Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 165-167

Endovascular management of peripheral congenital arteriovenous malformation and arteriovenous fistula in Nepal


Department of Vascular and Endovascular Surgery, Annapurna Hospital, Kathamndu, Nepal

Date of Web Publication8-Aug-2018

Correspondence Address:
Dr. Sandeep Raj Pandey
Department of Vascular and Endovascular Surgery, Annapurna Hospital, Kathamndu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_11_18

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  Abstract 


Introduction: The management of peripheral arteriovenous malformations (AVMs) and arteriovenous fistula (AVF) remains challenging in Nepal due to their unpredictable behavior and high recurrence rate. Materials and Methods: This report describes cases of peripheral AVM and AVF. We report the case of a 20-year-old male with AVMs draining from a superficial femoral artery (SFA) with multiple feeders on the left lower thigh who underwent embolization of SFA feeders. Other case was a 60-year-old female with very high-flow AV fistula from the inferior gluteal artery with large venous varix of draining vein who underwent coil embolization of nidus followed by glue embolization. Results: Both patients got relieved of pain and significantly decreased mass n pulsation. The outcome was satisfactory without complication. Conclusion: Treatment for peripheral AVM and AVF is a challenge due to their unpredictable behavior. There is a wide plethora of embolic agents, each with its particular characteristics that makes it ideal for certain situations. Familiarity with these and their modes of use and action can help in selecting the correct agent depending on the goal of embolization.

Keywords: Arteriovenous fistula, arteriovenous malformations, embolotherapy


How to cite this article:
Pandey SR. Endovascular management of peripheral congenital arteriovenous malformation and arteriovenous fistula in Nepal. Indian J Vasc Endovasc Surg 2018;5:165-7

How to cite this URL:
Pandey SR. Endovascular management of peripheral congenital arteriovenous malformation and arteriovenous fistula in Nepal. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2018 Dec 10];5:165-7. Available from: http://www.indjvascsurg.org/text.asp?2018/5/3/165/238720




  Introduction and Background Top


A tangle of blood vessels in the peripheral parts bypassing normal tissue and directly diverting blood from the arteries to the veins are called peripheral arteriovenous malformation (AVM). An abnormal communication between an artery and a vein in peripheral parts is called peripheral arteriovenous fistula (AVF). Peripheral AVM and AVF are rare congenital lesions. Complete eradication of the nidus of an AVM is the only potential cure.[1] Surgical resection is often difficult, and recurrence of the AVM is common with incomplete resection. Transcatheter embolization now plays a significant role in the treatment of AVM and AVF.[2] For very large malformations, preoperative embolization may be helpful before surgical intervention due to the increased risk of massive bleeding associated with such anomalies. This report describes cases of peripheral AVM and AVF treated by me at Nepal with my proctor Dr. Virender Singh Sheorain from my fellowship Institute Medanta, India. We report a case of a 20-year-old male with AVMs draining from a superficial femoral artery (SFA) with multiple feeders on his lower thigh who underwent embolization of nidus. The other case was a 60-year-old female with very high-flow AVF from the inferior gluteal artery with large venous varix of draining vein who underwent coil embolization of nidus followed by glue embolization.

Objective

The objective of this study was to assess the treatment results of coils and glue embolization of peripheral AVM and AVF at Nepal.


  Materials and Methods Top


Case of arteriovenous malformations

A 20-year-old male found painful pulsatile nodules on his left lower thigh which was progressively enlarging for several months. Computed tomography (CT)—angiography showed AVMs draining from SFA with multiple feeders on his lower thigh. The patient underwent embolization of nidus with n-butyl cyanoacrylate (NBCA) and lipiodol through right-side CFA approach with 5 fr sheath and progreat microcatheter [Figure 1].
Figure 1: Arteriovenous malformations

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Case of arteriovenous fistula

A 60-year-old female consists of pain and pulsation in her buttock which has also been progressively enlarging for several years. CT angiography showed very high-flow AV fistula from the inferior gluteal artery with large venous varix of draining vein. She underwent coil embolization of nidus followed by glue embolization through the right femoral approach. It was followed by percutaneous lipiodol injection [Figure 2].
Figure 2: Arteriovenous fistula

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  Results Top


Both patients got relieved of pain and significantly decreased mass n pulsation. The outcome was satisfactory without complication.


  Discussions Top


The current management of peripheral AVM and AVF based on the new concept of a multidisciplinary team approach[3] can minimize the morbidity and reduce the recurrence of the lesion. There has recently been further expansion of the limited role of embolotherapy as adjunctive therapy for surgical resection. This approach has even been helpful in high-risk lesions with high-flow status. Numerous embolic materials have been developed, ranging from simple Gelfoam pledgets to complex systems employing microcatheter and detachable coils. We chose NBCA coils as the permanent embolic agents. Some use NBCA to temporarily control the bleeding because it cannot act as a permanent agent to control a lesion effectively as there is no evidence of permanent damage to the endothelium.[4] Some use ethylene—vinyl alcohol copolymer (Onyx®, Micro Therapeutics, Irvine, CA, USA) instead of NBCA. Onyx®, unlike other liquid embolic agents does not adhere to the endothelial wall and catheter tip.[5] However, Onyx® is also less adhesive than NBCA; therefore, NBCA is preferred to Onyx® for high-flow lesion.


  Conclusion Top


Treatment for peripheral AVM and AVF is a challenge due to their unpredictable behavior. There is a wide plethora of embolic agents, each with its own particular characteristics that makes it ideal for certain situations. Familiarity with these and their modes of use and action can help in selecting the correct agent depending on the goal of embolization. Embolotherapy is essential to manage peripheral AVM and AVF and to improve the results of treatment and reduce the risk of bleeding associated with open resection with limited morbidity and no recurrence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim JY, Kim DI, Do YS, Lee BB, Kim YW, Shin SW, et al. Surgical treatment for congenital arteriovenous malformation: 10 years' experience. Eur J Vasc Endovasc Surg 2006;32:101-6.  Back to cited text no. 1
    
2.
Jacobowitz GR, Rosen RJ, Rockman CB, Nalbandian M, Hofstee DJ, Fioole B, et al. Transcatheter embolization of complex pelvic vascular malformations: Results and long-term follow-up. J Vasc Surg 2001;33:51-5.  Back to cited text no. 2
    
3.
Lee BB, Bergan JJ. Advanced management of congenital vascular malformations: A multidisciplinary approach. Cardiovasc Surg 2002;10:523-33.  Back to cited text no. 3
    
4.
Ikoma A, Kawai N, Sato M, Tanaka T, Sonomura T, Sahara S, et al. Pathologic evaluation of damage to bronchial artery, bronchial wall, and pulmonary parenchyma after bronchial artery embolization with N-butyl cyanoacrylate for massive hemoptysis. J Vasc Interv Radiol 2011;22:1212-5.  Back to cited text no. 4
    
5.
Cantasdemir M, Kantarci F, Mihmanli I, Numan F. Embolization of profunda femoris artery branch pseudoaneurysms with ethylene vinyl alcohol copolymer (onyx). J Vasc Interv Radiol 2002;13:725-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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