Pseudoaneurisma e fístula arteriovenosa da artéria femoral profunda após rotura completa do músculo vasto medial: tratamento endovascular / Pseudoaneurysm and arteriovenous fistula of the deep femoral artery after complete rupture of the vastus medialis muscle: endovascular treatment

Resumo A artéria femoral profunda, devido às suas características anatômicas, se encontra protegida da maioria dos traumatismos vasculares. Relatamos um caso de pseudoaneurisma de ramo perfurante da artéria femoral profunda, associado à fístula arteriovenosa, secundário a rotura completa do músculo vasto medial em paciente jogador de futebol. A ressonância magnética demonstrou lesão muscular associada a pseudoaneurisma, e a angiotomografia confirmou a presença de pseudoaneurisma associado a fístula arteriovenosa de ramo da artéria femoral profunda. Foi realizado tratamento endovascular da fístula através da embolização com micromolas fibradas e drenagem cirúrgica do hematoma muscular. O paciente evoluiu bem, sem queixas clínicas no 30º dia de pós-operatório e também após 1 ano.

Abstract Due to its anatomical characteristics, the deep femoral artery is protected from most vascular injuries. We report a case of a soccer player with pseudoaneurysm of a perforating branch of the deep femoral artery, associated with an arteriovenous fistula and secondary to complete rupture of the vastus medialis muscle. Magnetic resonance imaging showed muscle damage associated with a pseudoaneurysm and angiotomography confirmed the presence of a pseudoaneurysm associated with a deep arteriovenous fistula of a branch of the deep femoral artery. Endovascular treatment of the fistula was performed by embolization with fibrous microcoils and surgical drainage of the muscle hematoma. The patient recovered well, was free from clinical complaints on the 30th postoperative day and also after 1 year.

Tratamento endovascular de doença oclusiva venosa central com fístula arteriovenosa funcionante / Endovascular treatment of central vein occlusion in patients with functioning arteriovenous fistulas

Resumo Contexto A maior sobrevida dos doentes dialíticos somada à incapacidade de obtenção de órgãos suficientes para atender a demanda, bem como à dificuldade de acesso aos serviços de saúde, levou ao aumento da fila para transplante e ao prolongamento do tempo de utilização do acesso venoso central para hemodiálise. A etiologia mais comum de estenose de veia central é o acesso venoso central prolongado, pelas lesões intimais decorrentes da presença do cateter. Objetivos Avaliar resultados de angioplastia para tratamento de doença oclusiva venosa central com fístula arteriovenosa periférica funcionante. Métodos Estudo tipo coorte retrospectivo com revisão de prontuários de 47 doentes com lesões estenóticas ou oclusivas. A avaliação dos doentes foi realizada em 30 dias, 6 meses e 1 ano após a recanalização ou correção da estenose com ATP ou ATP/aplicação de stent. Resultados Lesões estenóticas foram encontradas em 25 doentes (53%), e oclusões, em 22 (47%) doentes. A angioplastia percutânea transluminal (ATP) com stent foi utilizada em 64% dos doentes, e angioplastia isolada com balão, em 36% deles. A análise de resultados clínicos mostrou elevada taxa de melhora clínica precoce (30 dias) em 82% dos doentes (intervalo de confiança [IC] 71-93%). Após 1 ano de seguimento, a taxa de perviedade primária foi de 57%, e a taxa de perviedade primária assistida foi de 72% (IC 57-84%). Conclusão O tratamento endovascular das estenoses ou oclusões de veia central sugere melhora clínica dos sintomas e taxas adequadas de perviedade no período de 1 ano, apesar da limitação no tamanho amostral.

Abstract Background The increased survival of dialysis patients and the inability to obtain sufficient organs to meet demand for transplantation, compounded by poor access to health services, have caused the transplant waiting lists to grow, extending the time spent using central venous accesses for hemodialysis. The most common etiology of central vein stenosis is prolonged central venous access, due to intimal injuries caused by the presence of the catheter. Objectives To assess the results of angioplasty to treat central vein occlusion in patients with functioning peripheral arteriovenous fistulas. Methods Retrospective cohort study with review of medical records from 47 patients with stenotic or occlusive lesions. Patients were assessed at 30 days, 6 months, and 1 year after recanalization or correction of stenosis with transluminal percutaneous angioplasty (TPA) or TPA/stenting. Results Stenotic lesions were detected in 25 patients (53%) and occlusions were found in 22 (47%) patients. TPA with stenting was used in 64% of patients and balloon angioplasty in isolation was used in 36%. Analysis of clinical results showed a high rate of early clinical improvement (30 days), seen in 82% of patients (confidence interval [CI] 71-93%). After 1 year of follow-up, the primary patency rate was 57% and the assisted primary patency rate was 72% (CI 57-84%). Conclusions Endovascular treatment of central vein stenosis or occlusions suggests clinical improvement of symptoms and adequate rates of patency at 1 year, notwithstanding the limited sample size.

Malformaciones vasculares cerebrales de alto flujo en pediatría: experiencia en un hospital pediátrico de alta complejidad / High-flow vascular malformations of the brain in pediatrics: Experience in a tertiary care children's hospital

Introducción. Las malformaciones vasculares cerebrales de alto flujo son poco comunes en la edad pediátrica. El objetivo del trabajo es diferenciar y agrupar estas enfermedades según edad de debut, manifestaciones clínicas y angioarquitectura.Población y método. Se realizó un estudio retrospectivo y observacional. Se analizaron las historias clínicas, los estudios por imágenes y los protocolos de procedimientos de pacientes del Hospital J. P. Garrahan con diagnóstico de malformaciones vasculares cerebrales desde enero de 2010 hasta enero de 2020.Resultados. Ciento ochenta y tres pacientes cumplieron los criterios de inclusión. Se identificaron 131 pacientes con malformaciones arteriovenosas con nido (MAV) y 52 con fístulas directas (sin nido), entre los que se hallaron 19 malformaciones aneurismáticas de vena de Galeno, 23 fístulas piales y 10 fístulas durales. La edad promedio fue de 105 meses para las MAV, 1,7 meses para las malformaciones aneurismáticas de vena de Galeno, 60,5 meses para fístulas piales y 41 meses para fístulas durales.Conclusión. Según su angioarquitectura, las malformaciones vasculares cerebrales de alto flujo tuvieron nido (MAV) o fueron fístulas directas (malformaciones aneurismáticas de vena de Galeno, fístulas piales y fístulas durales). Las MAV se manifestaron a partir de la primera infancia, sobre todo, por hemorragia intracraneana. Las fístulas directas se expresaron en la primera etapa de la vida, frecuentemente, con insuficiencia cardíaca.

Introduction. High-flow vascular malformations of the brain are uncommon in pediatrics. The objective of this study is to establish the differences among these pathologies and group them by age at onset, clinical manifestations, and angioarchitecture.Population and method. This was a retrospective and observational study. The medical records, imaging studies, and procedure protocols of patients seen at Hospital J. P. Garrahan diagnosed with vascular malformations of the brain between January 2010 and January 2020 were analyzed.Results. A total of 183 patients met the inclusion criteria. It was possible to identify 131 patients with arteriovenous malformations with a nidus (AVMs) and 52 with direct fistulas (without a nidus), including 19 vein of Galen aneurysmal malformations, 23 pial fistulas, and 10 dural fistulas. The average age of patients was 105 months for AVMs, 1.7 months for vein of Galen aneurysmal malformations, 60.5 months for pial fistulas, and 41 months for dural fistulas.Conclusion. Based on their angioarchitecture, high-flow vascular malformations of the brain presented a nidus (AVMs) or direct fistulas (vein of Galen aneurysmal malformations, pial fistulas, and dural fistulas). AVMs were observed in early childhood, especially due to intracranial hemorrhage. Direct fistulas occurred in the first stage of life, commonly with heart failure.

Intrahepatic Arterioportal Fistula: A Rare Cause of Portal Hypertension After Deceased Donor Liver Transplant.

A 43-year-old male patient, who received a deceased donor liver transplant for background ethanol-related decompensated cirrhosis, presented 7 months after transplant with mild abdominal distension and pain. On evaluation, the patient had thrombocytopenia, high serum-ascites albumin gradient ascites, and deranged liver functions. The Doppler study of the splenoportal axis showed hepatofugal flow in the recipient's portal vein, normal hepatic veins, a normal liver, splenomegaly, mild ascites, and multiple periportal collaterals. A transjugular liver biopsy and a hepatic venous pressure gradient measurement were done, which suggested mild portal tract inflammation with portal tract fibrosis with prominent portal venous thickening and normal hepatic venous pressure gradient (4 mm). However, the patient had a progressive increase in ascites and a dramatic increase in serum bilirubin level. A triple-phase computed tomography was done that showed rapid contrast flow in both the portal and hepatic arterial phase, suggesting arterialization of the portal flow with possible suspicion of a communicating arterioportal fistula. The patient underwent digital subtraction angiography, which was followed by an embolization of the arterioportal fistula. After embolization, serum bilirubin gradually decreased and ascites resolved. A repeat Doppler of the portal venous system showed established hepatopetal flow with progressively rising portal flow velocities.

Endovascular Management of a Ruptured Iliac Aneurysm With an Inferior Vena Cava Fistula.

Aortocaval fistula is uncommon and often associated with a ruptured iliac or abdominal aortic aneurysm. It has a high mortality secondary to the aneurysmal rupture but also to a high output heart failure. Open surgery has been the standard; however, endovascular management has emerged with lower mortality. We present a patient with a ruptured iliac aneurysm and an inferior vena cava fistula successfully treated with an endograft with embolization of the right hypogastric artery. The patient arrested on induction and was resuscitated with aortic balloon inflation. Endovascular therapy can be safely used in the management of iliac/aortocaval fistula.

Fístulas arteriovenosas pulmonares en un paciente pediátrico: un reporte de caso / Pulmonary arteriovenous fistulas in a pediatric patient: a case report

Las fístulas arteriovenosas pulmonares son malformaciones congénitas dadas por la comunicación directa anómala entre arterias y venas, con una incidencia mundial de 2-3 : 100 000 habitantes. La presentación es, en general, única, asintomática, y aparecen en forma incidental como hallazgo imagenológico en la adultez, y su tratamiento de elección es la embolización endovascular.Se describe la inusual presentación clínica en una paciente de 10 años, que ingresó por disnea, tos, cianosis central y cefalea. Se encontró hipoxemia persistente, hipocratismo digital, nódulos parahiliares pulmonares, gases arteriales con gradiente alvéolo-arterial aumentado. La tomografía axial computarizada de tórax de alta resolución confirmó la presencia de una malformación arteriovenosa pulmonar en la región parahiliar derecha, la cual no se asociaba con la enfermedad de Rendu-Osler-Weber. La paciente fue tratada con embolización endovascular transcutánea. Tras 1,5 años de seguimiento, no hubo recaídas. Son pocos los casos reportados de estas fístulas en la edad pediátrica

Pulmonary arteriovenous fistulas are congenital malformations due to anomalous direct communication between arteries and veins; the incidence is 2-3 : 100,000 inhabitants. This condition is usually asymptomatic and incidentally appearing in adult imaging findings. Transcutaneous endovascular embolization is the technique of choice for treatment. The unusual presentation in a 10-year-old patient is described; she was presented to the Emergency Department with dyspnea, cough, central cyanosis and headache. The examination revealed persistent hypoxemia and digital clubbing; chest X-ray with images suggestive of parahilar nodules, arterial blood gases with increased alveolar arterial gradient. The high resolution computed tomography of the thorax revealed pulmonary arteriovenous malformation in the right parahilar region not associated with Rendu-Osler-Weber disease. The patient was treated with transcutaneous endovascular embolization, and after a year and a half of follow-up there were no relapses. There are few reported cases of pulmonary arteriovenous fistulas in the pediatric age.

Treatment Outcomes of Endovascular Embolization Only in Patients with Unruptured Brain Arteriovenous Malformations: A Subgroup Analysis of ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations).

BACKGROUND AND PURPOSE: Endovascular embolization only has been advocated for treatment of brain arteriovenous malformations in recent trials. Our aim was to evaluate the results of embolization only in a cohort of patients who were enrolled in the A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) study at 39 clinical sites in 9 countries. MATERIALS AND METHODS: We analyzed the rates and severity of stroke and death in patients who underwent embolization only. Events were identified through in-person neurologic follow-up visits performed at 6-month intervals during the first 2 years and annually, with telephone contact every 6 months thereafter. All event-related data were reviewed by independent adjudicators. RESULTS: Among 30 patients who had embolization planned, 26 underwent embolization only. A total of 13 stroke events were reported in the follow-up period among 26 subjects (ischemic, hemorrhagic, or both in 4, 7, and 2 subjects, respectively). The adverse event occurred after the first embolization in 11 of 13 patients. One patient had a major motor deficit, and 2 patients developed major visual field deficits. One event was fatal. The modified Rankin Scale score was 0-2 at last follow-up in 11 of the 12 stroke survivors. Estimated stroke-free survival was 46% at 12 months. CONCLUSIONS: Although the rates of stroke and/or death were high in patients treated with embolization only in ARUBA, the rates of favorable outcomes following stroke were high during follow-up.

Novel Utility of Amplatzer Septal Occlusion Device to Treat Persistent Aortocaval Fistula following Ruptured Endovascular Aortic Aneurysm Repair (rEVAR).

Aortocaval fistulas following endovascular repair of ruptured abdominal aortic aneurysms (rAAA) are rare. We herein describe repair using an Amplatzer Septal Occluder in a 68-year-old male who presented to the emergency department 6 months after ruptured endovascular aneurysm repair (rEVAR) with right heart failure. With the assistance of diagnostic angiography and intravascular ultrasound, the patient was found to have a 1.2 cm diameter aortocaval fistula and a type-II endoleak. His aortocaval fistula was successfully closed using an Amplatzer septal occluder device after failure of attempted closure with an Amplatzer plug and coiling of the aneurysm sac. His symptoms of heart failure improved, and he was discharged to an acute rehabilitation unit. Follow-up at 3 months demonstrated continued improvement in heart failure symptoms, and a small persistent type II endoleak. Aortocaval fistulae are a potentially fatal complication of rAAA. We discuss the sequelae and treatment strategies of aortocaval fistulas following rEVAR including the use of the Amplatzer Septal Occluder.

Dural sinus malformation with giant pouch (DSMGP): symptoms and treatment.

OBJECTIVE: The aim of this study is to describe the clinical manifestations and treatment options of patients having dural sinus malformation with giant pouch (DSMGP) in a tertiary pediatric center. INTRODUCTION: Dural sinus malformation with giant pouch (DSMGP) is a rare vascular malformation affecting fetuses, newborns, and infants. It is characterized by a dilated dural sinus frequently thrombosed with arteriovenous fistula (AVF) in its wall. There is a few information about symptoms, best treatment, and prognosis of the disease. MATERIAL AND METHODS: Medical charts of cases of DSMGP were retrospectively analyzed from January 2010 to January 2019. Our hospital is a pediatric tertiary center. An adult patient managed by the authors in another institution was added to the series. RESULTS: Eight pediatric patients from 0 to 9 months were managed, four were males. The adult patient was a 40-year-old male. Symptoms were mass effect in 4 pediatric cases. Exophthalmos was present in the pediatric case and adult case. Both cases had venolymphatic malformation of the orbit. Congestive heart failure (CHF), epistaxis and facial vein engorgement, and intracranial hemorrhage (ICH) were the symptoms in other 3 cases. A child has spontaneous resolution of the disease. DISCUSSION: Transverse sinus and superior sagittal sinus are affected more commonly. Patients with totally thrombosed pouch had mass effect symptoms. These cases were managed by surgical excision. When AVFs are present, clinical manifestations were secondary to cerebral venous hypertension or cardiac overload. If cavernous sinus drained the shunt (capture), epistaxis and facial veins engorgement could be present. AVFs are amenable to embolization, achieving the control of venous hypertension in most cases. Cavernous malformation could be present and must be controlled because its enlargement could be a sign of uncontrolled venous hypertension. On the other hand, DSMGP can be accompanied by venolymphatic malformation conforming a cerebral venous metameric syndrome.

The NASSAU (New ASSessment of cerebral Arteriovenous Malformations yet Unruptured) Analysis: Are the Results From The ARUBA Trial Also Applicable to Unruptured Arteriovenous Malformations Deemed Suitable for Gamma Knife Surgery?

BACKGROUND: The optimal management of unruptured brain arteriovenous malformations (AVMs) is controversial after the ARUBA trial. OBJECTIVE: To confirm or repudiate the ARUBA conclusion that "medical management only is superior to medical management with interventional therapy for unruptured brain arteriovenous malformations." METHODS: Data were collected from 1351 patients treated with Gamma Knife Surgery (GKS; Elekta AB, Stockholm, Sweden) for unruptured and untreated AVMs The follow-up was 8817 yr (median 5.0 and mean 6.5). The results of the analyses were compared to that found in patients randomized to medical management only in the ARUBA trial and extrapolated to a 10-yr time period. Our data were also compared to the natural course in a virtual AVM population for a 25-yr time period. RESULTS: The incidence of stroke was similar among ARUBA and our patients for the first 5 yr. Thereafter, the longer the follow-up, the relatively better outcome following treatment. Both the mortality rate and the incidence of permanent deficits in patients with small AVMs were the same as in untreated patients for the first 2 to 3 yr after GKS, after which GKS patients did better. Patients with large AVMs had a higher incidence of neurological deficits in the first 3 yr following GKS. The difference decreased thereafter, but the time until break even depended on the analysis method used and the assumed risk for hemorrhage in patent AVMs. CONCLUSION: The ARUBA trial conclusion that medical management is superior to medical management with interventional therapy for all unruptured AVMs could be repudiated.

Treatment of Unruptured Brain Arteriovenous Malformations: A Single-Center Experience of 86 Patients and a Critique of the A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) Trial.

OBJECTIVE: The A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial has received fierce criticism, including considerable selection bias, poor generalizability, questionable clinical practices (only 15.8% underwent surgical resection, the gold standard for arteriovenous malformation [AVM] treatment), and short follow-up (33 months) for a disease process that carries a life-long risk. In this study, we sought to present our own experience treating unruptured brain AVMs to provide supporting evidence of the ARUBA trial criticism. METHODS: All cases of treated brain AVMs from 2004 to 2017 at our institution were retrospectively reviewed and included in the analysis if they met ARUBA trial inclusion criteria. The primary outcome was symptomatic stroke or death. Secondary outcomes included AVM obliteration, long-term clinical impairment (modified Rankin Scale score >1), and new major or minor postoperative deficit. RESULTS: Of the 245 reviewed cases, 86 met the ARUBA trial criteria. Treatment included microsurgical resection alone (2.3%), preoperative embolization followed by microsurgical resection (62.8%), stereotactic radiosurgery alone (10.5%), embolization followed by stereotactic radiosurgery (15.1%), and embolization alone (9.3%). The primary outcome was met in 8.3%, new perioperative major and minor complications occurred in 5.8% and 12.8%, and long-term clinical impairment in 4.5%. AVM obliteration was observed in 92.4% overall and in 100% of patients who underwent surgical resection. CONCLUSIONS: The criticism of the ARUBA trial is warranted, as our study found that treatment of unruptured brain AVMs has an acceptable safety profile when approached in a multidisciplinary manner at an experienced institution, using surgical resection as the primary treatment modality when applicable.

Correção cirúrgica de pseudoaneurismas e fístula arteriovenosa complexa entre vasos poplíteos / Surgical repair of pseudoaneurysms and complex arteriovenous fistula between popliteal vessels

A fístula arteriovenosa (FAV) é uma comunicação anormal e permanente entre uma artéria e uma veia devido a traumas penetrantes e lesões iatrogênicas. O trauma penetrante na parede arterial pode levar à formação de pseudoaneurismas (PSA) e, se houver lesão venosa concomitante, à formação de uma FAV. Os autores apresentam o caso de um paciente portador de FAV complexa de vasos poplíteos associada a pseudoaneurisma de artéria poplítea, sugeridos a partir de exames clínicos e exames de imagem, e tratados por cirurgia convencional devido à indisponibilidade de um stent graft com diâmetro apropriado, além de a cirurgia endovascular não estar disponível no serviço em que o paciente foi operado

An arteriovenous fistula (AVF) is an abnormal and permanent communication between an artery and a vein caused by penetrating traumas or iatrogenic injuries. A penetrating trauma to the endothelial wall can lead to formation of pseudoaneurysms (PSA) and to formation of an AVF. Here, the authors present the case of a patient with a complex AVF of popliteal vessels, associated with popliteal artery pseudoaneurysm, suggested by clinical features and imaging exams, and treated with conventional surgery due to unavailability of a stent graft with appropriate diameter and because endovascular surgery isn't provided at the service where this patient was operated

Aneurisma de subclávia como etiologia de oclusão arterial aguda de membro superior: relato de caso / Subclavian aneurysm as etiology of acute upper limb arterial occlusion: case report

Os aneurismas dos membros superiores são extremamente raros comparados com outros aneurismas periféricos. O reconhecimento e o tratamento são essenciais. A falta do diagnóstico e conduta precoces podem causar grandes limitações físicas e evoluir com complicações nervosas e vasculares. O aneurisma de subclávia é uma doença pouco frequente na população, com raros casos relatados no Brasil. Apresenta um alto risco de complicações como ruptura, trombose e embolismo. Objetivo: Relatar o caso da paciente atendida pela Cirurgia Vascular do Hospital do Servidor Público Municipal, portadora de aneurisma de subclávia direita, que evoluiu com oclusão da artéria braquial ipsilateral decorrente de embolia arterial. Método: Revisão de prontuário e de literatura. Resultado: O aneurisma de subclávia pode evoluir com eventos tromboembólicos que devem ser diagnosticados e tratados precocemente. A correção do aneurisma, seja por técnicas endovasculares ou por abordagem supra ou infraclaviculares, deverá ser realizado em todos os pacientes como medida de prevenção para complicações futuras.

Endovascular occlusion of pial arteriovenous macrofistulae, using pCANvas1 and adenosine-induced asystole to control nBCA injection.

Background In large-caliber pial macrofistulae (pMF), the combination of high blood flow velocity and large efferent artery diameter makes control over the endovascular vessel occlusion difficult and may result in the inadvertent venous passage of occlusive devices or embolic agents. Case descriptions Patient 1: A 27-year-old man presented with headache and ataxia. An infratentorial pMF supplied by both superior cerebellar arteries with venous ectasia was found. The first treatment attempt using balloons and coils failed since the position of either device could not be controlled because of a distal diameter of the feeding artery of 8 mm. In a second session a pCANvas1 (phenox) was deployed at the level of the arteriovenous connection and adenosine-induced asystole allowed the controlled injection of nBCA/Lipiodol with partial occlusion of the pMF. A remaining arteriovenous shunt was occluded under asystole in a third session. The procedures were well tolerated, the patient returned to normal and DSA confirmed the occlusion of the fistula. Patient 2: A 13-year-old boy with hereditary hemorrhagic teleangiectasia presented with an intracerebral hemorrhage from an aneurysm of the left MCA. Twelve weeks after the aneurysm treatment a feeding MCA branch (diameter 4.5 mm) of a right frontal pMF was catheterized. The macrofistula was occluded by deployment of a pCANvas1, followed by the injection of nBCAl/Lipiodol under adenosine-induced asystole. Conclusion pCANvas1 and adenosine-induced asystole allow a controlled injection of nBCA/Lipiodol for the endovascular occlusion of high-flow pMF without venous passage of the embolic agent.

Extending the indications for transvenous approach embolization for superficial brain arteriovenous malformations.

INTRODUCTION: Transarterial embolization is the standard endovascular treatment strategy for intracranial arteriovenous malformations (AVMs). The transvenous approach has been indicated for the embolization of deep AVMs meeting a set of strict eligibility criteria. The present study aims to assess the safety and efficacy of the transvenous approach for superficial AVMs. METHODS: A retrospective series of 12 patients presenting with cortical AVMs were treated by endovascular embolization using a transvenous approach with a curative intent. RESULTS: Nine patients (75%) had ruptured AVMs at admission. The mean nidus size was 1.9 cm, six patients (50%) had a nidus in eloquent areas and the median Spetzler-Martin grade was 2. The rate of immediate angiographic occlusion of the AVMs was 91.6% (11/12). One patient in whom immediate angiographic occlusion was not achieved showed spontaneous occlusion at the 6-month follow-up. No procedural or clinical complications were observed. The mean and median modified Rankin scale (mRS) scores at discharge were 1.7 and 2 (range 0-3, SD=0.96), and the mean and median mRS scores at 6 months were 1.6 and 2 (0-3, 1.16). Nine patients (75%) were independent (mRS ≤2) at discharge and 11 patients (91.6%) were independent (mRS ≤2) at the 6-month follow-up. CONCLUSIONS: The curative transvenous embolization of superficial intracranial AVMs is feasible and appears safe and effective when strict anatomical selection is respected. This technique extends the current indications for transvenous embolization of intracranial AVMs and may improve cure rates while reducing embolization-related complications.

Responses to ARUBA: a systematic review and critical analysis for the design of future arteriovenous malformation trials.

OBJECTIVE The ARUBA study (A Randomized Trial of Unruptured Brain Arteriovenous Malformations [AVMs]) on unruptured brain AVMs has been the object of comments and editorials. In the present study the authors aim to systematically review critiques, discuss design issues, and propose a framework for future trials. METHODS The authors performed a systematic review of the French and English literature on the ARUBA study published between January 2006 and February 2015. The electronic search, including the Cochrane Library, MEDLINE (PubMed and Ovid), CINAHL, and EMBASE databases, was complemented by hand searching and cross-referencing. The comments were categorized as items related to the design, the conduct, and the analysis and interpretation of the trial. RESULTS Thirty-one articles or letters were identified. The pragmatic design, with heterogeneity of patients and lack of standardization of the treatment arm, were frequently stated concerns. The choice of outcome measures was repeatedly criticized. During the trial, low enrollment rates, selection bias, and premature interruption of enrollment were frequent comments. The short follow-up period, the lack of subgroup analyses, the lack of details on the results of the various treatments, and a contentious interpretation of results were noted at the analysis stage. A fundamental problem was the primary hypothesis testing conservative management. The authors believe that other trials are needed. Future trials could be pragmatic, test interventions stratified at the time of randomization, and look for long-term, hard clinical outcomes in a large number of patients. CONCLUSIONS In the authors' view, the ARUBA trial is a turning point in the history of brain AVM management; future trials should aim at integrating trial methodology and clinical care in the presence of uncertainty.

Intervention for A randomized trial of unruptured brain arteriovenous malformations (ARUBA) - Eligible patients: An evidence-based review.

While intervention for ruptured arteriovenous malformations (AVMs) of the brain is typically warranted, the management of unruptured AVMs remains controversial. Despite numerous retrospective studies, only one randomized controlled trial has been conducted, comparing the role of medical management alone to medical management plus surgical and/or radiosurgical intervention in patients with unruptured AVMs: A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA). To great controversy, ARUBA concluded that medical management alone was superior to intervention for unruptured AVMs, which was subsequently challenged by various single-institution and multi-center studies analyzing outcomes of ARUBA-eligible patients. This review summarizes studies returned from a PubMed database search querying, 'ARUBA,' 'ARUBA-eligible,' 'surgery unruptured AVM,' and "radiosurgery unruptured AVM". The rates of the primary endpoint of symptomatic stroke or death were low among the analyzed studies (0-12.2%, mean 8.0%) and similar to the medically managed arm of ARUBA (10.1%). Likewise, the percentage of patients with impaired functional outcomes (modified Rankin score ≥2) in the reviewed studies was low (5.9%-13.1%; mean: 9.9%) and comparable to the 14.0% observed in the medically management arm of ARUBA. The key findings of ARUBA and subsequent work in its aftermath are overviewed and analyzed for the role of surgery and/or radiosurgery in patients with unruptured AVMs.

Terapia endovascular en trauma vascular periférico: experiencia inicial / Endovascular therapy in peripheral vascular trauma: initial experience

Objetivos Mostrar nuestra experiencia inicial en el manejo endovascular de lesiones arteriales periféricas ocasionadas por trauma. Materiales y métodos Revisión retrospectiva de las fichas clínicas e imágenes diagnósticas y terapéuticas de 7 casos de trauma vascular: 2 seudoaneurismas de vasos tibiales, una fístula arteriovenosa (FAV) asociada a seudoaneurisma de vasos ilíacos, un seudoaneurisma gigante de arteria poplítea, una FAV de vasos poplíteos, una oclusión aguda de arteria poplítea en trauma contuso, y un caso de lesión iatrogénica de arteria subclavia con seudoaneurisma por catéter intraarterial central. En ambos casos de seudoaneurisma de arterias tibiales se efectuó embolización con coils. El caso de FAV asociada a seudoaneurisma ilíaco se manejó con una endoprótesis cubierta. Los casos de seudoaneurisma de arteria poplítea y la FAV de vasos poplíteos se repararon mediante stents cubiertos. La oclusión aguda de arteria poplítea se trató con un stent autoexpandible. En el caso del catéter intraarterial central, se selló el orificio con balón de angioplastia. Resultados Todos los pacientes fueron tratados de forma exitosa y evolucionaron sin complicaciones inmediatas; los seguimientos varían entre 3 meses y 3 años, sin evidencia de complicación. Discusión Si bien el tratamiento clásico del trauma vascular tiene plena vigencia en la actualidad, la terapia endovascular, con las herramientas disponibles, permite realizar el tratamiento definitivo o transitorio, a fin de mejorar las condiciones locales y poder efectuar una reparación abierta con menos complicaciones que la cirugía de urgencia.

Objectives To show our initial experience in endovascular management of peripheral artery trauma. Materials and methods We retrospectively collected the data of seven cases of vascular trauma: two tibial artery pseudoaneurysms, one case of arteriovenous fistula (AVF) associated to iliac vessel pseudoaneurysm, one giant pseudoaneurysm of the popliteal artery, a popliteal vessel AVF, an acute occlusion of the popliteal artery due to blunt trauma and a case of iatrogenic lesion of the subclavian artery with pseudoaneurysm resulting from a central intra-arterial catheter. Coil embolization was performed in both cases of tibial artery pseudoaneurysms. The case of iliac vessel pseudoaneurysm and AVF was treated with a stent graft. A covered stent was used to exclude both the popliteal pseudoaneurysm and popliteal vessel AVF. A bare stent was used in the case of acute popliteal occlusion. The intra-arterial central catheter in the subclavian artery was managed by means of compression with an angioplasty balloon. Results All patients were successfully treated with no immediate complications. Follow up ranges from 3 months to 3 years with no evidence of complication up to this point. Discussion Although the classic approach to vascular trauma treatment is still very much an alternative, endovascular therapy, through all of its tools, allows either definitive treatment or transient management, improving local conditions and thus to proceed at a later date with an elective open vascular repair with fewer difficulties and complications.