血管内治療が有効であった小児医原性椎骨動静脈瘻の1例

Pediatric Iatrogenic Vertebral Arteriovenous Fistula Successfully Treated with Endovascular Treatment:A Case Report

Ⅰ．はじめに

　医原性椎骨動脈損傷は，頚静脈への中心静脈カテーテル挿入時の誤穿刺時に発生し，0.5〜11.4%の合併症率と報告されている⁹⁾．椎骨動脈損傷により椎骨動静脈瘻や仮性動脈瘤，血管解離・閉塞による脳梗塞などの多彩な症状を呈するが，正確な頻度は不明である^5,9,10)．また，頭蓋外椎骨動静脈瘻は椎骨動脈とその周囲の静脈や静脈叢との間に生じる動静脈瘻で，原因として特発性，外傷性，動脈硬化，血管炎，放射線障害などがあり^6,13)，約60%が外傷を含む医原性と言われる^9,11)．椎骨動静脈瘻の治療には外科治療と血管内治療があり，近年は血管内治療の報告が多く認められるが，治療適応や選択について一定の見解はない．今回われわれは，血管内治療で良好な経過を示し，塞栓術時のコイルにはhydrogel coilが有効であった小児医原性椎骨動静脈瘻の1例を経験したので報告する．

　OBJECT:We report a relatively rare case of pediatric iatrogenic extradural vertebral arteriovenous fistula.

　CASE:A five-year-old boy with a history of multiple surgeries for Total Anomalous Pulmonary Venous Return（TAPVR）exhibited vascular engorgement of his right neck from about 4 years old. We thought that this was caused by his past operations. He demonstrated swollen blood vessels in the right neck and pulmonary hypertension with increased right heart load. A right extradural vertebral arteriovenous fistula was seen on angiography. A high flow shunt was present at the V1 segment, at the level of the sixth cervical vertebra, and a 12 mm venous pouch was present anterior to the vertebral artery. We recognized the outlet passages of the cranial tract were the vertebral venous plexus, internal jugular vein, and right atrium. We performed endovascular transarterial embolization using a hydrogel coil. As a result, we treated with a high volume embolization ratio. Following treatment, the arteriovenous fistula disappeared while anterograde blood flow of the vertebral artery was preserved. The patient demonstrated no neurological deficits, improved right heart load, and his venous pouch of the neck. He has had no recurrence in the two years after treatment.

　CONCLUSION:Endovascular surgery is effective and safe for the treatment of iatrogenic vertebral arteriovenous fistula.