Successful Use of Neurovascular Plug for Embolization of Scalp Arteriovenous Fistula: A Novel Technique

Purpose: We report a case of a pediatric patient developing a delayed-onset scalp arteriovenous fistula (AVF) and pseudoaneurysm managed with a new technique. Technique: A 10-year-old boy presented to the outpatient clinic complaining of a growing pulsatile mass in the right side of the skull after head trauma 6 months ago. He had no neurological deficits. Imaging studies revealed scalp AVF with pseudoaneurysm. The arterial feeding was from the right temporal artery, while the blood was drained into the superior sagittal sinus and the facial vein. The fistula was occluded successfully by a microvascular plug (MVP). Follow-up angiography 1 year later showed that the AVF was no longer seen with complete embolization of pseudoaneurysm, total occlusion of the abnormal vessels, and the absence of MVP migration. Conclusion: To the best of our knowledge, we report the first case of successfully using MVP to treat scalp AVF. The MVP is a novel technique with its unique ability to achieve rapid, safe, effective, and permanent vascular occlusion through a single device. Besides, the possibility of delayed-onset traumatic vascular injuries should be considered in a patient with head or facial trauma.

Superficial temporal artery pseudoaneurysm as cause of refractory headache

Case presentation: A 36-year-old male presented with moderate, progressive headache, in the left temporal region, irradiating to the ipsilateral frontal region, with several months of evolution, refractory to analgesic medication, including opioids. He reported a closed traumatic brain injury (TBI) 5 years before in a motorcycle collision with an automobile, without a helmet. At the physical examination, it was possible to verify a pulsatile mass measuring 1.5 cm in diameter, with fremitus, in the left temporal region. The magnetic resonance imaging scan presented a round lesion, encapsulated, on the course of the superficial temporal artery (STA). The digital subtraction angiography confirmed the diagnosis of STA pseudoaneurysm. A surgical resection of the aneurysm was performed, leading to the complete resolution of the headache. Discussion: The STA pseudoaneurysm is a rare condition, representing less than 1% of aneurysms, usually presenting as a late complication of TBI. The majority of cases are asymptomatic, although focal symptoms and even bleeding may occur. The presentation with a chronic refractory headache is exceptional. Its treatment is indicated for local symptom resolution, aesthetic purposes, and rupture prevention, done by clipping and resection of the pseudoaneurysm. Conclusion: Even though unusual, the awareness of this condition is important for the etiological diagnosis of a persistent temporal headache in a patient with a history of TBI.

A Pulsatile Chest Mass After Bentall Procedure: A Case Report

Aortic dissection is an aggressive and life-threatening cardiac disease that’s highly challenging in surgical operation. Bentall procedure comes with potential complications. How to manage these complications is important when it comes to improving patient outcome. In this case, we present a 41-year-old male patient with iatrogenic aortic dissection. He had aortic valve replacement and repair of an atrial septal defect in 2012. After five years, he suffered reoperation for aortic dissection. A year later, the patient was readmitted for a voluminous pulsatile mass over the anterior thorax, confirming the presence of a huge pseudoaneurysm originating from the left coronary bottom performed during the Bentall procedure. This required a third operation to repair the hemorrhagic site. Pseudoaneurysm is a common complication after the inclusion technique in the Bentall procedure. Effective hemostasis or tension-free anastomosis is important toward improving patient outcome.

Management of Post-traumatic Peripheral Arterial Pseudoaneurysm in Antananarivo

Background: Pseudoaneurysm is the usual complication of arterial injury. The aim of this study is to describe the etiology and the management of post-traumatic peripheral arterial pseudoaneurysm in Antananarivo. Methods: This is a bicentric retrospective study for 10 years period (January 2010 to December 2019), performed in Cardiovascular Unit in Joseph Ravoahangy Andrianavalona Teaching Hospital and in Vascular Unit in Soavinandriana Hospital Center, including all patient who underwent a surgical procedure of post-traumatic peripheral arterial pseudoaneurysm. Results: 38 patients were recorded in 10 years period, which 26 patients recorded in JRA hospital and 12 patients in Soavinandriana Hospital. Patients were 33 males (86.84%) and 5 females (13.15%). Gunshots wounds (47.36%) and stabs wounds (34.21%) were the commonest circumstances of etiology. Pulsatile mass (84.21%), pain (60.52%) and palpable thrill (71.05%) were the usual of peripheral pseudoaneurysm. Doppler ultrasound (94.73%) and computed tomographic angiography (13.15%) performed the diagnosis of the pseudoaneurysm. Femoral artery (39.47%) and brachial artery (31.57%) were the most involved vessels. All patients underwent an open surgery. Surgical procedures were arterial repair in 26 patients (68.42%), reversed saphenous vein interposition in 5 patients (13.15%), PTFE graft in 2 patients (5.26%) and ligation excision in 5 patients (13.15%). There was no reoperation or mortality in early postoperative period. Conclusion: Trauma is the most common etiology of pseudoaneurysm in Antananarivo. Open surgical repair remains the procedure to treat the post-traumatic peripheral arterial pseudoaneurysm in our experience.

Percutaneous treatment of a Right Axillary Pseudoaneurysm

We present a very rare case of a 62-year-old male who was presented to our department with a large pulsatile mass on the upper lateral part of the right hemi thorax. He had undergone multiple vascular surgeries in the past months, last one including right axillary-femoral artery bypass grafting (AFBG). Last few days a large, growing pulsatile mass was identified. Contrast computed tomography identified 6x8 cm pseudoaneurysm of the right axillary artery. An open surgical repair was unsuccessful. He underwent an endovascular treatment using a stent graft via left femoral access. The patient had an uneventful recovery and remained well on follow-up.

A Rare Case of Pseudoaneurysm of the Brachial Artery in Supracondylar Humerus Fracture

Introduction: Supracondylar humerus fractures are very common fractures in children. About 10–14% are associated with vascular complications. We report a rare case of pseudoaneurysm of the brachial artery which was promptly detected in a well-perfused hand nearly 2 weeks after reduction and fixation. Case Report: A 10-year-old girl with Type I open supracondylar fracture of the left humerus (Modified Gartland Type 2) presented 2 weeks post-fixation with pulsatile mass in the elbow. Imaging revealed a pseudoaneurysm of brachial artery which was managed by excision and reconstruction using great saphenous vein graft. The fracture united uneventfully and the child made a full return to pre-fracture level of activity. Conclusion: The case highlights the occurrence of pseudoaneurysm of brachial artery, a rare complication seen few days or weeks after the injury, which coincides with the post-operative period in children managed by surgical fixation. This emphasizes the need for periodic monitoring of the neurovascular status of the children even after successful reduction and fixation. Keywords: Supracondylar humerus fracture, vascular complication, pseudoaneurysm.

Aortic Aneurysm: Clinical Findings, Diagnostic and Treatment

The aorta is the largest artery in the body and can have aneurysms, which are focal expansions of the vessel wall that can occur anywhere throughout the artery. These can be classified as thoracic, abdominal or thoracoabdominal aneurysms and can be caused by several etiologies, including degenerative, infectious, and genetic causes. Most aortic aneurysms are asymptomatic and are detected incidentally while looking for other primary diseases with a physical exam finding of a pulsatile mass, or with imaging such as ultrasound, computed tomography, x-rays, or magnetic resonance imaging. When symptoms are present, they are often nonspecific and occur due to inflammation, rapid expansion, compression/erosion of the aneurysm into surrounding structures, or rupture. Uncontrolled aortic aneurysms can lead to fatal outcomes, thus making proper management essential. Management can range from medical treatment to surgical repair based on location, size, rate of expansion, and presence of symptoms.

A pulsatile chest mass after Bentall procedure: a case report

Aortic dissection is an aggressive and life-threatening cardiac disease with highly challenging in surgical operation. Bentall procedure was potential complications. How to manage them would be important to improve patient outcomes. In this case, we present a 41-year-old male patient with iatrogenic aortic dissection. He had aortic valve replacement and repair of atrial septal defect in 2012. After 5 years, he suffered reoperation for aortic dissection. A year later the patient was readmitted for a voluminous pulsatile mass over the anterior thorax, confirming the presence of a huge pseudoaneurysm originating from the left coronary bottom performed during the Bentall procedure, requiring a third operation to repair the hemorrhagic site. The pseudoaneurysm was common complication after inclusion technique in Bentall procedure. How to effective hemostasis or tension-free anastomosis was important to improve patient outcomes.

Peripheral AVMS pre-operative embolization using plug and push technique with low-density NBCA/LIPIODOL can be used in high-flow feeding arteries at Hue Central Hospital, Vietnam: a case report

Purpose: The aim of this study was to report our experience in one casepre-operative embolization of high-flow peripheral arteriovenous malformations (AVMs) using plug and push technique with low-density NBCA/LIPIODOL. Case presentation: A patient 26 years old man hospitalized at Hue Central Hospital, Vietnam with big pulsatile mass at right femoral above the knee. Doppler ultrasound showed a mass with high systolic and diastolic velocities. Patient felt discomfort and he has a desire to resolve this condition. Angiogram showed a large and high-flow arteriovenous malformation type IV according to Yakes classification. A multidisciplinary discussion was required between surgeon and interventionist because of the high risk of in-operative hemorrhage. Patient was treated with low-density NBCA/LIPIODOL 12.5% embolic agents by transarterial approach using plug and push technique before surgical excision. Results: Technical success was achieved in this patient. Complete devascularization was obtained and surgical excision was performed at 4 days after embolization procedure. Non-target NBCA/LIPIODOL embolization was not observed. Conclusions: Embolization using plug and push technique with low-density NBCA/LIPIODOL is an promising and interesting option for management of peripheral high-flow AVMs either pre-operatively or as a single treatment.

Femoral Pseudoaneurysm in IV Drug Abusers: Single-center Study Experience

Background: Pseudoaneurysm of the femoral artery is the most common complication among IV drug abusers who inject drugs in groin. These are usually infective and potentially fatal so it requires astute clinical recognition and prompt treatment, possessing a significant challenge to vascular surgeons. Methods: We present a retrospective descriptive study and the prevalent practice of their management covering the period from 2013 July- December 2019 at our center. Data regarding demography, presentation, surgical management, and the outcome was analyzed. Results: Among 368 femoral pseudoaneurysm operated during the period, groin swelling with pulsatile mass was the most frequent presentation accounting 304 (82.61%) patients. About 67.12% (247 patients) of the pseudoaneurysm has purulent discharge and 60.07% (221 patients) had bleeding at presentation out of which 211patients had hepatitis C (HCV), hepatitis B (HBsAg) and/or Human Immunodeficiency virus (HIV) status positive. Thirty six patients (9.78%) presented with femoral pseudoaneurysm in both groins. Ligation and excision of the pseudoaneurysm were done in all cases while delayed revascularization was done in eight patients with expanded Polytetrafluoroethylene (ePTFE) graft in one patient and venous bypass grafts in other 7 cases. All patients after bypass had no major limb loss and two patients had a patent graft at five years follow up. There were nine mortalities and thirty two patients underwent amputation. Conclusions: Infected femoral pseudoaneurysm can be managed by ligation of the involved artery with delayed revascularization if required without major limb and life loss. Keywords: Delayed revascularization; drug abuser; infected pseudoaneurysm; ligation