Insuficiencia cardíaca de alto gasto asociada a fístula arteriovenosa: caso clínico / High output heart failure associated with arteriovenous fistula: clinical case / Insuficiência cardíaca de alto débito associada a fístula arteriovenosa: caso clínico

La creación de una fístula arteriovenosa (FAV) determina un incremento del gasto cardíaco, cuya magnitud está relacionada con el tamaño del cortocircuito. En el escenario adecuado esta puede conducir al desarrollo de insuficiencia cardíaca (IC) con alto gasto cardiaco. Se presenta el caso de un paciente que desarrolla IC luego de la confección de una FAV para hemodiálisis crónica y sus implicancias clínicas posteriores. Se revisan aspectos diagnósticos y terapéuticos referidos a la IC de alto gasto.

The creation of an arteriovenous fistula (AVF) determines an increase in cardiac output, the magnitude of which is related to the size of the shunt. In the right scenario, this can lead to the development of heart failure (HF) with high cardiac output. The case of a patient who develops HF after creating an AVF for chronic hemodialysis and its subsequent clinical implications is presented. Diagnostic and therapeutic aspects related to high-output HF are reviewed.

A criação de uma fístula arteriovenosa (FAV) determina aumento do débito cardíaco, cuja magnitude está relacionada ao tamanho do shunt. No cenário certo, isso pode levar ao desenvolvimento de insuficiência cardíaca (IC) com alto débito cardíaco. É apresentado o caso de um paciente que desenvolve IC após confecção de FAV para hemodiálise crônica e suas subsequentes implicações clínicas. Aspectos diagnósticos e terapêuticos relacionados à IC de alto débito são revisados.

Traumatic high flow arterioportal fistula. Correction by a covered stent.

The arterio-portal fistula is a rare entity, generally associated with different causes, among which penetrating trauma stands out. They can occur at the beginning asymptomatic or manifest by a wide spectrum of signs and symptoms with severe limitation of the patient's quality of life and even compromise it. Immediate therapeutic action, whether surgical or endovascular, is vital for the definitive solution of the primary triggering cause. We present the case of a patient with a stab wound to the abdomen who developed an arterioportal fistula with associated portal hypertension as a complication. It is treated by placing a covered stent at the level of the anomalous communication, with definitive clinical and imaging resolution.

Endovascular Repair of a Spontaneous Popliteal Arteriovenous Fistula Associated With a Venous Aneurysm.

Popliteal arteriovenous fistulae (PAF) are anomalous communications between the arterial and venous systems of the lower extremity. They are usually secondary to trauma and are rarely associated with additional vascular defects. The coexistence of a PAF and a venous aneurysm is rare and usually occurs in patients with connective tissue disorders. Evidence regarding the management of this type of anomaly is scarce. However, both open and endovascular approaches seem feasible alternatives for treating this condition. Here, we describe a spontaneous popliteal arteriovenous fistula associated with a venous aneurysm in a 42-year-old male patient who presented with a popliteal mass. Satisfactory endovascular closure of the fistula and exclusion of the venous aneurysm were achieved using an Amplatzer™ Vascular Plug II.

An unusual case of femoral arteriovenous fistula associated with acute limb ischemia following femoral vein catheterization for hemodialysis / Um caso incomum de fístula arteriovenosa femoral associada a isquemia aguda de membro após cateterização da veia femoral para hemodiálise

Abstract Co-occurrence of acute limb ischemia (ALI) and arteriovenous fistula (AVF) as a manifestation of inadvertent arterial injury during percutaneous femoral vein dialysis catheter insertion is a rare and dangerous, but preventable complication. Iatrogenic femoral AVF commonly presents late, with leg swelling or high output cardiac failure. However, the co-occurrence of a femoral AVF with both progressive leg swelling, and acute thromboembolism has not been previously reported. We report the case of an iatrogenic femoral AVF with superficial femoral artery (SFA) thrombosis and distal embolism in a 53-year-old female who underwent percutaneous femoral access for temporary hemodialysis. Both the SFA and AVF were managed with open surgical repair.

Resumo A coocorrência de isquemia aguda de membro (IAM) e fístula arteriovenosa (FAV) como uma manifestação de lesão arterial inadvertida durante a inserção de cateter para hemodiálise por via femoral percutânea é uma complicação rara e perigosa, porém evitável. A FAV femoral iatrogênica geralmente tem apresentação tardia, com edema dos membros inferiores ou insuficiência cardíaca de alto débito. No entanto, a coocorrência de FAV femoral com edema progressivo dos membros inferiores e tromboembolismo agudo não foi previamente relatada. Relatamos o caso de uma FAV femoral iatrogênica com trombose da artéria femoral superficial (AFS) e embolia distal em uma paciente do sexo feminino, 53 anos, submetida à acesso femoral percutâneo para hemodiálise temporária. Tanto a AFS quanto a FAV foram manejadas com reparo cirúrgico aberto.

Anatomy of the Middle Meningeal Artery

Introduction The middle meningeal artery (MMA) is an important artery in neurosurgery. As the largest branch of the maxillary artery, it provides nutrition to the meninges and to the frontal and parietal regions. Diseases, including dural arteriovenous fistula (DAVF), pseudoaneurysm, true aneurysm, traumatic arteriovenous fistula (TAVF), Moya-Moya disease (MMD), recurrent chronic subdural hematoma (CSDH), migraine, and meningioma,may be related to the MMA. The aim of the present study is to describe the anatomy of the MMA and to correlate it with brain diseases. Methods A literature review was performed using the PubMed, Scielo, Scientific Direct, Ebsco, LILACS, TripDataBase and Cochrane databases, with the following descriptors: neurosurgery, neuroanatomy, meninges and blood supply. Discussion The MMA is embedded in a cranial groove, and traumatic or iatrogenic factors can result in MMA-associated pseudoaneurysms or arteriovenous fistulas (AVFs). In hemodynamic stress, true aneurysms can develop. Arteriovenous fistulas, pseudoaneurysms, and true aneurysms can be effectively treated by endovascular or surgical removal. In MMD, the MMA plays a role in the development and in the improvement of collateral circulation. Finally, in cases of CSDH, when standard surgery and drainage fail, MMA embolization can constitute a great alternative. Conclusion The MMA is a relevant structure for the understanding of neurosurgical diseases. In conclusion, every neurosurgeon must know the anatomy of the MMA sufficiently to correlate it with the diagnosed pathology, thus obtaining treatment effectiveness and preventing brain lesion.

Treatment-Associated Stroke in Patients Undergoing Endovascular Therapy in the ARUBA Trial.

Background and Purpose: Since the publication of ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations), outcomes in treated and untreated patients with unruptured arteriovenous malformation have been thoroughly compared. However, no prior analysis of ARUBA patients has sought to identify risk factors for perioperative stroke. Improved understanding of risks within the ARUBA cohort will help clinicians apply the study's findings in a broader context. Methods: The National Institute of Neurological Disorders and Stroke database was queried for all data relating to ARUBA patients, including demographics, interventions undertaken, and timing of stroke. Retrospective cohort analysis was performed with the primary outcome of perioperative stroke in patients who underwent endovascular intervention, and stroke risk was modeled with multivariate analysis. Results: A total of 64 ARUBA patients were included in the analysis. One hundred and fifty-ninth interventions were performed, and 26 (16%) procedures resulted in stroke within 48 hours of treatment. Posterior cerebral artery supply (adjusted odds ratio, 4.42 [95% CI, 1.23­15.9], P=0.02) and Spetzler-Martin grades 2 and 3 arteriovenous malformation (adjusted odds ratio, 7.76 [95% CI, 1.20­50.3], P=0.03; 9.64 [95% CI, 1.36­68.4], P=0.04, respectively) were associated with increased perioperative stroke risk in patients who underwent endovascular intervention. Patients treated in the United States or Germany had a significantly lower stroke risk than patients treated in other countries (adjusted odds ratio, 0.18 [95% CI, 0.04­0.82], P=0.02). Conclusions: Knowing patient and lesion characteristics that increase risk during endovascular treatment can better guide clinicians managing unruptured brain arteriovenous malformation. Our analysis suggests risk of perioperative stroke is dependent on Spetzler-Martin grade and posterior-circulation arterial supply. Differences in regional treatment paradigms may also affect stroke risk.

Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study.

BACKGROUND: In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs. METHODS: The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points. RESULTS: A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope - 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes - 8.24%, p < 0.001; - 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22). CONCLUSION: The rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.

Emergent Hybrid Treatment of a Ruptured Scalp Arteriovenous Fistula with Eyelid involvement: Technical Note.

BACKGROUND: Scalp arteriovenous fistulas (AVFs) are a rare vascular disease usually presenting as a progressively increasing pulsating mass in the scalp. These lesions can be associated with mild to severe complications, including congestive heart failure. If ruptures, this pathology constitutes a life-threatening medical emergency because of its potential to cause severe bleeding and acute anemia. METHODS: We describe the case of a young woman with a ruptured Yokouchi type C scalp AVF with eyelid involvement. RESULTS: The patient presented with hypovolemic shock and acute anemia due to severe bleeding from the lesion. Emergent treatment through a combined endovascular and open surgical approach was required to stop bleeding and stabilize the patient. CONCLUSIONS: Emergent and effective treatment is required to stop bleeding when a scalp AVF ruptures. A combination of endovascular embolization and microsurgical excision of the shunt is a treatment option.

Angioaccesos para hemodiálisis en el trasplante renal: implicaciones hemodinámicas sobre el corazón izquierdo / Angioaccess for hemodialysis in kidney transplantation: hemodynamic implications for the left heart

Las complicaciones cardiovasculares representan la principal causa de morbilidad y mortalidad en pacientes con enfermedad renal crónica, por lo que el objetivo de este artículo es demostrar la influencia de la permanencia de la fístula arteriovenosa sobre variables eco cardiográficamente mensuradas en el corazón izquierdo. Para ello, se definió un estudio multivariable, longitudinal, prospectivo y controlado de grupos independientes después de una intervención que incluyó 39 pacientes a los que se le cerró el angioacceso (grupo de estudio) y 42 que no fueron expuestos a la cirugía (grupo control). Ambos grupos exhibían trasplante renal funcionante. Los principales resultados surgenal comparar el predominio entre el grupo de estudio con el de control, la edad promedio; 45,6 y 44,1 años, el sexo masculino, 24 (60%) y 23 (53,5%) y el color de la piel blanca; 33 (82,5%) y 32 (74,4%). La etiología de la nefropatía originaria más frecuente fue la nefropatía vascular hipertensiva; 12 (30%) vs 14 (32,6%). Entre las manifestaciones clínicas, en el grupo de estudio se evidenció remisión de las palpitaciones y la disnea de esfuerzo. Respecto a la tensión arterial, para la sistólica oscilaba; de 123 ±13,4 a 120,5 ±9,2 vs de 125,6 ±8,4 a 128 ±8,3 mm Hg (p= 0,000), mientras la diastólica variaba de; 76,8 ±7,5 a 76,3 ±6,2 vs 78,6 ±4,9 a 82,4 ±3,9 mm Hg (p= 0,000). El hematocrito comportaba valores equivalentes; 0,43 ±0,06 y 0,45 ±0,06 vs 0,42 ±0,05 y 0,42 ±0,06 l/l (p= 0,035) y la creatinina sérica mostró descenso en los pacientes intervenidos de; 106,8 ± 26,2 hasta 99,8 ±23,9 µ Mol/l vs 114 ±27,8 a 120,3 ±31 µ Mol/l (p= 0,002). Las variables ecocardiográficas mensuradas comparativamente según la localización de los angioaccesos a nivel del codo izquierdo; diámetro del ventrículo izquierdo: 3,12 ±4,08 vs 1,48 ±3,46 mms (p=0,001), fracción de eyección del ventrículo izquierdo: 2,99 ±5,47 vs -1,98 ±6,23 % (p=0,018) y el volumen telediastólico: -23 ±33,41 vs 10,86 ±36,87 ml (p=0,006). El codo contralateral revelaba; para la fracción de eyección del ventrículo izquierdo: 3,32 ±3,42 vs -2,18 ±4,78 % (p=0,037) y para el gasto cardíaco: -1,29 ±0,88 vs -0,26 ±0,86 l/min (0,020). Las conclusiones demuestran que el cierre del angioacceso a pacientes con trasplante renal funcionante respecto a los no intervenidos, contribuye a la regresión de las alteraciones morfológicas y hemodinámicas constatadas por ecocardiografía transtorácica en el corazón izquierdo a nivel de las diferentes localizaciones de los accesos vasculares.

Cardiovascular complications represent the main cause of morbidity and mortality in patients with chronic renal disease, so the objective of this article is to demonstrate the influence of the patency of the arteriovenous fistula on echocardiographic variables measured in the left heart. For this, a multivariate study, longitudinal, prospective and controlled study of independent groups after an intervention that included 39 patients who had their angioaccess closed (study group) and 42 who were not exposed to surgery (control group). Both groups exhibited functional kidney transplantation. The main results emerge when comparing the prevalence between the study group and the control group, the average age; 45.6 and 44.1 years, the male sex, 24 (60%) and 23 (53.5%) and the white skin color; 33 (82.5%) and 32 (74.4%). The most frequent etiology of the original nephropathy was hypertensive vascular nephropathy; 12 (30%) vs 14 (32.6%). Among the clinical manifestations, remission of palpitations and dyspnea on exertion were evidenced in the study group. With regard to blood pressure, for the systolic it ranged from 123 ±13.4 to 120.5 ±9.2 vs. 125.6 ±8.4 to 128 ±8.3 mmHg (p= 0.000), while the diastolic varied from; 76.8 ±7.5 to 76.3 ±6.2 vs. 78.6 ±4.9 to 82.4 ±3.9 mmHg (p= 0.000). The hematocrit had equivalent values; 0.43 ±0.06 and 0.45 ±0.06 vs 0.42 ±0.05 and 0.42 ±0.06 l/l (p= 0.035) and the serum creatinine showed decrease in the operated patients from; 106.8 ±26.2 to 99.8 ±23.9 µMol/l vs 114 ±27.8 to 120.3 ±31 µMol/l (p= 0.002). The echocardiographic variables measured comparatively according to the location of the angioaccesses at the left elbow level; diameter of the left ventricle: 3.12 ±4.08 vs 1.48 ±3.46 mms (p=0.001), ejection fraction of the left ventricle: 2.99 ±5.47 vs -1.98 ±6.23 % (p=0.018) and the telediasolic volume: -23 ±33.41 vs 10.86 ±36.87 ml (p=0.006). The contralateral elbow revealed; for the left ventricular ejection fraction: 3.32 ±3.42 vs -2.18 ±4.78 % (p=0.037) and for cardiac output: -1.29 ±0.88 vs -0.26 ±0.86 l/min (0.020). The conclusions show that the our study has shown that closing the angioaccess to patients with functioning renal transplants with respect to those not operated, contributes to the regression of morphological and hemodynamic alterations observed by transthoracic echocardiography in the left heart at the different locations of the vascular accesses.

Avaliação clínica da maturação da fístula arteriovenosa para hemodiálise: revisão de escopo / Evaluación clínica de la maduración de la fístula arteriovenosa para hemodiálisis: revisión de alcance / Arteriovenous fistula maturation clinical assessment for hemodialysis: a scoping review

Resumo Objetivo: Mapear as evidências de pesquisa disponíveis para avaliação clínica da maturação da fístula arteriovenosa. Métodos: Estudo do tipo Scoping review, com busca realizada entre outubro a novembro de 2019 nas bases de dados JBI, Cochrane, Biblioteca Virtual em Saúde, PubMed, e CINAHL, sendo incluídos estudos com pacientes maiores de 18 anos, com doença renal crônica pré-dialítica ou já em hemodiálise, submetidos à cirurgia da fístula arteriovenosa; texto disponível; e idiomas inglês, espanhol ou português. Foram excluídos estudos relacionados a fase pós-operatória ou relacionados a cuidados com próteses/enxertos arteriovenosos. Resultados: Foram identificadas 1954 publicações elegíveis, dos quais 38 compuseram a amostra final. O estudo compreendeu publicações entre 1998 e 2018, com abrangência internacional do tema (94,7%). O profissional executor da avaliação foi predominantemente o enfermeiro ou equipe de enfermagem (47,4%), e a avaliação teve início no pós-cirúrgico imediato, até meses após a cirurgia. Dentre as técnicas de avaliação clínica, 23 estudos (60,5%) recomendaram o exame físico e 15 (39,5%) a combinação anamnese e exame físico. Conclusão: A presente revisão apresentou o mapeamento de evidências, nas quais a avaliação clínica da fístula arteriovenosa deve incluir anamnese e exame físico, sendo apresentados vários elementos ligados a permeabilidade e respostas vasculares do acesso. Houve a predominância do profissional enfermeiro como avaliador, sendo ressaltada a necessidade do treinamento para execução da avaliação, além de uma avaliação mais abrangente, com aplicação do Processo e Teorias de Enfermagem, e Linguagens Padronizadas, o que pode propiciar um novo campo de investigação e desenvolvimento na área.

Resumen Objetivo: Mapear las evidencias de investigación disponibles para evaluación clínica de la maduración de la fístula arteriovenosa. Métodos: Estudio tipo scoping review, cuya búsqueda fue realizada entre octubre y noviembre de 2019 en las bases de datos JBI, Cochrane, Biblioteca Virtual em Saúde, PubMed y CINAHL. Se incluyeron estudios con pacientes mayores de 18 años, con enfermedad renal crónica predialítica o ya en hemodiálisis, sometidos a cirugía de fístula arteriovenosa y textos disponibles en inglés, español o portugués. Se excluyeron estudios relacionados con la fase posoperatoria o relacionados con cuidados de prótesis/injertos. Resultados: Se identificaron 1.954 publicaciones elegibles, de las cuales 38 formaron parte de la muestra final. El estudio comprendió publicaciones entre 1998 y 2018, con alcance internacional del tema (94,7 %). El profesional que ejecutó la evaluación fue predominantemente el enfermero o el equipo de enfermería (47,4 %) y la evaluación comenzó en el posoperatorio inmediato, hasta meses después de la cirugía. Entre las técnicas de evaluación clínica, 23 estudios (60,5 %) recomendaron el examen físico y 15 (39,5 %) la combinación entre anamnesis y examen físico. Conclusión: La revisión presentó el mapeo de evidencias, en las cuales la evaluación clínica de la fístula arteriovenosa debe incluir anamnesis y examen físico. También se presentaron varios elementos relacionados con la permeabilidad y respuestas vasculares del acceso. Hubo una predominancia del profesional enfermero como evaluador y se destaca la necesidad de entrenamiento para llevar a cabo la evaluación, además de una evaluación más abarcadora, con aplicación del proceso y teorías de enfermería y un lenguaje estandarizado, lo que puede proporcionar un nuevo campo de investigación y desarrollo del área.

Abstract Objective: To map the available research evidence for arteriovenous fistula maturation clinical assessment. Methods: A scoping review, with a search conducted between October and November 2019 at JBI, Cochrane, Virtual Health Library, PubMed, and CINAHL. Studies with patients over 18 years old, with pre-dialysis chronic kidney disease or already under hemodialysis, who underwent arteriovenous fistula surgery were included; available text; and in English, Spanish, and Brazilian Portuguese. Studies related to the postoperative phase or related to care with prostheses/arteriovenous grafts were excluded. Results: One thousand nine hundred and fifty-four eligible studies were identified; 38 made up the final sample. The study comprised studies between 1998 and 2018, with an international scope of the theme (94.7%). The professional who performed the assessment was predominantly the nurse or nursing team (47.4%), and assessment started in the immediate post-surgical period, even months after surgery. Among the clinical assessment techniques, 23 studies (60.5%) recommended physical examination and 15 (39.5%) the combination of medical history and physical examination. Conclusion: This review presented the mapping of evidence, in which arteriovenous fistula clinical assessment must include medical history and physical examination. Several elements related to the permeability and vascular responses of the access were presented. There was a predominance of professional nurses as evaluators. There was need for training to carry out the assessment, in addition to a more comprehensive assessment, with the application of the Nursing Theory and Standardized Languages and Process, which may provide with a new field of research and development in the area.

Fístula arteriovenosa traumática em região temporal: um desafio terapêutico / Traumatic arteriovenous fistula in the temporal region: a therapeutic challenge

Resumo As fistulas arteriovenosas podem ser congênitas ou traumáticas, sendo as primeiras mais comuns e diagnosticadas na infância e as últimas mais raras e com diagnóstico mais tardio. Ambas necessitam de tratamento intervencionista, que pode ser endovascular ou correção cirúrgica, sendo que cada caso deve ser estudado individualmente. Este artigo apresenta o caso de um paciente de 46 anos, com fístula arteriovenosa na artéria temporal superficial esquerda com suas veias correspondentes decorrente de trauma contuso na região temporal na infância. O diagnóstico foi confirmado por exame de imagem, e o paciente foi submetido a tratamento cirúrgico convencional, apresentando melhora dos sintomas. O caso chama atenção para uma afecção rara, sua investigação diagnóstica e condutas terapêuticas. As fistulas arteriovenosas traumáticas apresentam baixa incidência, ocorrem em variadas localizações e podem causar sintomas, requerendo tratamento, às vezes desafiador, com melhora da qualidade de vida do paciente.

Abstract Arteriovenous fistulas can be congenital or traumatic, the former being more common and diagnosed in childhood, and the latter being rarer and diagnosed later in life. Both require interventional treatment, which may be endovascular, or surgical repair and each case must be studied individually. This article presents the case of a 46-year-old patient with an arteriovenous fistula (AVF) between the left temporal artery and its corresponding veins resulting from a blunt trauma to the parietal region during childhood. The diagnosis was confirmed by imaging examination and he underwent conventional surgical treatment with improvement of symptoms. The case calls attention to a rare condition, its diagnostic investigation, and therapeutic approaches. The incidence of traumatic arteriovenous fistulas is low. They can occur in a variety of ways and can cause symptoms, requiring treatment, which is sometimes challenging, resulting in improvement in the patient's quality of life.

[Congenital renal arteriovenous fistula: a rare cause of acute abdomen and a review of its literature]. / Fístula arteriovenosa renal congénita: una causa rara de abdomen agudo y revisión de la literatura.

Introduction: Congenital renal arteriovenous fistula is an abnormal connection between the arterial and venous system. Since the first case described in 1928 by Varela et al, no more than 200 cases have been published. Material and methods: A 45-year-old woman consulted for severe abdominal and low-back pain associated with arterial hypertension. The CT scan showed an infrarenal retroperitoneal lesion with invasion of neighboring structures. Results: During the abdominal exploration, a vascular-looking lesion of 60 x 34 x 41 mm was identified. It was associated with right nephrectomy. Discussion: The etiology of congenital fistulas remains unknown; it is believed that a congenital arterial aneurysm erodes into an adjacent vein and gradually increases its size. Other authors believe that the fistula exists since birth and gradually increases its size until it causes symptoms. Conclusion: Congenital arteriovenous fistulas are rare entities, representing less than 25% of all renal arteriovenous malformations.

Introducción: La fístula arteriovenosa renal congénita es una conexión anómala entre el sistema arterial y venoso. Desde el primer caso descrito en 1928 por Varela y cols, no más de 200 casos han sido publicados. Material y Método: Mujer de 45 años consultó por dolor abdominal y lumbar severo, asociado a hipertensión arterial. En tomografía computada se observó lesión retroperitoneal infrarrenal con invasión de estructuras vecinas. Resultados: En exploración abdominal se identificó lesión de aspecto vascular de 60 x 34 x 41 mm. Se asoció a nefrectomía derecha. Discusión: La etiología de las fístulas congénitas sigue siendo desconocida, se cree que un aneurisma arterial congénito erosiona hacia una vena adyacente y aumenta su tamaño lentamente. Otros autores creen que la fístula existe desde el nacimiento e incrementa progresivamente de tamaño hasta producir síntomas. Conclusión: Las fístulas arteriovenosas congénitas son entidades raras, representando menos del 25% del total de las malformaciones arteriovenosas renales.

Reparación endovascular de aneurisma de arteria ilíaca común asociado a fístula arterio-venosa ílio-ilíaca: reporte de caso / Endovascular repair of common iliac artery aneurysm associated with ilio-iliac arteriovenous fistula: case report

Resumen Introducción: Los aneurismas aislados de arteria ilíaca común son una patología infrecuente y habitualmente el diagnóstico es incidental. Su manejo solía ser por vía abierta, pero con el advenimiento de la cirugía endovascular, se han identificado mejores desenlaces en los pacientes llevados a este tipo de procedimientos, reservando la reparación abierta en los casos agudos y rupturas. La asociación entre estos aneurismas con fístulas ílio-ilíacas son infrecuentes y su manejo endovascular se ha reportado en solo una ocasión. Objetivo: Se presenta un caso de un paciente masculino de 82 años, con esta asociación, en el cual se decidió llevar de manera electiva a manejo endovascular de su patología. Discusión: En la literatura el manejo endovascular es ampliamente recomendado por su perfil de seguridad, sin embargo, no existe suficiente evidencia ante la presencia de una fístula ílio-ilíaca de manera concomitante, por ser una condición infrecuente. Conclusión: En el presente caso, abordamos de manera endovascular esta relación, obteniendo resultados favorables, con adecuado control de la patología, sin presentación de complicaciones.

Introduction: The isolated aneurysms of the common iliac artery correspond to an infrequent pathology; and the diagnosis of this entity is usually incidental. Its management is usually by open route, but with the advent of endovascular surgery, better outcomes have been identified in patients taken to this kind of procedure, reserving open repair for the urgent cases, like ruptures. The association between these aneurysms with ilio-iliac fistula is uncommon and their endovascular management has been reported only in one case in the literature. Aim: A case of an 82-year-old male patient will be presented, with this association, who was taken to an endovascular repair of his pathology, with good postoperative results. Discussion: In the literature, endovascular management is recommended by its safety profile, however there is insufficient evidence in the presence of an ilio-iliac fistula concomitantly, because it is an infrequent condition. Conclusion: In the present case, we address this relationship endovascularly, obtaining favorable results, with adequate control of the pathology, without presenting any complications.

Hereditary Hemorrhagic Telangiectasia in a Sickle Cell Trait Patient: A Report of a Rare Case with Use of Nuclear Medicine, and a Literature Review.

BACKGROUND Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is a rare autosomal dominant disease. CASE REPORT Here, we report a case of a 49-year-old Brazilian woman with a history of multiple hospitalizations, sometimes life-threatening anemia, and uncommon clinical manifestations. CONCLUSIONS We provide a brief literature review regarding the most common signs and symptoms, history, diagnosis, and treatment. Special attention is given to the techniques for identifying hemorrhagic areas, to the presence of angiodysplasia in gastric tissue, and the identification of sickle cell trait, this being an unprecedented hematological condition in the presentation of the disease. Thus, further studies on the relationship between sickle cell trait and the syndrome are needed.

Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial.

BACKGROUND: In A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA), randomisation was halted at a mean follow-up of 33·3 months after a prespecified interim analysis showed that medical management alone was superior to the combination of medical management and interventional therapy in preventing symptomatic stroke or death. We aimed to study whether these differences persisted through 5-years' follow-up. METHODS: ARUBA was a non-blinded, randomised trial done at 39 clinical centres in nine countries. Adults (age ≥18 years) diagnosed with an unruptured brain arteriovenous malformation, who had never undergone interventional therapy, and were considered by participating clinical centres to be suitable for intervention to eradicate the lesion, were eligible for inclusion. Patients were randomly assigned (1:1) by a web-based data collection system, stratified by clinical centre in a random permuted block design with block sizes of two, four, and six, to medical management alone or with interventional therapy (neurosurgery, embolisation, or stereotactic radiotherapy, alone or in any combination, sequence, or number). Although patients and investigators at a given centre were not masked to treatment assignment, investigators at other centres and those in the clinical coordinating centre were not informed of assignment or outcomes at any of the centres. The primary outcome was time to death or symptomatic stroke confirmed by imaging, assessed by a neurologist at each centre not involved in the management of participants' care, and monitored by an independent committee using an adaptive approach with interim analyses. Enrolment began on April 4, 2007, and was halted on April 15, 2013, after which follow-up continued until July 15, 2015. All analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00389181. FINDINGS: Of 1740 patients screened, 226 were randomly assigned to medical management alone (n=110) or medical management plus interventional therapy (n=116). During a mean follow-up of 50·4 months (SD 22·9), the incidence of death or symptomatic stroke was lower with medical management alone (15 of 110, 3·39 per 100 patient-years) than with medical management with interventional therapy (41 of 116, 12·32 per 100 patient-years; hazard ratio 0·31, 95% CI 0·17 to 0·56). Two patients in the medical management group and four in the interventional therapy group (two attributed to intervention) died during follow-up. Adverse events were observed less often in patients allocated to medical management compared with interventional therapy (283 vs 369; 58·97 vs 78·73 per 100 patient-years; risk difference -19·76, 95% CI -30·33 to -9·19). INTERPRETATION: After extended follow-up, ARUBA showed that medical management alone remained superior to interventional therapy for the prevention of death or symptomatic stroke in patients with an unruptured brain arteriovenous malformation. The data concerning the disparity in outcomes should affect standard specialist practice and the information presented to patients. The even longer-term risks and differences between the two therapeutic approaches remains uncertain. FUNDING: National Institute of Neurological Disorders and Stroke for the randomisation phase and Vital Projects Fund for the follow-up phase.

Traumatic arteriovenous fistula with serious haemodynamic repercussions: endovascular treatment.

Major abdominal arteriovenous fistula (AVF) is a rare clinical condition defined as an abnormal communication between the aorta or iliac arteries and the inferior vena cava or the iliac or renal veins. Penetrating trauma, including iatrogenic injuries, accounts for less than 20% of these AVFs. Endovascular techniques were useful in the management of vascular lesions. The authors report the case of a patient with high-output heart failure and high-flow AVF between the left external iliac artery and the left external iliac vein manifested 17 years after a gunshot wound. Endovascular approach was satisfactorily performed with the implantation of a septal occlusion device to interrupt abnormal vascular communication and preserve artery and vein patency. There were improvement of symptoms and control images showed arteriovenous communication closure.

Percutaneous Endovascular Repair of a Ruptured Extent III Thoracoabdominal Aortic Aneurysm with Bilateral Large Common Iliac Aneurysms and Aortocaval Fistula.

Ruptured thoracoabdominal aneurysms (rTAAAs) are rare and carry a significant rate of morbidity and mortality. Aortocaval fistula secondary to rTAAA is even more infrequent. We describe an urgent and staged endovascular treatment of a ruptured extent III thoracoabdominal aortic aneurysm with an aortocaval fistula by performing vena cava stenting to treat aortocaval fistula as a damage control maneuver prior to transfer and subsequent TAAA repair with a physician-modified endograft at a quaternary level hospital.

Microsurgery for Unruptured Cerebral Arteriovenous Malformations in the National Inpatient Sample is More Common Post-ARUBA.

BACKGROUND: The ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) was the first randomized control trial to investigate unruptured cerebral arteriovenous malformation (cAVM) treatments and concluded that medical management was superior to interventional therapy for the treatment of unruptured cAVMs. This conclusion generated considerable controversy and was followed by rebuttals and meta-analyses of the ARUBA methodology and results. We sought to determine whether the ARUBA results altered treatment trends of cAVMs within the United States. METHODS: Using the National Inpatient Sample, the largest all-payer inpatient care database within the United States, we isolated patients who were admitted on an elective basis for cAVM treatment and determined the treatment modality undergone by these patients. The cohort was dichotomized separately at 2 ARUBA time points: the European Stroke Conference presentation in May 2013, and The Lancet publication in February 2014. RESULTS: We found that the overall treatment rate of unruptured cAVMs decreased after both time points. However, the rate of surgical excision alone, relative to other modalities, was significantly increased, and endovascular intervention demonstrated a nonsignificant decrease. CONCLUSIONS: Our findings suggest that the ARUBA trial has influenced unruptured cAVM treatment patterns within the United States. Although the overall treatment rate has decreased, unruptured cAVMs, when treated post-ARUBA, are most commonly approached with surgical excision alone.

Microsurgical Resection of a Left Supramarginal Gyrus AVM Causing Radionecrosis.

Late radiation necrosis is a rare entity presenting in 2.2% to 9% of radiation-treated arteriovenous malformations (AVMs). It occurs by a mean of 3 years following treatment. There are few reports in the literature of radionecrosis and solid lesions treated with surgery.1-4 To the authors' knowledge, this case has the longest interval between radiosurgery and the presentation of cerebral necrosis. In this surgical video, we present the case of a 51-year-old female with a left supramarginal gyrus AVM that received radiosurgery with gamma knife; after 20 years, she began having seizures and aphasia. The magnetic resonance imaging scan revealed a lesion simulating an intra-axial tumor causing important edema and mass effect. Medical treatment was given including high-dose steroids without success, therefore microsurgery was performed. The surgery was presented in a step-by-step basis and correlation was performed with the involved adjacent anatomy, to illustrate the anatomy of the approach and surgical landmarks. The patient's symptoms resolved completely, and the postoperative magnetic resonance imaging scan showed complete resection and resolution of the edema. The histopathological findings were consistent with a radionecrosis and AVM. The patient signed the Institutional Consent Form, which states that she accepts the procedure and allows the use of her images and videos for any type of medical publications in conferences and/or scientific articles.