In Reply to: Re: Case 0400_10 -- Recurrent Pseudoaneurysm and Arteriovenous Fistula Following Embolization posted by Moni Stein on April 13, 2000 at 13:10:57:
This case highlights several facets of the always-interesting AVM, AVF embolization debate. The appearance of the venous fistula and recruitment of arterial feeders post trauma is interesting and frustrating in the face of what appeared to be a "slam dunk" initially. Moni's description of the operative repair tells us that we need to find a better percutaneous method.
I have had some similar cases (mostly congenital or iatrogenic AVF/AVM) and the arterial recruitment really makes my job hard. Getting to the nidus is not always as safe or easy as some think. In this case, the "nidus" could be considered the venous communication, since controlling this led to success. In fact, since this is not a tumor, perhaps occluding the fistula would be enough?
I was not crazy about the stent in the vein concept due to the potential of chronic venous problems in a young, active individual.
If you occluded the venous outflow to inject thrombin, I think you would have to occlude the neck of the pseudoaneurysm, as occluding just upstream in the SFA may still allow thrombin to shoot down toward the pop vein (the upstream and downstream SFV fill on the angio).
Maybe direct an occlusion balloon via the SFV into the pseudoaneurysm, inflate, pull back gently (ball-valve the neck) and then percutaneous thrombin into the PA?
The burning issue is then would clot from the PA migrate north causing much dyspnea post procedure?
Great case.