic carotid artery injury require a high index of clinical suspicion. We report herein a 20-year-old male victim of internal carotid artery injury induced by a motorcycle accident, who initially presented with a clear consciousness and had normal computed tomogram (CT) of brain. Two days after injury, the patient suffered from left hemiplegia and coma. The follow-up brain CT showed acute infarction of right cerebrum and severe cerebral edema. Emergency craniotomy for brain decompression and anticoagulation therapy was carried out. After a three-month treatment, he was discharged and underwent regular follow-up in the outpatient department. Six months later, the patient had intact awareness but remained in a left-sided hemiparetic state.     

Nitric Oxide Resistance Reduces Arteriovenous Fistula Maturation in Chronic Kidney Disease in Rats

Background

Autologous arteriovenous (AV) fistulas are the first choice for vascular access but have a high risk of non-maturation due to insufficient vessel adaptation, a process dependent on nitric oxide (NO)-signaling. Chronic kidney disease (CKD) is associated with oxidative stress that can disturb NO-signaling. Here, we evaluated the influence of CKD on AV fistula maturation and NO-signaling.

Methods

CKD was established in rats by a 5/6^th nephrectomy and after 6 weeks, an AV fistula was created between the carotid artery and jugular vein, which was followed up at 3 weeks with ultrasound and flow assessments. Vessel wall histology was assessed afterwards and vasoreactivity of carotid arteries was studied in a wire myograph. The soluble guanylate cyclase (sGC) activator BAY 60–2770 was administered daily to CKD animals for 3 weeks to enhance fistula maturation.

Results

CKD animals showed lower flow rates, smaller fistula diameters and increased oxidative stress levels in the vessel wall. Endothelium-dependent relaxation was comparable but vasorelaxation after sodium nitroprusside was diminished in CKD vessels, indicating NO resistance of the NO-receptor sGC. This was confirmed by stimulation with BAY 60–2770 resulting in increased vasorelaxation in CKD vessels. Oral administration of BAY 60–2770 to CKD animals induced larger fistula diameters, however; flow was not significantly different from vehicle-treated CKD animals.

Conclusions

CKD induces oxidative stress resulting in NO resistance that can hamper AV fistula maturation. sGC activators like BAY 60–2770 could offer therapeutic potential to increase AV fistula maturation.     

Effects of intracavernous administration of adrenomedullin on erectile function in rats.

We have reported that adrenomedullin (AM)-induced vasodilation is at least in part nitric oxide (NO)-cGMP-dependent in the rat. Although it is well known that NO is much involved in the erectile function, it is controversial as to whether AM influences the erectile function. Thus, we examined the effects of AM on intracavernous pressure (ICP) during penile erection. The left carotid artery of rats was cannulated to monitor of mean arterial pressure (MAP). Bipolar electrodes were positioned on the cavernous nerve. The right cavernous body was cannulated with a needle connected to a pressure transducer to monitor ICP. Electrical stimulation (ES) increased ICP in a voltage-dependent manner. Elevation of ICP continued during ES. The intracavernous injection of 0.5 nmol AM significantly potentiated ES-induced increases in both maximal developed ICP/MAP and area under the curve (ICP trace; AUC). Since AM slightly lowered MAP, ICP was normalized by MAP. i.v. administration of N(omega)-nitro-L-arginine, a NO synthase inhibitor, markedly decreased AM/ES-induced ICP elevation. However, in the presence of E-4021, a cGMP-specific phosphodiesterase inhibitor, AM further increased both ICP/MAP and AUC. These results suggest that a NO-cGMP pathway is involved in the regulation of AM-induced rat cavernous vasorelaxation.     

Gender-related differences in octogenarians with congenital coronary artery fistula: a report of two cases and a review

Aim

To highlight gender-related differences in octogenarians with a congenital coronary artery fistula (CAF).

Materials and methods

We present two elderly female patients with a congenital fistula, a septuagenarian and a nonagenarian, and review the world literature between 1954–2010.

Results

The septuagenarian patient presented with easy fatigability and the nonagenarian patient with acute myocardial infarction contralaterally to the fistula. Coronary angiography (CAG) demonstrated a coronary-pulmonary artery fistula (CPF). The nonagenarian patient underwent percutaneous coronary intervention of the right coronary artery. CAG revealed a CPF associated with a huge multiple aneurysmal formation. Data from 57 mainly symptomatic patients with a mean age of 75.3 years (range 70–87 years) were collected. The cohort was subdivided into female (mean age 84.3 years) and male (mean age 75.2 years) subgroups and compared with each other. Multi-origin (bilateral and multilateral) was prevalent in females, 40% versus 12% in males. Aneurysmal formation was found in females and males in 40% and 18%, respectively. Ethnicity was 65% Caucasian and 35% Asian. Multi-origin fistulas were prevalent in the Asian (45%) compared with the Caucasian (11%) subset.

Conclusions

A septuagenarian and a nonagenarian female patient with congenital CAF are presented. On reviewing the literature, important differences were found between elderly females and males with congenital CAF.     

Secondary aortoenteric fistula

Secondary aortoenteric fistula (SAF) is an uncommon but very important complication of abdominal aortic reconstruction. The complication often occurs months to years after aortic surgery. The clinical manifestation of the aortoenteric fistula is always upper gastrointestinal bleeding. Treatment of the disease is early surgical intervention. If operative treatment is not performed promptly, the mortality is high. A case of secondary aortoduodenal fistula found 6 years after aortic reconstructive surgery, with the clinical presentation of upper gastrointestinal bleeding, is presented. On Immediate exploratory laparotomy, the proximal part of abdominal aorta was clamped. Duodenorrhaphy and aortic reconstruction with patch graft at the proximal suture line of aortic prosthesis was performed. Fortunately there was no pus, so tissue culture was not done. The intervention was concluded with an omentoplasty to protect the patch graft and to separate it from duodenorrhaphy. The patient did well after the surgical management. Because of the increasing number of elective aortic aneurysm repairs in the aging population, it is likely that more patients with secondary aortoenteric fistula will present to the clinical physicians in the future. So, a high index of suspicion is necessary for prompt diagnosis and treatment of this life-threatening event.     

Anatomical variations of the intracavernous branches of the internal carotid artery with reference to the relationship of the internal carotid artery and sixth cranial nerve. A microsurgical study

Thirty cavernous sinuses were dissected and examined using microsurgical methods under a magnification of X10 and X16. The anatomical variations of the intracavernous branches of the internal carotid artery (ICA) and the anatomical relationship of the sixth nerve with the ICA are described and discussed in relation to the findings from other microsurgical works.     

"No-reflow" phenomenon during percutaneous carotid angioplasty in a scleroderma patient

Atherosclerosis remains the most common etiology of carotid artery stenosis, but other systemic diseases can also cause this disease. Percutaneous carotid angioplasty and stenting (CAS) with and without distal embolic protection devices is gaining acceptance as the treatment of choice. No-reflow phenomenon due to distal embolization has been previously described mainly during percutaneous intervention of degenerated saphenous vein graft. We describe a patient with systemic sclerosis who underwent CAS with distal embolic protection device with occurrence of no-reflow phenomenon during the procedure that resolved after retrieval of the filter device.     

Systemic arteriovenous fistula leads to pulmonary artery remodeling and abnormal vasoreactivity in the fetal lamb

Several cases of systemic arteriovenous fistula diagnosed in the human fetus have been associated with the postnatal development of persistent pulmonary hypertension. The aim of this study was to determine the effects of a prenatally created systemic arteriovenous fistula on the structure and reactivity of the pulmonary circulation in the fetal lamb. A fistula between the jugular vein and carotid artery was created in fetal lambs at 119-124 days of gestation. At delivery (134-139 days), left pulmonary artery (LPA) pressure was increased in the fistula group (n = 12) compared with controls (n = 11, P < 0.01). The pulmonary vascular resistance was significantly higher in the fistula group (P < 0.05), whereas mean LPA blood flow was not statistically different between the two groups. Morphometric analysis of the pulmonary vascular bed revealed an increase in the number of peripheral muscular arteries, together with an increase in pulmonary arterial medial thickness in the fistula group. There was no difference in the relative number or size of intraacinar arteries. In vitro organ bath studies on pulmonary arterial rings showed impaired endothelium-dependent relaxation in the fistula group compared with controls. However, endothelial nitric oxide synthase protein expression was similar in both groups, whereas endothelium-independent relaxation to sodium nitroprusside was greater in the fistula group compared with controls. A systemic arteriovenous fistula leads to both structural and functional alteration of the pulmonary vasculature, which might lead to the development of persistent pulmonary hypertension after birth.     

Autogenous arteriovenous elbow fistula for haemodialysis and upper extremity ischemia

BACKGROUND: The autogenous brachiocephalic or brachiobasilic arteriovenous elbow fistula is not considered to be only the secondary haemodialysis access. In patients with an unsuitable forearm vessel bundle, it is indicated as primary access and it is the method preferred to the fistula creation using a vascular prosthesis. Its rather rare complication is the development of upper extremity ischemia. AIM: To summarise current knowledge of this fistula type and its associated complications METHODS: Review of the literature. RESULTS: The creation and maturation of the fistula and occurrence of the steal syndrome is influenced by a number of factors. The analysis and awareness of such factors will provide for creation of a suitable fistula as well as for timely complication diagnostics and treatment. CONCLUSIONS: The autogenous elbow fistula utilising the brachial artery and the cephalic or basilic vein in the upper extremity represents a high-quality haemodialysis access. Its potential complication is the occurrence of the steal syndrome. Its occurrence and manifestations do not constitute indications for ligation of the access. The gathered information shows that a suitable surgical procedure can help meet the basic rule for haemodialysis access--resolving the ischemia and maintaining the access.     

Haemangiomas of the orbit

The authors describe their experience with systemic therapy of cavernous haemangiomas making use of interferon alpha. They have successfully used the method in treating two female patients with cavernous haemangiomas in the orbit. In the first patient, the IFN therapy was followed by surgical removal of the tumour. In the second patient, surgical operation was not suitable. After the IFN therapy, the patient's state improved both subjectively and objectively. Decreased level of bFGF in urine prove to be the criterion for successful treatment by IFN. The authors also stress the risk of complications in sucklings. When choosing the method of treatment, they emphasize the necessity of interdisciplinary cooperation.     

Osteogenic Sarcoma of the Sella After Radiation Treatment of a Pituitary Adenoma

ObjectiveTo report an uncommon case of osteogenic sarcoma of the sella turcica after radiation treatment of a pituitary adenoma.MethodsWe present the clinical history, physical findings, laboratory data, imaging studies, and pathologic findings in a patient found to have osteogenic sarcoma of the sella after radiation therapy for a nonfunctioning pituitary adenoma.ResultsSix years after transsphenoidal resection and postoperative fractionated radiation therapy for a nonfunctioning pituitary adenoma that extended to the cavernous sinus, a 45-year-old man presented with a sinus infection, diplopia, and ophthalmoplegia of the right eye. A computed tomographic scan of the head showed a mass in the sella with involvement of the optic chiasm and right cavernous sinus. Transsphenoidal resection and debulking of the tumor revealed an osteogenic sarcoma. The patient was discharged from the hospital with residual diplopia and ophthalmoplegia. He was treated with levothyroxine, testosterone, and hydrocortisone. Six weeks later, the patient was readmitted after he was found unresponsive, and computed tomographic scans disclosed a massive cerebrovascular accident. He died a few days later.ConclusionOsteogenic sarcoma is a rare, late complication of radiation treatment of pituitary adenoma. Although radiotherapy remains an effective adjunctive treatment in patients with pituitary adenomas, particularly those with residual or recurrent tumor, potential complications must be acknowledged. (Endocr Pract. 2004;10: 335-338)