Letter to the Editor Response

Jacques Lara-Reyna University of Illinois College of Medicine at Peoria, IL
OSF Saint Francis Medical Center, Peoria, IL

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Jonathan R Garst University of Illinois College of Medicine at Peoria, IL
OSF Saint Francis Medical Center, Peoria, IL

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Nolan Winslow University of Illinois College of Medicine at Peoria, IL
OSF Saint Francis Medical Center, Peoria, IL

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Jeffrey D Klopfenstein University of Illinois College of Medicine at Peoria, IL
OSF Saint Francis Medical Center, Peoria, IL

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Open access

We thank Kalantari and coauthors for their letter regarding our innovative approach to spinal arteriovenous fistulas (sAVFs) and congratulate them on presenting their experience. Our publication states that sAVF can be treated by endovascular embolization or open surgical obliteration of the fistula via excision, clipping, or ligation. In our case, because of the inability to clip the fistulous point safely and changes in intraoperative monitoring signals that could indicate effects on the patient’s clinical status, we deemed it necessary to proceed with a direct arteriotomy and intravascular packing with Surgicel (Ethicon Inc.), an oxidized cellulose absorbable hemostat, as an alternative to clipping to avoid direct transverse compression of the nerve.

The consistency and configuration of the oxidized cellulose allowed satisfactory packing at the level of the arteriotomy and subsequent suturing to prevent the material’s migration or dislodgement. This technique and the hemostatic agent differ from the experience of Kalantari et al., who, even though the occlusion occurred serendipitously, were able to achieve resolution of the fistula using Floseal. This hemostatic agent has a more gelatinous foamy consistency and higher viscosity than Surgicel, having the potential to migrate in the intravascular system and probably cause thrombosis. In the Kalantari et al. report, it is unclear if the Floseal was applied directly over the venous bleeding or if there was intravascular spread in the fistulous point.

Floseal has been demonstrated to provide efficacious hemostasis among several specialties, and its use is currently widespread.1

Pertinent to the underlying pathology in the present illustrative case, Karim et al.2 shared their experience with preoperative embolizations of head and neck arteriovenous malformations before dental procedures to minimize the risk of excessive bleeding. Floseal was applied over the surgical bed after direct puncture sclerotherapy and embolization, providing satisfactory hemostasis.2

It is important to note that initial experiences like ours and that of Kalantari and colleagues are always essential for innovation and improvement in surgical techniques. However, as illustrative cases, they are subject to scrutiny, and prospective analysis should be considered to define their safety and the long-term outcomes using these techniques.

References

  • 1

    Echave M, Oyagüez I, Casado MA. Use of Floseal®, a human gelatine-thrombin matrix sealant, in surgery: a systematic review. BMC Surg. 2014;14:111.

  • 2

    Karim AB, Lindsey S, Bovino B, Berenstein A. Oral surgical procedures performed safely in patients with head and neck arteriovenous malformations: a retrospective case series of 12 patients. J Oral Maxillofac Surg. 2016;74(2):255.e18.

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  • 1

    Echave M, Oyagüez I, Casado MA. Use of Floseal®, a human gelatine-thrombin matrix sealant, in surgery: a systematic review. BMC Surg. 2014;14:111.

  • 2

    Karim AB, Lindsey S, Bovino B, Berenstein A. Oral surgical procedures performed safely in patients with head and neck arteriovenous malformations: a retrospective case series of 12 patients. J Oral Maxillofac Surg. 2016;74(2):255.e18.

    • PubMed
    • Search Google Scholar
    • Export Citation

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