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eComment: It could be an iatrogenic arteriovenous fistula

Hospital Clínico San Carlos, C/Profesor Martín Lagos s/n, 28023 Madrid, Spain

Post-sternotomy intercostal artery pseudoaneurysm. Sonographic diagnosis and thrombosis by ultrasound-guided percutaneous thrombin injection

In this article, Fernandez Alonso et al. describe a very interesting case of post-sternotomy pseudoaneurysm formation and an easy diagnosis and treatment using ultrasound-guided percutaneous thrombin injection [1]. However, some questions must be addressed:

The authors did not use CT-scan or arteriography diagnosis, however an iatrogenic mammary or intercostal arteriovenous fistula must have been ruled out. Two possible causes of poststernotomy fistulas [2–5] have been suggested. One cause is trauma produced by the sternal wire, which generates a fistulous communication between the artery and the vein and a hematoma, which causes the pseudoaneurysm. In some cases the hematoma could extend subcutaneously along the passage of the sternal wire. The other cause postulated is trauma in the region caused by retraction or electrocautery during operation. At what level of the second intercostal space did the pseudoaneurysm appear? Was it subcutaneous or intrathoracic?

There is a risk of fistula recurrency if there is only pseudoaneurysm occlussion or anterograde artery embolization due to retrograde flow via epigastric artery. In such cases, as we reported some years ago, we recommend embolization of the anterograde and retrograde pedicles [5].

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1. Fernandez Alonso S, Mendieta Azcona C, Fernandez Heredero A, Riera de Cubas L. Post-sternotomy intercostal artery pseudoaneurysm. Sonographic diagnosis and thrombosis by ultrasound-guided percutaneous thrombin injection. Interact CardioVasc Thorac Surg 2009;9:722–724.[Abstract/Free Full Text]
2. Hassan A, Campbell DR, Bethune DC, Ali IS. Fistulae of the internal thoracic vessels: report of two cases. Eur J Cardiothorac Surg 2002;21:358–360.[Abstract/Free Full Text]
3. Longmaid HE 3rd, Jay M, Phillips D. Angiographic evaluation of poststernotomy arteriovenous fistula of the internal mammary artery and vein. Cardiovasc Intervent Radiol 1980;3:150–152.[CrossRef][Medline]
4. Deuvaert FE, Dumont N, Van Nooten G, De Paepe J, Primo G. Poststernotomy arteriovenous fistula of internal mammary origin with pseudoaneurysmal subcutaneous extension. J Cardiovasc Surg (Torino) 1987;28:343–344.[Medline]
5. Silva J, Gonzalez-Santos J, Pérez M, Ruiz M, Vallejo JL. Iatrogenic mammary arteriovenous fistula caused by sternal wire. Ann Thorac Surg 1998;66:1398–1399.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Google Scholar Articles by Silva, J. PubMed PubMed Citation Articles by Silva, J. Related Collections Related Article