Tag Archives: fistula

Print Release, Vascular Surgery

PUBLISHED: Fistulogram for a Cephalic Arch Aneurysm

Fistulogram for a Cephalic Arch Aneurysm
Tiffany R. Bellomo, MD1,2; Brett J. Salomon, MD1,2; Jonah Thomas, MD2; Anahita Dua, MD, MS, MBA, FACS1
1Massachusetts General Hospital
2Mass General Brigham

More than 100,000 arteriovenous fistulas (AVFs) are created annually in the United States, but are frequently complicated by venous outflow stenosis, aneurysm formation, and aneurysms that often require angiographic evaluation and intervention. Cephalic arch stenosis is a particularly common cause of dysfunction in brachiocephalic fistulas due to high flow. This is typically managed with fistulogram-guided angioplasty, although repeated interventions are associated with restenosis and access-related complications.

This article present the case of a 63-year-old, right-hand dominant male with end-stage renal disease secondary to glomerulonephritis on dialysis through a left upper extremity brachiocephalic AVF that was complicated by recurrent cephalic arch stenosis requiring multiple angioplasties, which ultimately resulted in the development of a cephalic arch aneurysm. Subsequent fistulograms demonstrated a high-grade stenosis that could not be traversed despite multiple attempts.

Comprehensive preoperative evaluation included focused history, physical examination, duplex ultrasound, and computed tomography venography. The fistulogram described in this article demonstrated a patent, high-flow AVF with a saccular aneurysm of the proximal cephalic vein measuring up to 28 mm without thrombus and no hemodynamically significant flow-limiting stenosis. Given the absence of flow limitation and the risk of compromising future access, stent placement was deferred.

This case highlights the importance of individualized decision-making in the management of complex AVF complications. Fistulograms serve as a critical diagnostic and therapeutic tool, allowing real-time assessment of anatomy and flow to guide intervention. In select patients, conservative endovascular management with surveillance may preserve access durability and delay the need for more invasive procedures.

General Surgery, Print Release

PUBLISHED: Anal Examination Under Anesthesia with Abscess Drainage and Evaluation for Fistula

Anal Examination Under Anesthesia with Abscess Drainage and Evaluation for Fistula
Jennifer Shearer, MD; Brooke Gurland, MD, FACS
Stanford University School of Medicine

Anorectal abscesses most commonly result from obstruction of glandular crypts in the anorectal canal. Abscesses are commonly diagnosed by clinical exam with fluctuance, induration, and tenderness around the perianal tissue.

Abscesses are managed with incision and drainage. For superficial perianal abscesses, bedside lancing can be performed, but for more complex or ischiorectal or postanal abscess, examination under anesthesia in the operating room is preferred. Complete evacuation of the abscess with breakdown of loculated abscess pockets is critical to fully control the infection. Drains may also be left in a deep abscess pocket to prevent the skin prematurely closing before the cavity has healed.

Imaging is selectively performed with CT or MRI to identify occult infections or further identify proximal extent of abscess cavity or associated fistula. For recurrent abscesses, associated fistula tracts should also be identified and, if possible, treated intraoperatively. Antibiotics are utilized for patients with cellulitis or those who are immunosuppressed. This video article presents an adult male with recurrent anorectal abscesses with a new anterior abscess collection, which was managed with anal exam under anesthesia with incision and drainage of abscess collection and drain placement.

Neurosurgery, Preprint Release

PREPRINT RELEASE: Microsurgical Resection of an Intracranial Dural Arteriovenous Fistula

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Microsurgical Resection of an Intracranial Dural Arteriovenous Fistula
Charite Hospital Berlin
PD Dr. med. Marcus Czabanka

A patient suffering from an AV fistula fed by the external carotid artery, who has failed occlusion via embolization, is being operated on by Dr. Czabanka to definitively treat the fistula. With the help of CT navigation and ICG angiography, Dr. Czabanka is able to microscopically devascularize the problematic malformation.