Case 2 HingKiu Chan, MS4 1. Initials and Age Short clinical history

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Presentation transcript:

Case 2 HingKiu Chan, MS4 1. Initials and Age Short clinical history Radiographic images (maximum 5) 4. Hospital Course: outcome, surgery, path, etc. (short paragraph) 5. Diagnosis 6. Radiographic features and differential diagnosis for findings 7. One or 2 pertinent references 8. Medical Student Name 9. Your case will be presented to your colleagues on the last Friday of the rotation.

HPI DB is a 63 y.o. man with history of GSW in 1990 to LLE s/p multiple surgical repairs and skin grafts who presents to the ED with bleeding from skin wound. He presented to the ED previously with similar complaint. Wound with active stream projecting out of wound at the anterior tibial surface and woke up with a trash bag wrapped around his LLE that was filled with blood.

CT Angiogram Chronic fracture of left tibia and fibula

Bright aorta IVC

Aorta splitting into common iliac

IVC splitting into common iliac vein

Hypertropy of left common iliac artery

Left common iliac into internal and external iliac

Contrast in the left external iliac vein compare to the right Again external iliac artery is hypertrophic

Same

Contrast in the left femoral vein

Profunda coming off

Contrast in the left superficial femoral vein Again SFA is hypertrophic

Contrast in left Popliteal vein Popliteal artery is hypertropic

Anterior tibial artery coming off (enlarged compare to right) About 9mm in diameter Deep venous varices

Pseudoanerysm 2mm distal to the origin of AT

Distal to the pseudoanerysm

Outcome Underwent a lower extremity angiogram confirming the fistula Large AV fistula with associated pseudoanerysm arising from just beyond the origin of the anterior tibial artery and draining int o the anterior tibial vein

Embolization Successful treatment of an anterior tibial artery to anterior tibial vein traumatic AV fistula with associated pseudoanerysm using overlapping covered stents extending from the tibioperoneal trunk to the popliteal artery as well as plug and coil embolization of the anterior tibial artery and the associated traumatic fistula. Resolution of the AV fistula at the conclusion of this procedure with preserved 2 vessel runoff Recovering well after procedure

Diagnosis DDx AVF secondary to traumatic and previous surgeries Cirrhosis imaging can cause hypertrophic vein in some region

Radiographic Features Early contrast filling of the vein Hypertrophied vein and artery Deep venous varices AVF appears as a blush with rapid opacification of the adjacent deep vein If AVF is suspect in the beginning, duplex US is the diagnostic test of choice -> mosaic color pattern Other modality include MRA

References American Journal of Roentgenology. 2009;193: 1425-1433. 10.2214/AJR.09.2631 Read More: http://www.ajronline.org/doi/ref/10.2214/AJR.09.2631