Society For Clinical Vascular Surgery

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Repair of Large Venous Aneurysm Under Deep Hypothermic Circulatory Arrest
Mark Archie, MD, William Quinones, MD.
UCLA, Los Angeles, CA, USA.

Repair of a Large Iliac Venous Aneurysm Secondary to A High-Flow Arteriovenous Malformation Under Deep Hypothermic Circulatory Arrest
Objective: High-flow arteriovenous malformations (AVMís) pose a challenge for vascular surgeons. While endovascular techniques have been developed, there remain the challenges of aneurysm formation, distal embolization, and skin necrosis. We describe a case of a high-flow pelvic AVM, which following multiple interventions eventually developed an 11 cm pulsatile iliac venous aneurysm causing ureteral compression and moderate pain.
Methods: A 20-year-old male who initially presented with heart failure due to a high-flow arteriovenous malformation of the left iliac system. He had multiple embolization attempts, which resulted in a large sacral wound. Given worsening of his heart failure, endografts wereplaced form the left distal external vein into the inferior vena cava (IVC). This resolved the heart failure. Over the subsequent 6 years, he developed an 11 cm left iliac pulsatile venous aneurysm (Fig 1). Given chronic abdominal pain and the risk of rupture, the patient opted for an open repair. A left retroperitoneal incision was used for exposure. The aneurysm was exposed while he was placed on DHCA to 18 degrees Celsius. The aneurysm was plicated over the endograft and multiple arterial and venous feeders were over-sewn. The total DHCA time was 24 minutes.
Results:The patient had an isoelectric EEG upon rewarming, but regained consciousness with no neurologic deficit. His abdominal pain resolved.
Conclusion: High-flow AVMís with aneurysmal degeneration may be treated with open repair in select patients with no interventional alternatives using DHCA to minimize blood loss.
Fig 1. MRV and operative view of venous aneurysm.

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