Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 46, Num. 3, 2000, pp. 213-214

Journal of Postgraduate Medicine, Vol. 46, No. 3, July-September, 2000, pp. 213-214

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Endovascular glue embolisation of Intercostal Arteriovenous fistula: A non surgical treatment option

Siddhartha W, Parmar H, Shrivastav M, Limaye U

Department of Radiology, King Edward VII Memorial Hospital, Parel, Mumbai - 400 012, India.
Address for correspondence: Hemant Parmar, Department of Radiology, King Edward VII Memorial Hospital, Parel, Mumbai- 400 012, India. E-mail: kemrad@vsnl.com

Code Number: jp00074

14-year-old boy presented with a progressively growing swelling in the right infrascapular region. The patient had undergone a pleural tapping six months back. Plain and contrast enhanced CT Scan showed enhancing serpiginous channels in the intercostal space suggestive of an intercostal vascular malformation. Digital substraction angiogram (DSA) performed through the right transfemoral route showed hypertrophied right 8^th intercostal artery with a large muscular branch opening into a large venous pouch of fistula (Figure 1A). This ultimately drained via multiple veins into the dilated intercostal veins, azygous and paraspinal veins (Figure 1B). T7,T9, T10 intercostal arteries on the right side were normal.

A 1.8F Magic flow guided microcatheter (BALT, France) catheter was navigated into the feeding artery and was advanced as far into the nidus of the fistula as possible. Guiding the catheter into the fistula was easy due to high flow at the fistula site. The fistula had a moderate flow. The fistula, the feeding artery and the draining vein were occluded with the N-Butyl Cyano Acyrlate (NBCA) and lipidiol mixture of 33% (Figure 2). Post embolisation check angiogram showed complete obliteration of the fistula (Figure 3). Right T9 intercostal arteries showed collateral branches with regular but prominent opacification of the dilated intercostal vein draining the fistula. However the fistula was not seen. These collaterals were also occluded with gelfoam particles. At the end of the procedure the pulsatile swelling had became firm and non pulsatile. On a six months follow-up the patient was asymptomatic and there was considerable decrease in the size of the swelling.

Discussion

Intercostal arteriovenous fistulas (AVF) occur following trauma in the form of penetrating missile injury or a stab wound. Intercostal AVF due to iatrogenic trauma is rare and has been reported following pleural biopsy, pleural tapping and CT guided biopsy of a chest mass.^1-4 Ligation of the feeding artery by open surgery has been the treatment of choice for intercostal AVF. NBCA has been traditionally used in the neurointerventional procedures for occlusion of the arteriovenous malformations and fistulas in brain. It was successfully and effectively used in the management of intercostal AVF in the present case.

Trauma to the chest leads to the fistulous communication of the intercostal artery and the intercostal veins as they run close to each other. Injuries to these vessels lead to pseudoaneurysm formation, which later ruptures into the vein and results in high pressure-low pressure fistulas.^1,5 Rarely a direct arterial aneurysm forms which can later rupture and cause fistula formation. Underlying developmental defect or inflammatory condition of the vessels aggravate the condition and can also predispose to fistula formation. If the cutting edge of the aspirating needle is inappropriately directed then it can induce AVF formation.

Intercostal AVF clinically presents as a slowly growing pulsatile swelling at the site of previous tapping or trauma, sometimes with catastrophic hemathorax following its rupture. ¹ On examination there is usually a bruit or murmur at the site of the lesion. Though colour Doppler has been used to diagnose the intercostal fistulas,⁶ angiograms remain the gold standard for diagnosis. It accurately depicts the site of the fistula, localises the feeder artery, the draining veins and also shows abnormal feeder vessels and the feasibility of endovascular treatment in a particular patient.

Conventional treatment of these AVFs is surgical ligation of the feeder vessels. This can be difficult at times, and can cause significant morbidity and mortality.⁷

Endovascular treatment is a safe and effective method of treating intercostal AVFs. There have been reports of coil embolisation used to treat a fistula between the internal mammary artery and the innominate vein by Anguera.⁷ We did not find any mention of endovascular treatment of intercostal AVF in the literature. As the clinical course of these AVFs is undefined, open surgical or endovascular treatment is generally warranted because of the potential risk of significant complications. Surgical repair is associated with significant mortality and morbidity. Percutaneous endovascular embolisation of the AVF with glue/coils offers a new radical and effective option, especially because of its high success rates and lower morbidity rates. Secondly endovascular means is less traumatic and allows precise and selective occlusion of only the abnormal fistulous opening. It does not injure the surrounding great vessels, nor does it cause any injury to the nerves.

References

1. Lai JH, Yan HC, Kao SJ, Lee SC, Shen CY. Intercostal arteriovenous fistula due to pleural biopsy. Thorax 1990; 45: 976-978.
2. Cox PA, Keshishian JM, Blades BB. Traumatic arteriovenous fistula of the chest wall and lung- secondary to insertion of an intercostal catheter. J Thorac Cardiovasc Surg 1967; 54: 109-112.
3. Coulter TD, Maurer JR, Miller MT, Mehta AC. Chest wall arteriovenous fistula: an unusual complication after chest tube placement. Ann Thorac Surg 1999; 67: 849-850.
4. Kasper AS, Walter M. An arteriovenous fistula in an unusual site. Zentralbl Chir 1995; 120: 657-659.
5. Howell JB. Intercostal fistula due to pleural biopsy. Thorax 1991; 46: 688.
6. Derdeyn CP, Middleton WD, Allen BT, Nordlicht SM. Acquired intercostal arteriovenous fistula: colour Doppler ultrasonographic diagnosis. J Ultrasound Med 1993; 12: 679-681.
7. Anguera I, Real I, Morales M, Vazquez F, Montana X, Pare C. Left internal mammary artery to innominate vein fistula complicating pacemaker insertion. Treatment with endovascular transarterial coil embolisation. J Cardiovasc Surg (Torino) 1999; 40: 523-525.

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