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INTRODUCTION: Cephalic arch stenosis (CAS) is often recurrent, resistant to treatment and the intervention outcome is not well validated so far. We purposed to assess the clinical outcomes of CAS treatment in patients with hemodialysis access. METHODS: Electronic bibliographic sources were searched up to December 4 2023 to identify studies reported outcome after treating CAS. Direct and indirect evidence was combined to compare odds ratios (OR) and surfaces under the cumulative ranking curves across the different treatment modalities through meta-analysis and network meta-analyses (NMA). This systematic review was conducted in accordance with the PRISMA-P. The review is registered in PROSPERO (CRD42022296513). RESULTS: Four randomized controlled trials (RCTs) and 15 non-RCTs were included in the analysis. The study population differed in fistula type, restenosis or thrombosis, and significant heterogeneity was observed among the publications. The risk of bias was low to serious. Meta-analysis found no significant difference between DCB and PTA in primary patency at 6 and 12 months (OR 1.16 and 0.60, respectively; low certainty of evidence). Favorable result with STG compared to stent or PTA at 3, 6, and 12 month was observed (OR 4.28, 5.13, and 13.12, and 4.28, 5.13, 13.12, respectively; low certainty of evidence). Regarding primary patency, the treatment rankings, from highest to lowest, were STG (92.7%), transposition (76.0%), stent (67.5%), DCB (46.3%), and PTA (64.5%) at 12 months. CONCLUSION: Despite data limitations, the low-quality evidence suggests that STG may merit consideration as a primary treatment option when all alternatives are applicable, given their potential for better primary patency and higher treatment ranking.

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Pediatric arteriovenous shunts can be challenging to embolize and the consequences of excess venous penetration disastrous. Moreover, the congenital nature of most shunts necessitates neonatal intervention whenever (medically refractory) heart failure occurs. Here, we describe current endovascular treatment strategies based on personal experience and literature review. While disparate, arteriovenous malformation, dural arteriovenous fistula (AVF), pial AVF, and vein of Galen aneurysmal malformation share unifying features such as high output heart failure and venous hypertension. This tutorial is divided into passages on Goals, Access, and Treatment which respect differences among pediatric arteriovenous shunts while maintaining a narrative economy.

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Dural arteriovenous fistula (DAVF) of the craniocervical junction is exceptionally rare. The anatomy of the craniocervical junction area is very complex and is composed of the medulla and spinal cord along with intricate neurovascular structures. A thorough assessment of the angioarchitecture of the fistula is obligatory for choosing the most appropriate treatment for the patient. In this report, we describe the nuance of microsurgical obliteration of craniocervical junction DAVF utilizing intraoperative angiography. A 38-year-old male in a normal state of health was referred to our hospital for an abnormality in his brain checkup. Workup diagnostics showed a DAVF on the craniocervical junction area with feeders from ascending pharyngeal, vertebral, and occipital arteries, with the draining vein mainly to the basal vein of Rosenthal. Microsurgical obliteration of the main draining vein was done with the help of intraoperative digital subtraction angiography with a good outcome. Craniocervical DAVF is a rare entity. Meticulous evaluation of arterial and venous fistula points is necessary to decide the best treatment option for this case. Microsurgical obliteration is a feasible and more straightforward procedure for treating craniocervical DAVF.

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PURPOSE: Spontaneous direct carotid-cavernous fistula (CCF) are usually caused by a ruptured carotid cavernous aneurysm. We studied treatment of spontaneous direct CCFs in a single-center cohort of a high-volume tertiary referral center, reporting anatomical details, technical approaches of treatment, and outcomes. METHODS: Adult patients with a spontaneous direct CCF treated between 2010-2022 with follow-up MRI and/or DSA imaging available were retrospectively analyzed. We studied age, sex, clinical presentation, angiographic findings, treatment techniques, outcomes, and complications. RESULTS: Out of 80 patients with CCFs, twelve patients were treated for a non-traumatic direct CCF (15%) in 13 sessions. Median age was 65 years. Two patients had an underlying connective tissue disorder. In 10 cases, the direct CCF was caused by a ruptured cavernous carotid aneurysm. The direct CCFs were treated by endovascular transarterial embolization (10 cases), transvenous embolization (1 case), or surgery (1 case). Selective closure of the shunt was possible in 10 patients. Two patients were treated with parent vessel occlusion (PVO; one endovascular; one surgical, with bypass). Complications occurred in 2 / 12 patients (17%), with permanent morbidity in two patients (17%): trigeminal neuralgia after PVO and new infarct after surgical PVO and bypass. Selective closure of CCF resulted in no morbidity. There was no mortality in our series. CONCLUSION: Spontaneous direct CCFs are caused by rupture of a cavernous carotid aneurysm in most cases. Selective closure of the shunt, usually feasible transarterially with coils, achieves good results. Reconstructive endovascular techniques are preferred to minimize treatment related neurological complications.

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PURPOSE: To evaluate the choroidal arterial abnormality in central serous chorioretinopathy (CSC). METHODS: Fifty-two eyes from 52 patients with CSC were retrospectively evaluated. Arterial and venous ultrawide-field indocyanine green angiography were merged after color and transparency adjustments to compare the choroidal arterial and venous vasculature. Specifically, we evaluated whether the choroidal arteries directly fill the pachyvessel without interconnection of choriocapillaris (arterial pachyvessel; aPV). Then, the clinical characteristics of patients with and without arterial pachyvessel were compared. RESULTS: Pachyvessel under subretinal fluid was detected in 47 of 52 eyes (90.4%). An arterial pachyvessel was detected in eight of 52 eyes (15.4%). Of those eight eyes with arterial pachyvessel, seven (87.5%) showed sustained staining through the venous phase, suggesting they are arteriovenous shunt, while one eye (12.5%) showed diminished fluorescence in the venous phase, suggesting this pachyvessel was purely an artery. Patients with arterial pachyvessel experienced more CSC recurrences (non-aPV group: 2.09 ± 1.44 times vs. aPV group: 3.25 ± 1.28 times; p = 0.039) and pachychoroid neovasculopathy (PNV) development (non-aPV group: 2.3% vs. aPV group: 37.5%, p = 0.009). CONCLUSION: The presence of arterial pachyvessel in eyes with CSC may represent choroidal circulatory imbalance and focal shear stress to Bruch's membrane, leading to a chronic nature and PNV development.

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BACKGROUND: Interruption of the fistulous point is the goal of treatment of spinal dural arteriovenous fistulas (dAVFs). Microsurgery remains a highly efficient treatment in terms of complete occlusion with the lowest risk of recurrence rate. It is reported that the hardest step involves finding the fistulous site itself, potentially extending surgical access and time and increasing potential postoperative surgical-related complications. The accurate preoperative detection of the shunt and spinal level together is crucial for guiding optimal, fast, and safe microsurgical treatment. METHODS: We describe a preoperative angiographic protocol for achieving a safe and simple resection of spinal dural arteriovenous fistulas based on a 6-year institutional experience of 42 patients who underwent minimally invasive procedures. Two illustrative cases are included to support the technical descriptions. RESULTS: The suspected artery associated with the vascular malformation of interest is studied in our angiographic protocol through nonsubtracted selective acquisitions in lateral projection. The resulting frames are reconstructed with three-dimensional rotational angiography. The implementation of the preoperative angiographic protocol allowed 100% of intraoperative identification of the fistulous point in all cases with the use of a minimally invasive approach. CONCLUSIONS: Nowadays, neurosurgeons advocate for minimally invasive procedures and procedures with low morbidity risk for treatment of spinal dural arteriovenous fistulas. Our preoperative approach for accurate angiographic localization of the fistulous point through nonsubtracted and three-dimensional reconstructed angiography allowed us to achieve safe and definitive occlusion of the shunt.

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This case report details the management of a 66-year-old male with hemophilia A (HA) who presented with recurrent hematuria, and was found to have renal artery aneurysms and was subsequently diagnosed with a renal arteriovenous (AV) shunt. While the primary focus centers on the successful endovascular coil embolization of renal artery aneurysms, the concomitant presence of the AV shunt accentuates the significance of this case. Imaging techniques were crucial in the discovery of renal aneurysms and the diagnosis of the AV shunt malformation of the renal artery. This included an ultrasound, CT-angiography and digital subtraction angiography. The treatment approach employed prioritized endovascular coil embolization for its efficacy and reduced morbidity. Following the initial successful embolization, the identification of the AV shunt during subsequent embolization led to its targeted treatment. The case was also complicated by acute prostatitis that was treated medically. The patient's HA required careful administration of coagulation factor replacement therapy to control bleeding throughout the process. This case highlights the importance of reporting on the management of rare and complex pathologies to better understand and guide future treatments, especially involving this rare combination of renal AV shunts and hemophilia A.

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Significance: Despite 20 years of research and new treatment methods, diabetic foot ulcer (DFU) remains a common problem with frequent recurrences and complications. Recent Advances: There are reports that nerve decompression (ND) surgery has been observed to produce significantly fewer DFU recurrences than standard of care (SOC). The explanation of this apparent superiority has not been understood. Critical Issues: Microcirculation is understood to be involved in diabetic peripheral neuropathy (DPN) and DFU. There is an underappreciation of the participation in DPN of entrapment neuropathy (EN) due to nerve swelling and impingement in fibro-osseous tunnels. Reducing c-fiber compression in EN by ND generates recovery of subepidermal capillary flow. ND studies have found improved neuromuscular function and epidermal microcirculation phenomena, including chronic capillary ischemia (CCI) and pressure-induced vasodilatation (PIV). There is no current therapy recommended for impaired microcirculation. Clinical and animal evidence has demonstrated that release of locally compressed peripheral nerves improves the epidermal microcirculation which is under sympathetic control. Future Directions: Using epineurolysis to relieve nerve compressions is a physiology-based therapeutic intervention and provides the scientific foundation clarifying how ND reduces DFU recurrence risk. Incorporating ND with current SOC treatments could improve DFU recurrence risk, hard-to-heal ulcers, neuroischemic wounds, amputation risk, and the resulting costs to society. More studies using ND for DFU, especially evidence-based medicine Level I studies, are needed to confirm these preliminary outcomes.

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A 53-year-old woman was diagnosed with liver dysfunction in August 20XX. Computed tomography (CT) revealed multiple hepatic AV shunts, and she was placed under observation. In March 20XX + 3, she developed back pain, and CT performed during an emergency hospital visit showed evidence of intrahepatic bile duct dilatation. She was referred to our gastroenterology department in May 20XX + 3. We conducted investigations on suspicion of hereditary hemorrhagic telangiectasia (HHT) with hepatic AV shunting based on contrast-enhanced CT performed at another hospital. HHT is generally discovered due to epistaxis, but there are also cases where it is diagnosed during examination of liver damage.

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OBJECTIVE: Isolated spinal aneurysms (ISAs) are rare causes of subarachnoid hemorrhage (SAH), which encompass a highly heterogeneous group of clinical entities with multifarious pathogeneses, clinical characteristics, and treatment strategies. Therefore, knowledge about the ISAs remains inadequate. In this study, the authors present a comprehensive analysis of clinical data associated with ISAs at their institutions to enhance the understanding of this disease. METHODS: Patients with ISAs confirmed by spinal angiography or surgery at the authors' institutions between 2015 and 2022 were included. Data regarding clinical presentation, lesion location, aneurysm morphology, comorbidities, treatment results, and clinical outcomes were reviewed. RESULTS: Seven patients with ISAs were included in the study. Among them, 4 patients (57.1%) experienced severe headache, and 3 patients (42.9%) reported sudden-onset back pain. Additionally, lower-extremity weakness and urinary retention were observed in 2 of these patients (28.6%). Four of the aneurysms exhibited fusiform morphology, whereas the remaining were saccular. All saccular aneurysms in this series were attributed to hemodynamic factors. Conservative treatment was administered to 3 patients, 2 of whom underwent follow-up digital subtraction angiography, which showed spontaneous occlusion of both aneurysms. Four patients ultimately underwent invasive treatments, including 2 who underwent microsurgery and 2 who received endovascular embolization. One patient died of recurrent SAH, while the remaining 6 patients had a favorable prognosis at the latest follow-up assessment. CONCLUSIONS: The morphology of aneurysms may be associated with their etiology. Saccular ISAs are usually caused by pressure due to abnormally increased blood flow, whereas fusiform lesions may be more likely to be secondary to vessel wall damage. The authors found that a saccular spinal aneurysm in young patients with a significant dilated parent artery may be a vestige of spinal cord arteriovenous shunts. ISAs can be managed by surgical, endovascular, or conservative procedures, and the clinical outcome is generally favorable. However, the heterogeneous nature of the disease necessitates personalized treatment decision-making based on specific clinical features of each patient.

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PURPOSE: Bridging veins (BVs) serve as a route of pial venous reflux, and its anatomy is essential to understand the pathophysiology of dural arteriovenous shunts (dAVSs) around the craniocervical junction (CCJ) (from the jugular foramen level to the atlantal level). However, the anatomical variations of the BVs and their proximal connections remained poorly elucidated. This study aimed to radiologically investigate the anatomy of the bridging veins around CCJ and discuss the clinical significance of these BVs in the dAVS. METHODS: We investigated normal venous anatomy of the BVs from the jugular foramen level to the atlantal level using preoperative computed tomography digital subtraction venography in patients undergoing elective neurosurgery. BVs affected by the dAVSs in the same region were also evaluated. The three types of dAVS, craniocervical junction, anterior condylar, and proximal sigmoid sinus, were investigated. RESULTS: We identified six BV groups: superolateral, anterolateral, lateral, posterior, inferolateral, and inferoposterior. The superolateral and inferolateral groups, connected with the proximal sigmoid sinus and suboccipital cavernous sinus, respectively, were the largest groups. Each group has a specific downstream venous connection. The association with dVASs was observed only in the inferolateral group, which was typically the sole venous drainage in most dAVSs at the CCJ. CONCLUSION: We reported detailed anatomy of BVs from the jugular level to the atlantal level, which enhanced our understanding of the pathophysiology of dAVSs in the corresponding region.

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Pediatric pial arteriovenous shunts in the brain and spine are challenging to understand because of low incidence, variable presentation, and associations with genetic syndromes. What is known about their natural history comes from reviews of small series. To better understand the natural history and role for intervention, two cases are presented followed by a review of the literature. In the first case, an infant with a prior history of intracranial hemorrhage from a ruptured pial fistula returns for elective embolization for a second pial fistula which was found to be spontaneously thrombosed 2 weeks later. In the second case, a 5-year-old with a vertebro-vertebral fistula, identified on work up for a heart murmur and documented with diagnostic angiography, is brought for elective embolization 6 weeks later where spontaneous thrombosis is identified. In reviewing the literature on pediatric single-hole fistulae of the brain and spine, the authors offer some morphologic considerations for identifying which high-flow fistulae may undergo spontaneous thrombosis to decrease the potentially unnecessary risk associated with interventions in small children.

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BACKGROUND: This study reports the outcomes of a collaborative program between dialysis clinics and a referral hospital, which consisted of clinical monitoring and supplementary routine surveillance, for improving the quality of vascular access care. METHODS: This retrospective observational study was performed at five dialysis clinics as part of a 2-year collaborative program (2019-2020) in conjunction with a hospital-based dialysis access management center. A total of 392 hemodialysis patients (arteriovenous fistula [AVF], n = 339 and arteriovenous graft [AVG], n = 53) were included. Outcome measures included the prognosis of vascular access, clinic satisfaction, and referral rate to the hospital. RESULTS: Increased vascular access flow was observed and critical flow events decreased from the first to the second year (AVF: 18.3% vs. 12.7%, p < 0.001; AVG: 26.2% vs. 20.1%, p = 0.30). There were fewer percutaneous transluminal angioplasty events in the AVG group (0.77 per person-year vs. 0.51 per person-year, p = 0.005). New AVF or AVG creation events also remained low. All dialysis clinics were satisfied with the program. The overall referral rate from the participating clinics increased (65.7% vs. 72.0%) during the study period independently of the physical distance between the dialysis clinic and the hospital. CONCLUSION: The collaboration between dialysis clinics and a referral hospital for improving the quality of vascular access care was successful in this study, and the model can be used by other clinics and hospitals looking to improve care coordination in dialysis patients.

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BACKGROUND: Transcutaneous oxygen pressure (TcpO2) is a precise method for determining oxygen perfusion in wounded tissues. The device uses either electrochemical or optical sensors. AIM: To evaluate the usefulness of TcpO2 measurements on free flaps (FFs) in diabetic foot ulcers (DFUs). METHODS: TcpO2 was measured in 17 patients with DFUs who underwent anterolateral thigh (ALT)-FF surgery and compared with 30 patients with DFU without FF surgery. RESULTS: Significant differences were observed in the ankle-brachial index; duration of diabetes; and haemoglobin, creatinine, and C-reactive protein levels between the two groups. TcpO2 values were similar between two groups except on postoperative days 30 and 60 when the values in the ALT-FF group remained < 30 mmHg and did not increase > 50 mmHg. CONCLUSION: Even if the flap is clinically stable, sympathectomy due to adventitia stripping during anastomosis and arteriovenous shunt progression due to diabetic polyneuropathy could lead to low TcpO2 values in the ALT-FF owing to its thick fat tissues, which is supported by the slow recovery of the sympathetic tone following FF. Therefore, TcpO2 measurements in patients with DFU who underwent FF reconstruction may be less accurate than in those who did not.

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Arteriovenous malformation (AVM) is an anomaly of blood vessel formation. Numerous models have been established to understand the nature of AVM. These models have limitations in terms of the diameter of the vessels used and the impact on the circulatory system. Our goal was to establish an AVM model that does not cause prompt and significant hemodynamic and cardiac alterations but is feasible for follow-up of the AVM's progression. Sixteen female rats were randomly divided into sham-operated and AVM groups. In the AVM group, the saphenous vein and artery were interconnected using microsurgical techniques. The animals were followed up for 12 weeks. Anastomosis patency and the structural and hemodynamic changes of the heart were monitored. The hearts and vessels were histologically analyzed. During the follow-up period, shunts remained unobstructed. Systolic, diastolic, mean arterial pressure, and heart rate values slightly and non-significantly decreased in the AVM group. Echocardiogram results indicated minor systolic function impact, with slight and insignificant changes in aortic pressure and blood velocity, and minimal left ventricular wall enlargement. The small-caliber saphenous AVM model does not cause acute hemodynamic changes. Moderate but progressive alterations and venous dilatation confirmed AVM-like features. The model seems to be suitable for studying further the progression, enlargement, or destabilization of AVM.

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BACKGROUND: Intraorbital arteriovenous fistula (IOAVF) is a rare type of intracranial fistula that presents with ocular signs similar to those of cavernous sinus dural arteriovenous fistula. The treatment of IOAVF is based on the vascular architecture of each case due to its infrequent occurrence. The authors report the case of an IOAVF that was successfully treated with embolization via the facial vein, with good outcomes. OBSERVATIONS: A 78-year-old woman presented with left eyelid swelling, pulsatile ocular protrusion, and left ocular conjunctival hyperemia. Ophthalmological evaluation revealed elevated intraocular pressure; time-of-flight magnetic resonance angiography revealed a dilated left superior ophthalmic vein. Digital subtraction angiography showed an arteriovenous shunt in the left superior orbital fissure, which was treated using transvenous coil embolization. The patient experienced immediate improvement in left ocular protrusion and conjunctival hyperemia. Ophthalmological evaluation 1 month after treatment showed normal intraocular pressure in the left eye. No neurological symptoms were observed, and there was no recurrence of the arteriovenous shunt 3 months postoperatively. LESSONS: The authors report a rare case of IOAVF treated with embolization via the facial vein with a good outcome. A thorough understanding of the vascular architecture using three-dimensional images is useful for determining endovascular access and procedures.

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OBJECTIVE: Inflow arterial aneurysms are a rare but serious complication after long term arteriovenous fistulae (AVF), probably due to arterial wall remodelling after an increase in flow and shear stress, and kidney transplantation with immunosuppressive therapy. This study aimed to describe the outcomes of surgical treatment and long term follow up in a large cohort. METHODS: This prospective cohort study collected data from patients with a true inflow artery aneurysm after AVF creation that was surgically repaired between 2010 and 2022. Anastomotic and infected aneurysms or post-puncture pseudoaneurysms were excluded. Demographic data, access characteristics, symptoms, treatment strategies, and long term follow up were recorded; patency was estimated using Kaplan-Meier survival analysis. RESULTS: During the study period, 28 patients (64% men, mean age 60.1 years) were treated surgically for aneurysmal degeneration of the axillary or brachial (n = 23) or radial (n = 5) artery after an AVF (10 distal, 18 proximal) performed a mean of 18.3 ± SD 7.9 years previously. Most AVFs were ligated or thrombosed, while all patients except one had previously received kidney transplants. Most of the cases (n = 18) were symptomatic: 13 with pain or swelling, four with distal embolisation, and one rupture. They were repaired by aneurysm partial excision and graft interposition (11 great saphenous vein, six ipsilateral basilic vein, three cephalic vein, and two PTFE graft), ligation (n = 3), or direct end to end anastomosis (n = 3). No major complications occurred before discharge, after a mean hospital stay of 2.4 days. After a mean follow up of 4.8 ± 3.3 years, three cases presented complications: two recurrent proximal brachial aneurysms were repaired with an additional proximal interposition graft (one with further late infected pseudoaneurysm) and an asymptomatic post-traumatic graft thrombosis. Five year primary and secondary patency was 84% and 96%, respectively. CONCLUSION: Aneurysmal degeneration of the inflow artery is an unusual complication during long term follow up of AVFs. Aneurysm excision and, in general, autogenous graft interposition using the saphenous or ipsilateral arm vein is a safe and effective strategy.

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The evolution of ultrasound (US) techniques has greatly improved the evaluation of many parameters in dialysis vascular access, which is typically achieved through an arteriovenous fistula (AVF) or graft (AVG). These techniques include grayscale B-mode, color Doppler, power Doppler, spectral Doppler, non-Doppler US flow imaging techniques, contrast-enhanced US, and elastography. In conjunction with a patient's medical history and physical examination, US provides crucial information about the native vascular bed prior to the surgical creation of an arteriovenous anastomosis. It also tracks the maturation progress of the newly created AVF or AVG and aids in diagnosing potential complications of the vascular access. These complications include thrombosis, steal syndrome, aneurysms, pseudoaneurysms, hematomas, infection, ischemic neuropathy, exacerbation of preexisting congestive heart failure, and stenosis.

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Background: High-output heart failure (HF) is a form of HF where patients present with a high-output state with low systemic vascular resistance. This report presents the case of high-output HF in a patient with an arteriovenous shunt and no options for oral-administered drugs. Case summary: A 70-year-old male with a terminal jejunostomy fully depending on parenteral feeding through a vena saphena magna shunt presented with symptoms of shortness of breath. Echocardiography revealed eccentric hypertrophy with reduced left ventricular ejection fraction (LVEF) and atrial fibrillation with a heart rate of 70-100 b.p.m. Cardiac magnetic resonance imaging, endomyocardial biopsy, and cardiomyopathy lab revealed no cause of HF. High-output HF based on right heart catheterization due to the arteriovenous shunt or related to irregularity due to atrial fibrillation were potential causes. As a result of his malfunctioning gastrointestinal system, the pharmacological options were limited. He was treated with captopril sublingual, initially 6.25 mg three times daily (TID) and later 12.5 mg TID, which reduced blood pressure. Electrical cardioversion to sinus rhythm was successful but did not improve LVEF. Therefore, the patient was opted for surgically reducing the blood flow through the shunt, resulting in normalization of LVEF. Discussion: High-output HF is an uncommon form of HF with an uncertain prevalence. The most common aetiologies reported in the literature are obesity, cirrhosis, and arteriovenous shunts. Sublingual administration of captopril can be an effective treatment option for HF patients unable to absorb oral-administered drugs.

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Preoperative angiography in glioblastoma (GBM) often shows arteriovenous shunts and early venous filling (EVF). Here, we investigated the clinical implications of EVF in GBM as a prognostic and vascular mimicry biomarker. In this retrospective multicenter study, we consecutively enrolled patients who underwent angiography with a GBM diagnosis between 1 April 2013 and 31 March 2021. The primary and secondary endpoints were the differences in overall survival (OS) and progression-free survival (PFS), respectively, between cases with and without EVF. Of the 133 initially enrolled patients, 91 newly diagnosed with GBM underwent preoperative angiography and became the study population. The 6-year OS and PFS were significantly worse in the EVF than in the non-EVF group. Moreover, 20 GBM cases (10 with EVF and 10 without EVF) were randomly selected and evaluated for histological vascular mimicry. Except for two cases that were difficult to evaluate, the EVF group had a significantly higher frequency of vascular mimicry than the non-EVF group (0/8 vs. 5/10, p = 0.04). EVF on preoperative angiography is a robust prognostic biomarker for GBM and may help detect cases with a high frequency of histological vascular mimicry.