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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Acquired Arteriovenous Fistula
oftheAxillary Artery
Physical Examination andHistory
A 55-year-old male presented to the clinic in
October 2009 with swelling and discomfort
involving the left chest wall. He sustained a tear
of the biceps tendon 10years prior to this presentation. On examination, patient had prominent collateral veins in the chest wall with
palpable thrill and an audible bruit. Patient had
history of stapling of the biceps tendon into the
humeral head in an out-of-state hospital, and the
details of the procedure were not available.
According to the patient, he did not experience
any excessive intraoperative or postoperative
complication.
100
Fig. 100.1 A large arteriovenous stula involving cir-
Procedure
Patient was taken to the interventional radiology
suite, and a left subclavian/axillary arteriogram
was performed via right femoral artery approach
(Fig.100.1). A Newton H4 catheter was advanced
into the left subclavian/axillary artery, and a large
arteriovenous stula involving the circumex
humeral branches of the left axillary artery was
demonstrated. Patient underwent placement of
two covered stents (Fluency Bard, Tempe, AR).
In spite of the placement of two covered stents,
there was a signicant lling of the arteriovenous
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_100
cumex humeral branches of the left axillary artery visualized via retrograde femoral approach
stula (Fig.100.2). Therefore, patient underwent
direct puncture of the left brachial artery, left
cephalic vein, and left basilic vein 3weeks later
under ultrasound guidance (Fig.100.3). A coaxial microcatheter system was used to perform coil
embolization of all the feeding vessels with satisfactory occlusion of the stula (Fig. 100.4).
Patient was followed for 5 years without any
recurrence of the stula (Fig.100.5) and then was
lost to follow-up.
461
462
Fig. 100.2 Persistent stula despite covered stent place-
ment in axillary artery. Staples from orthopedic procedure
are seen in the left shoulder area
100 Acquired Arteriovenous Fistula oftheAxillary Artery
Fig. 100.4 DSA left axillary artery following coil embo-
lization showing absence of ow in the stula
Fig. 100.3 Retrograde cannulation via left brachial
artery with microcatheter coaxial system in the outow
vessels
Discussion
Iatrogenic injuries to the branches of the axillary artery may occur following orthopedic procedures, pacemaker implantation, lead
extraction, or insertion of large-bore catheters
(hemodialysis). Covered stents are useful for
Fig. 100.5 Left upper arm venogram showing patent
basilic vein without visualization of the arteriovenous
stula
management of subclavian/axillary artery
trauma and pseudoaneurysms, but in patients
with large arteriovenous stula involving the
branches of subclavian/axillary artery, the feeding vessels need to be coil embolized to prevent
retrograde ow into the stula. In this patient,
covered stent placement at the origin of the circumex humeral arteries was unsuccessful in
obliterating the stula. Microcatheter system is
extremely useful in placing microcoils in the
small branches feeding the stula [1]. In some
complex cases, with large arteriovenous stula,
multidisciplinary team approach consisting of
interventional radiology and plastic reconstructive surgeon is helpful in to achieve order opti-
References
463
mal outcomes. Congenital arteriovenous stulas
in contrast to acquired arteriovenous stulas are
more prone to recurrence.
Invited Commentary fromNitin
Jain, MD, MS (Master ofSurgery)
CT angiography is now performed as an initial
modality for the assessment of traumatic stulas.
It helps in identication of the inow and outow
tracts, and 3D rendering may help in selecting the
mode of treatment and preplanning for the denite treatment approach. Conventional angiography is still the gold standard for diagnosis and
also helps in the treatment of the AV stula.
Only approximately 2% of posttraumatic AVFs
resolve spontaneously [2]. Traumatic AVF may
have minimal manifestations of symptoms and
may also remain completely asymptomatic [3].
Early diagnosis and management of traumatic
AVFs is recommended in the acute setting to prevent subsequent complications. Surgical closure
of AVFs remains the gold standard [4] and may
be the only option available especially for AVF
involving axial vessels. Other treatment options
are now available that include covered stents, coil
embolization, use of glue, alcohol ablation, etc.
These options provide less invasive choice for
repairing the stula and are especially valuable in
crural vessels and in hemodynamically unstable
patients [5, 6]. In cases in which the axial vessels
are involved, resection of the stula and anatomical reconstruction is necessary. Long-standing
AVFs usually have multiple smaller draining
channels that may not be readily visualized if
power injector is not used during angiography.
In this case, the initial images demonstrated
one inow branch to the stula from circumex
humeral artery and one outow vein through
cephalic vein into the left axillary vein. A covered stent was successfully placed to cover the
ostium of the inow, and repeat angiography
demonstrated persistent opacication of the AVF,
likely from a separate inow channels from other
branches of axillary artery lling the left circumex humeral artery beyond the origin from axillary artery, which were not visualized previously,
but evident on subsequent angiogram.
Percutaneous approach was subsequently utilized to retrograde access the left cephalic vein
through the left basilica vein and coil embolization of dominant circumex humeral artery, and
outow draining vein was done through retrograde venous approach. Final arteriogram
through percutaneous access of left brachial
artery demonstrated satisfactory occlusion of the
stula. The second approach was effective as it
blocked the main inow both at the origin of left
circumex humeral artery and at the arterial end
of AV stula. Also, control of outow vein by
coil embolization is crucial and should be done
before inow occlusion, in case coil from inow
migrates during arterial end embolization.
Another approach that could be considered is
direct venous sac access and glue or onyx embolization of venous sac after occlusion of outow
vein by coil embolization.
References
1. Hans SS, Shepard AD, Reddy P, Rama K, et al.
Iatrogenic arterial injuries of spine and orthopedic
operation. J Vasc Surg. 2011;53:407–13.
2. Perry MO.Complications of missed arterial injuries. J
Vasc Surg. 1993;17:399–407.
3. Nagpal K, Ahmed K, Cuschieri R.Diagnosis and management of acute traumatic arteriovenous stula. Int J
Angiol. 2008;17:214–6.
4. Kollmeyer KR, Hunt JL, Ellman BA, Fry WJ.Acute
and chronic traumatic arteriovenous stulae in civilians. Arch Surg. 1981;116:697–702.
5. Kendrick AS, Sprouse LR.Repair of a combined femoral pseudoaneurysm and arteriovenous stula using a
covered stent graft. Am Surg. 2007;73:227–9.
6. O’Brien J, Buckley O, Torreggiani W.Hemolytic anemia caused by iatrogenic arteriovenous iliac stula
and successfully treated by endovascular stent-graft
placement. AJR Am J Roentgenol. 2007;188:306.
Part XXXI
Question Set
100 Multiple Choice Questions
101
Part IOpen Repair ofIntact
Abdominal Aortic Aneurysm
1. Because of the development of anastomotic
aneurysm and aneurysmal dilatations of visceral segment/iliac arteries following open
repair of infrarenal AAA, surveillance by
CTA scans of abdomen and pelvis should be
performed:
(a) Yearly
(b) Every 2years
(c) Every 5years
(d) Every 10years
2. Patient is scheduled for open repair of juxtarenal AAA with associated 80% stenosis of
left renal artery. Patient has well-controlled
hypertension on one medication with normal
renal function. Renal artery stenosis should
be managed by:
(a) Renal endarterectomy during open
repair
(b) Renal artery bypass graft originating
from aortic graft
(c) Unilateral renal artery stenting
(d) No intervention for renal artery
stenosis
3. During the repair of juxtarenal AAA, proximal aortic clamp is applied above the left but
below the right renal artery. Following completion of the proximal anastomosis with
release of the clamp, there is a tear of the
aorta involving the left renal artery. Bleeding
is controlled by Foley balloon ination in the
supraceliac aorta. Management of aortic tear
involving the renal artery should be treated
with:
(a) Primary repair
(b) Bypass graft from suprarenal aorta to
left renal artery
(c) Renal artery ligation
(d) Bypass graft to left renal artery aris-
ing from the main body of aortic
Dacron graft/ left limb of graft
4. A 76-year-old male has 7.5 cm transverse
diameter asymptomatic infrarenal AAA
with 15 mm neck and normal-sized iliac
arteries but very large IMA and arc of
Riolan. There is moderate stenosis of the
celiac artery of 70% and less than 50% stenosis of the SMA.Management options for
AAA include:
(a) Endovascular aneurysm repair (EVAR).
(b) Open repair with IMA reimplantation.
(c) Postpone the repair until patient is
symptomatic.
(d) SMA stenting followed by EVAR.
5. A patient is diagnosed with a large 6.5 cm
AAA. Preoperative CTA also reveals a
horseshoe kidney with its arterial supply
arising from two renal arteries originating
from the common iliac arteries. Management
should include:
(a) Open repair of AAA with renal
autotransplantation
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_101
467
468
101 100 Multiple Choice Questions
(b) Temporary axillofemoral bypass to
maintain retrograde arterial ow to the
kidney during open AAA repair
(c) Nephrectomy for the pelvic kidney
(d) Reimplantation of renal arteries into
the prosthetic graft during AAA
repair
6. During open repair of AAA, double IVC was
encountered. Management options include:
(a) Ligation of the left-sided vena cava
(b) Mobilization of the left-sided vena
cava near the neck of aneurysm
(c) Division of left-sided vena cava with
reconstruction at the end of the
procedure
(d) Select left retroperitoneal approach to
avoid left-sided IVC
7. Mycotic aneurysms of the abdominal aorta
are best managed by:
(a) Wide debridement of infected aorta,
inline reconstruction with cryopreserved graft or femoral popliteal vein
graft and prolonged antibiotics
(b) Should be treated similar to non-infected
AAAs
(c) Extra-anatomic bypass following aortic
resection
(d) Antibiotics alone
8. Which of the following best applies to a
patient with compensated cirrhosis [MELD
<10] undergoing open AAA repair?
(a) There is no difference in incidence of
perioperative complications in
patients with or without cirrhosis;
however, there is higher incidence of
intraoperative blood loss, increased
operative time, and increased LOS in
cirrhotics.
(b) Open repair in cirrhotic patients should
never be performed.
(c) The patient should receive pre-op FFP
even if PT/INR is normal.
(d) Open repair should be performed with-
out heparin administration during aortic
cross-clamping.
9. Major venous injury during open repair of
aortoiliac reconstruction is most commonly
associated with:
(a) Ruptured AAA repair
(b) Elective AAA repair
(c) Aortofemoral bypass
(d) Iliofemoral bypass
10. A patient develops paraplegia following
repair of an inammatory infrarenal abdominal aortic aneurysm, right common iliac
aneurysm, and right hypogastric artery aneurysm with an aorto-right external iliac
bypass, ligation of the right hypogastric
artery, and aorto-left femoral bypass graft.
The most common cause of paraplegia in
this patient is:
(a) Abnormal origin of the great radicular
artery (artery of Adamkiewicz)
(b) Hypotension
(c) Prolonged aortic clamping
(d) Interruption of pelvic arterial ow
11. The incidence of obstructive uropathy in
patients with inammatory AAA is:
(a) <10%
(b) 10–15%
(c) 16–25%
(d) Greater than 25%
12. Chronic contained rupture of AAA is sealed
by:
(a) Duodenum
(b) Inferior vena cava
(c) Anterior spinal ligament
(d) Left renal vein
13. The incidence of groin lymphatic complications is highest after:
(a) Aortofemoral bypass
(b) Fem-popliteal bypass
(c) Fem-tibial bypass
(d) Fem-peroneal bypass
14. In a patient with inammatory AAA, chronic
inammation usually extends from:
(a) The supraceliac aorta to the iliac
bifurcation
(b) Below the renal artery to just above
the iliac bifurcation
(c) Below the renal artery to the distal exter-
nal iliac artery
(d) Just above the iliac bifurcation to the
femoral arteries
15. The incidence of incisional hernia repair
6years following open AAA repair is
(a) <5%.
(b) 5–12%.
Part III Open Repair ofIntact andRuptured Iliac Artery Aneurysms
469
(c) 12–20%.
(d) Hernia does not occur after open AAA
repair.
Part II Open Repair ofRuptured
Abdominal Aortic Aneurysm
16. The incidence of pancreatitis and duodenal
obstruction is highest following:
(a) Aortofemoral grafting
(b) Elective open AAA repair
(c) Ruptured open AAA repair
(d) In patients with simultaneous cholecys-
tectomy and open AAA repair
17. A patient with a ruptured AAA and horseshoe kidney presents to the ER. The most
important factor in deciding the approach for
repair is:
(a) Experience of the surgeon.
(b) Open repair should be the only method
considered.
(c) Endovascular repair should always be
preferred.
(d) Approach should depend upon the
anatomy of the aneurysm and arterial
supply to the horseshoe kidney
18. During transperitoneal open repair of ruptured juxtarenal AAA, operative steps that
should be initially carried out are:
(a) Suprarenal control (division of crus
with mobilization/division left renal
vein) or supramesenteric/supraceliac
control.
(b) Passing a guidewire and a large aortic
balloon through the femoral artery.
(c) Opening the aneurysm sac and passing a
Foley catheter into the supraceliac
aorta.
(d) Repair of juxtarenal ruptured AAAs do
not need special maneuvers.
19. A ruptured AAA occurs in a patient with
prior endograft (EVAR). The best management for this patient is:
(a) Always repeat endovascular aneurysm
repair.
(b) Choice of endovascular vs open repair
depends upon the ndings of the CTA
abdomen and pelvis.
(c) Repair of a patient with ruptured AAA
with prior EVAR is lethal, and no further
treatment should be attempted.
(d) Should always undergo open repair.
20. A 53-year-old male with history of ruptured
AAA repair with open aortobifemoral grafting presents with an infected graft
(Staphylococcus aureus). He undergoes
removal of the graft and cryopreserved autograft which ruptures 2 weeks later. Patient
undergoes bilateral axillofemoral grafting
and removal of cryograft. Subsequently, he
develops multiple occlusions over the next
2years. Denitive management should be:
(a) In-line rifampin-soaked Dacron aortobi-
femoral graft
(b) Deep vein (femoral) autograft
(c) Retroperitoneal aortofemoral pros-
thetic graft reconstruction
(d) Thoracic aorta to femoral artery bypass
graft
Part III Open Repair ofIntact
andRuptured Iliac Artery
Aneurysms
21. Elective repair of intact common iliac aneurysm is recommended for size:
(a) <3cm AP/transverse diameter
(b) 3–3.4cm AP/transverse diameter
(c) >3.5cm AP/transverse diameter
(d) Only if the aneurysm is symptomatic
22. Open repair of ruptured iliac artery aneurysm carries a mortality of:
(a) <5%
(b) 5–10%
(c) 10–60%
(d) Patients with ruptured iliac aneurysm
present with exsanguination not amenable to open repair.
23. Ruptured mycotic aneurysm of aorta/iliac
artery should be treated with debridement,
IV antibiotics, and:
(a) Endovascular repair
(b) Use of deep veins (femoral or popliteal)
as arterial conduits
(c) Cryopreserved arterial allograft
(d) Axillofemoral graft
470
101 100 Multiple Choice Questions
24. In a patient with multiple comorbidities, ruptured hypogastric aneurysm is best treated
by:
(a) Coil embolization of the outow tract
of hypogastric artery and covered
stent graft from common iliac to
external iliac artery
(b) Open repair
(c) Amplatzer occluder plug at original
hypogastric artery
(d) Coil embolization through the superior
gluteal branch
Part IV Open Repair ofFemoral
Artery andFemoral Anastomotic
Aneurysms
25. Ruptured femoral anastomotic aneurysm
should best be treated by:
(a) Endovascular approach
(b) Direct open repair with proximal con-
trol obtained via retroperitoneal incision just above the groin
(c) Direct open repair
(d) Open repair with proximal occlusion of
the limb from the contralateral graft
limb
26. A 68-year-old male was found to have
3.2 cm right common femoral aneurysm
conrmed by duplex imaging. The incidence of contralateral synchronous femoral
artery aneurysm is:
(a) <25%.
(b) 25–50%.
(c) Greater than 50%.
(d) Contralateral femoral artery aneurysm is
present only if patient has AAA.
Part V Open Repair ofPopliteal
Artery Aneurysms
27. Rupture of popliteal aneurysm occurs overall
in:
(a) Less than 2%.
(b) 3–7%.
(c) 8–12%.
(d) Rupture of popliteal aneurysm occurs
only if patient sustains trauma.
28. A 60-year-old male undergoes open repair of
popliteal aneurysm with interposition greater
saphenous vein bypass graft. He subsequently undergoes repair of contralateral
popliteal artery aneurysm. At the time of
repair, there is no evidence of abdominal aortic aneurysm. Which of the following is true
regarding surveillance?
(a) Patient should undergo lifelong sur-
veillance of abdomen as AAA may
develop years after popliteal aneurysm repair.
(b) Patient should be evaluated for subcla-
vian aneurysm.
(c) Patient should undergo yearly abdomi-
nal aortogram.
(d) If patient does not have clinically palpa-
ble femoral aneurysm, the chances of
developing AAA are extremely low.
Part VI Open Repair ofSubclavianAxillary Aneurysm
29. A 70-year-old female has 3.5 cm partially
thrombosed left subclavian aneurysm at the
third portion of subclavian artery. Best management options include:
(a) No intervention as aneurysm is
thrombosed.
(b) Endovascular repair.
(c) Open repair.
(d) Hybrid repair.
Part VII Open Repair ofCarotid
Aneurysm
30. Perioperative stroke rate following open
repair of carotid aneurysm is:
(a) <2%
(b) 2–5%
(c) 6–9%
(d) 10–12%
Part X Carotid Endarterectomy
471
Part VIII Open Repair ofSMA
Aneurysm
31. If left untreated, superior mesenteric aneurysm will rupture in:
(a) <10% of patients
(b) 10–20% of patients
(c) 21–40% of patients
(d) 50% of patients
Part IX Resection ofCarotid Body
Tumor
32. Malignant carotid body tumor is treated with
en bloc resection of the tumor and the carotid
artery bifurcation followed by:
(a) Chemotherapy.
(b) Radiation.
(c) Chemotherapy and radiation.
(d) No treatment is necessary.
33. Postoperative stroke following resection of
carotid body tumor occurs in
(a) <1%
(b) 1–3%
(c) Approximately 4%
(d) >5%
Part X Carotid Endarterectomy
34. A 68-year-old female undergoes carotid endarterectomy with vein patch for radiationinduced carotid stenosis. She has a history of
neck lymph node dissection. The optimal
coverage for the carotid artery dissection
includes:
(a) Primary closure
(b) Sternocleidomastoid ap
(c) Free microvascular ap
(d) Pectoralis major myocutaneous ap
35. A 60-year-old male sustains a minor stroke
(NIH stroke scale 4) in the distribution of left
MCA.He has 90% stenosis of left ICA.He is
in an optimal risk for carotid recanalization.
Carotid revascularization (CEA/CAS)
should be performed:
(a) After a waiting period of 6 weeks.
(b) Should only be performed if patient
develops neurological symptoms.
(c) Early CEA/CAS should be considered
(within 10days).
(d) Carotid artery stenting is preferable to
CEA and should be done as an
emergency.
36. A 70-year-old male with a history of recent
TIA in the distribution of right MCA has
90% stenosis of right ICA with associated
heavily calcied plaque extending into the
junction of C1/C2 vertebral body. The optimal plan of management is:
(a) CAS
(b) CEA with intraoperative stenting with
tacking of upper end of the plaque
(c) Continue med management
(d) CEA under general anesthesia with
nasotracheal intubation and mandib-
ular subluxation
37. Use of shunt during CEA may be associated
with:
(a) Carotid artery dissection/
embolization.
(b) Spasm of distal ICA.
(c) Increased risk of postoperative intracere-
bral hemorrhage.
(d) Heparin-bonded shunts should be used
to increase ow through the shunt.
38. Postop intracerebral hemorrhage following
CEA:
(a) Never occurs following CAS.
(b) Occurs immediately.
(c) Incidence is increased if patient has
received TPA for acute neurological
symptoms.
(d) Is the result of hyperperfusion and
occurs typically between 24hours and
5days.
39. Symptomatic radiation-induced carotid stenosis is often:
(a) Bilateral and plaque extends for a
considerable distance cephalad.
(b) Always unilateral.
(c) CEA is contraindicated.
(d) CEA is associated with lower incidence
of cranial nerve palsy and wound
complications.
472
101 100 Multiple Choice Questions
40. Seizures following CEA usually occurs:
(a) Immediately after CEA
(b) 12hours–7days after CEA
(c) More commonly if CEA is performed in
an asymptomatic patient
(d) Due to acute hypoperfusion of the brain
41. Following left CEA, patient wakes up with
right hemiplegia and speech loss. Patient is
re-explored. No abnormality is detected at
the CEA site. On table carotid angiography
shows occlusion of the M1 segment of
MCA. Endovascular neurosurgeon is not
available in your hospital. The best management is
(a) IV TPA
(b) IV heparin
(c) IV integrilin
(d) Immediately transfer to neurointer-
vention center for plaque retrieval
42. Symptomatic recurrent carotid stenosis following CEA should be managed only by:
(a) Redo CEA.
(b) Medical management.
(c) Radiation therapy.
(d) CAS should be preferred.
43. A 65-year-old female develops severe instent stenosis of the common carotid artery.
Patient has also developed another heavily
calcied lesion at the origin of the internal
carotid artery. Best management option is:
(a) Place another stent.
(b) Balloon angioplasty.
(c) Consider CEA.
(d) Carotid interposition graft.
44. CEA for high plaque (extending to C2) may
be associated with CN injury. The most commonly injured nerve is:
(a) Vagus
(b) Glossopharyngeal
(c) Marginal mandibular
(d) Hypoglossal
Part XI Aortofemoral Grafting
45. Redo aortofemoral graft for aortoiliac occlusive disease is associated with mortality of:
(a) <5%
(b) 5–7%
(c) 8–10%
(d) Greater than 10%
46. A 60-year-old patient in otherwise good
medical condition presents with severe claudication and is found to have a TASC D
occlusion of left common and external iliac
artery. He also has a horseshoe kidney with
arterial supply from multiple renal arteries.
Best management would be:
(a) Aortofemoral grafting through trans-
peritoneal approach.
(b) Aortofemoral grafting through retroperi-
toneal approach.
(c) Crossover femoral-femoral graft.
(d) Percutaneous intervention (iliac stent-
ing) should be attempted as rst line
of treatment.
47. Radiation-induced iliac artery occlusion is
best treated by:
(a) Endovascular stenting
(b) Endarterectomy
(c) Surgical bypass
(d) Surgical bypass with adequate tissue
coverage
48. A 60-year-old male patient with left common and external iliac artery occlusion,
patent right common, and external iliac
artery, without signicant CAD, had a previously placed femoral-femoral crossover
graft which has failed/occluded. The procedure with the best primary patency is:
(a) Redo crossover femoral-femoral graft
(b) Axillofemoral graft
(c) Endovascular therapy
(d) Aortobifemoral graft
49. Late graft limb occlusion after aortobifemoral grafting occurs secondary to:
(a) Elongation and kinking of the graft
(b) Hypercoagulable state
(c) Femoral anastomotic stenosis sec-
ondary to recurrent atherosclerotic
disease
(d) Femoral anastomotic aneurysm
50. Aortofemoral grafting for juxtarenal occlusion may require suprarenal clamp. Incidence
of post-op renal failure is:
(a) Similar to infrarenal clamp.
(b) Greater than infrarenal clamp.
(c) Less than infrarenal clamp.