Resection of a large arteriovenous fistula of the brain using low-flow deep hypothermic cardiopulmonary bypass: Technical case report

OBJECTIVE AND IMPORTANCE: We present the second report in the literature on the use of low-flow hypothermic cardiopulmonary bypass to aide in the surg ical resection of a large intraparenchymal arteriovenous fistula. CLINICAL PRESENTATION: The patient was a 46-year-old man who was found to h ave a left sylvian arteriovenous fistula with a giant varix during a workup for chronic left frontal headaches and was referred to our center for mana gement. A cardiac workup revealed a cardiac output of 9 L per minute. INTERVENTION: Endovascular embolization of the lesion was initially attempt ed without success because of the high flow within the lesion and the large diameter of the feeding arteries. We then planned combined and staged endo vascular and surgical approaches to gradually eliminate the fistula. Endova scular embolization, both transarterial and transvenous, could not be perfo rmed because of the high flow in the fistula. Despite the stepwise reductio n of flow during the course of several weeks via surgical exposures and art erial ligations, the fistula remained difficult to remove because of its si ze and the turgor of the varix. Once hypothermic low-flow circulatory bypas s was used, however, decompression of the sac allowed access to the afferen t vasculature. CONCLUSION: The use of low-flow hypothermic circulatory bypass can facilita te the surgical extirpation of certain large intraparenchymal arteriovenous fistulas.