In Reply to: Case 0400_10 -- Recurrent Pseudoaneurysm and Arteriovenous Fistula Following Embolization posted by Editor on April 11, 2000 at 17:40:26:
As for the mechanism of formation of the AV fistula, I think that you have to assume it was there from the beginning and has enlarged in the meantime. I would carefully re-examine the original angio, especially if you still have the digital runs.
The fistula and its increasing flow are undoubtedly the reason that the original embo failed.
I would be careful about thrombin; this looks like a very large pseudoaneurysm, and the fistula is probably high flow.
You could consider doing a very complete angiogram, and coiling everything that feeds the area. You could also consider entering from the venous side, which might be possible after coiling up the arterial inflow.
Surgery would not be wrong here, but it might be very difficult to isolate and treat all of the offending branches. If surgery was tried, I would re-embolize, and have a catheter in place first.