Paraplegia due to posttraumatic pelvic arteriovenous fistula treated by surgery and embolization

Case report

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✓ A case is presented in which a posttraumatic pelvic arteriovenous fistula caused progressive paraplegia because of voluminous shunting into the epidural venous system. Surgical ligation and transcatheter embolization of major and minor arterial feeders decreased shunt flow sufficiently to permit direct embolization of the fistula by an injectable plastic. This combined approach may allow obliteration of unresectable acquired or congenital arteriovenous malformations.

Article Information

Address reprint requests to: Paul B. Chretien, M.D., Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20014.

© AANS, except where prohibited by US copyright law.

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Figures

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    Serpentine filling defects (arrowheads) due to enlarged vessels within the subarachnoid space. The caudal sac is deviated to the left (arrows) by an extradural mass.

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    Selective inferior mesenteric arteriogram reveals a massive collection of dilated vascular channels in the right side of the pelvis (small arrows) draining mainly into enlarged epidural veins (large arrows) which are responsible for displacement of the caudal sac.

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    Selective left internal iliac arteriogram. Left: Arterial phase reveals filling of distal right internal pudendal artery (curved arrows) and aneurysm (straight arrows) identifying the site of the original fistula. Note the luxuriant collateral circulation through the bladder and prostatic vascular beds. Right: Venous drainage is into the lumbar epidural plexus (arrows) since previous surgery had obliterated the internal iliac drainage pathways.

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    Postoperative aortogram. Left: Arterial phase shows dramatic diminution in size, but persistent opacification of the fistula (small arrows) by two left presacral and one right circumflex femoral feeders (large arrows). Right: Venous drainage into the epidural plexus still predominates.

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    Selective arteriograms of presacral feeder. Left: Before embolization there is persistent opacification of right pelvic fistula (arrows). Right: After Gelfoam embolization, proximal obstruction of this feeder is demonstrated (arrow) with reflux into the superior gluteal artery.

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    A Chiba needle (arrow) has been directly introduced into the fistula to fill the aneurysm with isobutyl cyanoacrylate mixed with radiodense tantalum (arrowheads). Note the return to midline of the previously displaced caudal sac (compare with Fig. 1).

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