0:01

So let's look at the scenario of this woman

0:02

who presents with bilateral ICI aneurysms.

0:06

And she's presenting for an

0:07

elective pipeline embolization.

0:10

What we see here is a beautiful procedure

0:12

that's performed to help this woman.

0:14

Now focused on the exit,

0:18

landing the plane, as I call it.

0:20

So the right common femoral artery, as I

0:22

mentioned in this particular case and in others,

0:24

was cannulated using the Seldinger technique and

0:27

a French sheath was in place in this setting.

0:29

But then the completion diagnostic

0:31

arteriogram was performed in preparation

0:33

for perhaps a closure device.

0:34

So tell me what you see here, and we can proceed.

0:41

Well, huh, I think that deserves

0:44

looking at one more time.

0:49

So what we see is injection and

0:51

then ultimate flow from the artery

0:54

that is moving antegrade to the vein

1:00

that, of course, is moving retrograde.

1:03

So what we see there is a communication

1:05

between the artery and the vein

1:08

which is anomalous and consistent with

1:11

a what?

1:11

An arteriovenous fistula.

1:13

This likely occurred, essentially, on access.

1:17

No buenum.

1:18

So if you wanted to confirm this

1:19

diagnosis, what would you do?

1:21

Maybe you would consider an ultrasound with Doppler.

1:23

But I would probably say

1:25

confirmation has been achieved.

1:27

The artery demonstrates high-frequency and

1:29

low-resistance flow, while the vein shows

1:31

high-velocity and arterialized waveform

1:33

patterns on ultrasound with Doppler.

1:36

So keep that in mind.

1:38

So how would you manage such an AVF complication?

1:42

Well, an acute AVF can actually be treated with

1:45

ultrasound-guided compression pretty effectively.

1:48

If that doesn't work, coil embolization

1:51

is a particularly effective option

1:53

for complicated AVFs with easily

1:55

accessible feeding and draining vessels.

1:57

Another option is, of course,

1:59

exclusion with a stent graft.

2:02

So in this particular setting,

2:03

what did the operator opt to do?

2:04

35 minutes of compression was

2:06

applied using an ultrasound.

2:07

No further complications were noted.

2:10

And of course, the operators in the room

2:11

recommended that the patient follow up

2:13

with ultrasound, which on review ended up

2:15

demonstrating that the AV fistula had resolved.

2:19

So how do we conclude and

2:21

summarize what we've discussed?

2:23

Well, first and foremost, arteriovenous

2:24

fistulas are anomalous connections between

2:26

the arterial and venous systems.

2:29

These AVFs present as high-frequency,

2:31

low-resistance flow, with continuous

2:33

flow and elevated diastolic velocities

2:36

through the pulse cycle on ultrasound.

2:38

When we have these risk factors associated with

2:41

the AVFs, what we want to be thinking about

2:43

is we want to think about these things that

2:44

increase the propensity for their formation.

2:47

Multiple puncture attempts, high blood pressure,

2:49

anticoagulation, increased or advanced age,

2:52

and double wall punctures, posterior arterial

2:54

wall penetration, et cetera, et cetera.

2:57

And when we think about management, we

2:58

want to think about the range, which can

3:00

include observation, because some of

3:02

them resolve, to surgical intervention.