Journal of Vascular Surgery
Volume 47, Issue 3 , Pages 654-656, March 2008

Post-traumatic superior mesenteric arteriovenous fistula: Endovascular treatment with a covered stent

  • Chun-Gen Wu, MD, PhD
    • ,
  • Yong-Dong Li, MD, PhD

      Affiliations

    • Corresponding Author InformationReprint requests: Yong-Dong Li, The Sixth Affiliated People’s Hospital, Shanghai Jiao Tong University, No. 600, Yi Shan Rd, Shanghai 200233, China.
    • ,
  • Ming-Hua Li, MD, PhD

Department of Diagnostic and Interventional Radiology, The Sixth Affiliated People’s Hospital, Shanghai Jiao Tong University, Shanghai, China.

Received 16 July 2007; accepted 6 October 2007.

Article Outline

This case report concerns a patient who sustained multiple stab wounds causing rupture of the liver, duodenum, stomach, and pancreas. Two months after the initial injuries were repaired, the patient complained of persistent epigastric pain, vomiting, and nausea, with marked deterioration of his clinical condition. Computed tomography showed early enhancement and enlargement of the superior mesenteric vein, and selective angiography demonstrated a fistula between the superior mesenteric artery and vein. A covered stent was placed into the superior mesenteric artery, with complete closure of the fistula. The patient was discharged with complete resolution of the symptoms and full general physical recovery after stent placement.

 

Post-traumatic arteriovenous fistulas affecting the superior mesenteric artery and vein are extremely rare.1 Only 40 cases have been cited in the English literature during the last 60 years1 since the first case was reported by Nusselt2 in 1947. The development of superior mesenteric arteriovenous fistula is commonly associated with trauma and iatrogenic injury.3, 4 Fistula may develop a few days to years after trauma owing to presumed, unrecognized injury to the superior mesenteric artery at initial presentation or operation.1, 5

Although many patients with this type of fistula remain asymptomatic,6 most reported in the literature have a delayed presentation of weight loss, nausea, vomiting, abdominal pain, ascites, diarrhea, and signs of right heart failure such as pulmonary effusions, mesenteric ischemia, or bleeding.7, 8, 9, 10 The most consistent symptom is abdominal bruits that can be palpated in the periumbilical or epigastric region just left of the midline with systolic accentuation on auscultation.11 Early recognition and treatment can prevent the late sequelae of portal hypertension. Although duplex ultrasound (DUS) scanning and computed tomography (CT) with a contrast agent can reveal abnormalities, mesenteric angiography is mandatory for a complete preoperative evaluation to define the exact location and extent of mesenteric vessel involvement.11

Treatment of superior mesenteric arteriovenous fistula with surgical or interventional approaches has been described. Both options have produced favorable results and, currently, there is no preference for either option as a standard recommendation. A surgical approach is considered the most successful method to treat traumatic mesenteric arteriovenous fistulas but clearly poses a more immediate procedural risk.12

Percutaneous transcatheter embolization with steel coils has been successfully applied for closure of superior mesenteric arteriovenous fistula,7, 13, 14, 15 but difficulties may arise depending on the specific anatomic features of the fistula. For example, coil migration may occur with a larger fistula, and distal arterial embolization of the coil with occlusion of mesenteric arterial branches may block a critical vessel supplying blood to the intestine, resulting in bowel ischemia. Thus, although surgical treatments for post-traumatic superior mesenteric arteriovenous fistula have been successful, complications still exist and novel methods with better recovery are needed.

Here, we present a case of delayed development of a post-traumatic superior mesenteric arteriovenous fistula in a young man after multiple stab wounds to the abdomen. The fistula was successfully managed with a covered Wallgraft stent (Boston Scientific, Natick, Mass). To our knowledge to date, this is the first report of occlusion of a superior mesenteric arteriovenous fistula using a covered stent.

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Case report 

A 20-year-old man presented with vomiting, nausea, and severe epigastric pain and was admitted to our hospital. Two months earlier, he sustained multiple stab wounds to the abdomen, causing rupture of the liver, duodenum, stomach, and pancreas. After repair of these initial injures in a rural hospital, the patient was discharged 1 month later with stable hemodynamics and remained asymptomatic for 2 months before entering our hospital with epigastric pain. DUS and CT of the abdomen did not reveal an abnormality that explained the symptoms. The patient remained unwell during the next week, complaining of persistent epigastric pain, vomiting, and nausea, and was admitted to our general surgical department.

The patient was normotensive, had a normal pulse rate, and did not have jaundice. Abdominal examination demonstrated a distended abdomen with hepatomegaly, splenomegaly, and local tenderness 2 cm below the xiphoid process. Auscultation of the abdomen revealed a machinery-type bruit with systolic accentuation 5 cm above the umbilicus, and palpation uncovered a distinct vascular pulsation at the same place.

The patient’s clinical condition deteriorated markedly after admission, with patches of ecchymoses around the anterior thorax, coldness in the limbs, brown vomit (1000 mL/d), and bloody-like diarrhea (2000 mL/d). His hemoglobin level was <80 g/L, and he subsequently presented with lethargy and progressive jaundice of the skin and mucous membranes. Laboratory tests showed that levels of carbon dioxide-combining power were <10 mmol/L, blood urea nitrogen was >20mmol/L, and creatinine was >400 μmol/L. At this stage, repeat color Doppler US imaging revealed hepatomegaly, splenomegaly, and ascites, with significant portal hypertension. Repeat CT showed early enhancement and enlargement of the portal vein and superior mesenteric vein in the artery phase.

Eleven days after entering the hospital, the patient underwent selective angiography of the superior mesenteric artery, which revealed a fistula communication between the superior mesenteric artery and vein, 5 cm away from the orifice of the former. The portal and superior mesenteric veins were enlarged and showed increased blood flow velocity (Fig, A).

  • View full-size image.
  • Fig. 

    Angiograms of a 20-year-old man who presented with vomiting, nausea, and epigastric pain for about 1 month. A, Anteroposterior angiography of the superior mesenteric artery reveals a fistula (left arrowhead) between the superior mesenteric artery and the superior mesenteric vein with dilation of the portal (curved arrowhead) and superior mesenteric veins (right arrowhead). B, Repeat angiography of superior mesenteric artery (long arrow) immediately after stent placement confirms incomplete occlusion of the fistula (upper arrowhead) with correct placement of the stent. C, Anteroposterior angiography of the superior mesenteric artery 1 week after the stent was deployed (between two short arrows) shows complete closure of the fistula without occlusion of the main branches of superior mesenteric artery (long arrow).

Stent implantation was chosen as the treatment paradigm, and informed consent was obtained from the patient and his family before the procedure. Three days later, a covered Wallgraft stent, 8 mm in diameter and 50 mm long, was placed into the superior mesenteric artery using the brachial approach (Fig, B). Immediately after the procedure, repeat selective angiography of the superior mesenteric artery revealed incomplete occlusion of the fistula with correct placement of the stent.

One week after stent deployment, follow-up angiography of the superior mesenteric artery confirmed complete closure of the fistula without occlusion of its main branches (Fig, C). The patient was discharged 1 week after stent placement with complete resolution of symptoms related to the post-traumatic superior mesenteric arteriovenous fistula and full recovery of his general physical health. The patient was instructed to take aspirin (300 mg/d) and ticlopidine (250 mg/d) orally for 6 months after the procedure. At the 6-month follow-up, the patient remained healthy, with no evident symptoms.

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Discussion 

To date, this is the first report to our knowledge to describe treatment of a post-traumatic superior mesenteric arteriovenous fistula with a covered stent. From the available treatment options for this patient, open surgery was chosen as the optimal strategy but was delayed with efforts to precisely locate the fistula with CT and DUS; however, attempts with these methods failed. The exact location of the fistula was finally found by angiography of the superior mesenteric artery; however, by this time the patient’s general physical had quickly deteriorated. After a multidisciplinary discussion, the plan for open surgery was aborted to avoid greater risks to the patient and stent implantation was chosen as the best option for saving the patient.

To ensure success of the stent implantation, several factors were considered. A 50-mm stent used, although a shorter stent graft, such as 3 cm would have been better, but owing to time constraints, this length was unobtainable. Precise care was taken during the procedure to avoid occlusion of the main branches of the superior mesenteric artery to prevent the occurrence of bowel ischemia. As for the long-term patency of the stent, the patient will receive follow-up examinations regularly at 6- or 12-month intervals with DUS or CT to estimate the possible latent complications.

The covered stent used in case was precisely positioned and deployed, and the patency of the main branches of the superior mesenteric artery was preserved. The patient was discharged 1 week after the procedure with complete resolution of symptoms, no complications, and with full recovery of his general physical health. No symptoms were evident at the first 6-month follow-up examination. The full recovery and termination of symptoms demonstrated that the stent placement was successful and preserved the main branches of the superior mesenteric artery despite the longer stent graft. Thus, covered stent implantation can be considered a viable and effective treatment for post-traumatic superior mesenteric arteriovenous fistula for these patients.

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We are grateful to Shu-Xin Li, MD, from the Department of Radiology, The First Affiliated Hospital, Zhengzhou University, for his kindness to revise and edit the English language in our article.

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References 

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 Competition of interest: none.

PII: S0741-5214(07)01603-5

doi:10.1016/j.jvs.2007.10.013

Journal of Vascular Surgery
Volume 47, Issue 3 , Pages 654-656, March 2008

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