Table of Contents  
COMMENTARY
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 186

Comments on endovascular management of postthrombotic ilio-iliac arteriovenous fistula with occluded common iliac vein: A case report and literature review


The Rane Center at St. Dominic, 2223 Eastover Drive, Jackson, MS 39211, United States

Date of Web Publication8-Aug-2018

Correspondence Address:
Dr. Seshadri Raju
The Rane Center at St. Dominic, 2223 Eastover Drive, Jackson, MS 39211
United States
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.238722

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How to cite this article:
Raju S. Comments on endovascular management of postthrombotic ilio-iliac arteriovenous fistula with occluded common iliac vein: A case report and literature review. Indian J Vasc Endovasc Surg 2018;5:186

How to cite this URL:
Raju S. Comments on endovascular management of postthrombotic ilio-iliac arteriovenous fistula with occluded common iliac vein: A case report and literature review. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2018 Dec 10];5:186. Available from: http://www.indjvascsurg.org/text.asp?2018/5/3/186/238722



The authors present an interesting and unusual case of iliac arteriovenous (AV) fistula associated with common iliac vein (CIV) chronic total occlusion (CTO). As is often the case, the management of such rare cases does not fit a standard template; an individualized approach is required.

Several unusual features in the presentation offered clues to the unusual pathology. Dilated thigh collaterals are not a feature of iliac CTO — most collaterals are transpelvic with this pathology. The dilated external iliac vein is not a feature of CIV occlusions either. The external iliac vein displays varying degrees of postthrombotic stenosis or even occlusion in continuity with the CIV occlusion. Spontaneous rupture and bleed is extremely rare in primary varices. They are limited to the lower leg because of the gravity pressure.

An elective AV fistula in the femoral vessels is sometimes used as an adjuvant after iliac vein thromboembolectomy or to augment inflow into iliac vein stents with marginal inflow. Such fistulae carry a double-edged sword. While iliac vein patency may be improved (as yet unproven by evidence grade), the risk of distal venous hypertension exists if fistula flow is not controlled. A 4 mm polytetrafluoroethylene conduit or sleeve over the saphenous conduit is used to control fistula flow. The fistula is typically retained for 6—8 weeks till the thrombectomized or stented segment is re-endothelialized. Such fistulae can be closed percutaneously with relative ease if the prosthetic conduit or sleeve is tagged with radiopaque clips. An alternative is to leave a loosely knotted heavy Nylon around the fistula with the tagged suture ends left under the skin. It can then be retrieved, and the knot tightened through a mini-incision at the time of closure. Open-free dissection of such fistulae is often hazardous because of the heavy cicatrix that develops around the fistula.






 

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