Traumatic arteriovenous fistula 52 years after injury
Article Outline
Untreated traumatic arteriovenous fistulae (AVF) have been associated with aneurysmal dilatation of the involved artery and vein, congestive heart failure, and limb ischemia. Open surgical repair of these lesions can be challenging due to the elevated venous pressure and surrounding inflammation. This case report describes a hybrid open and endovascular approach to treatment of a traumatic AVF in the right groin, presenting with aneurysmal ileo-femoral arteries and veins and pulmonary hypertension. It provides a rare look at the natural history of a traumatic AVF over 50 years following the initial injury.
Arterial trauma may lead to the development of an acquired arteriovenous fistula (AVF). There is significant variability in clinical presentation and subsequent potential clinical consequences of AVF based on the nature of the arterial trauma, the anatomic location, and duration of the arteriovenous communication. In a reported a series of 202 traumatic AVF, Robbs et al noted that only 1% of AVF were due to blunt trauma, while penetrating trauma, stab wounds, and gunshot wounds accounted for the vast majority of these lesions (63% and 26%, respectively).1 Significant lower extremity AVF that are not treated or do not resolve spontaneously may present months to years later with venous hypertension marked by limb edema, stasis dermatitis, and venous ulceration.2, 3, 4 Claudication and symptoms of congestive heart failure may also ensue. The present case represents an unusual clinical presentation of a large chronic right groin AVF 50 years after a gunshot wound and demonstrates the successful use of adjunct endovascular technology to repair this complex long-standing traumatic AVF.
Case report
A 72-year-old male fell and sustained a “saddle” injury that resulted in a pelvic fracture and urethral transection. A computed tomographic (CT) scan performed at the time of admission revealed marked dilatation of both the right iliac and femoral arteries and veins. The right external iliac artery measured 2.2 cm in diameter and the adjacent external iliac vein was 3.4 cm in diameter (Fig 1). The common iliac vein and inferior vena cava were also dilated and filled early with contrast. There were no associated pelvic collaterals or varicosities. Further diagnostic evaluation, including duplex ultrasound scan, revealed a large AVF between the right profunda femoris artery and vein. Upon further questioning, the patient reported that he had sustained an accidental gunshot wound to the right upper thigh approximately 50 years earlier. At the time, the diagnosis of AVF was known, but was not treated.
Fig 1.
Computed tomography angiogram demonstrating equal contrast opacification in both the dilated external iliac artery (short arrow) and dilated external iliac vein (long arrow) in a patient with a right groin AVF.
The patient would require intervention for his urethral injury, and it was felt that the pelvic venous hypertension produced by the AVF would create a significant risk for bleeding and thus compromise the urethral repair. Additionally, while the patient had no history of frank congestive heart failure or shortness of breath, he had recently been diagnosed with pulmonary hypertension with pulmonary artery pressures at 55 mm Hg to 60 mm Hg estimated from the tricuspid jet on echocardiogram. The plan was to repair the AVF before the urethral repair. Arteriography demonstrated an arteriovenous communication at the mid-deep femoral artery, which briskly filled the venous system, confirming the CT findings (Fig 2). Sharp angulation at the aortic bifurcation and significant tortuosity of the external iliac system precluded advancement of an appropriately sized sheath into the AVF from a contralateral groin approach.
Fig 2.
Angiography performed via a left groin puncture demonstrating the dilated right ileo-femoral arteries (short arrow) and arterio-venous communication at the level of the deep femoral artery (long arrow).
Direct surgical exposure of the right common femoral artery was performed with antegrade placement of a 7-F sheath. A direct approach was chosen in order to minimize any bleeding risk associated with a percutaneous approach, as emergent repair in this setting could have been hazardous. The origin of the AVF was found in the distal deep femoral artery, and a 22-mm-diameter Amplatzer II plug (AGA Medical Corporation, Plymouth, Md) was advanced and deployed without difficulty under fluoroscopic guidance. Follow-up imaging demonstrated complete obliteration of the distal deep femoral artery; however, collaterals off the proximal profunda provided filling of its distal branches that ultimately produced retrograde flow to the AVF. In order to address this, the right common femoral vein was also exposed and cannulated with a 7-F sheath. Through the right common femoral vein, a 16-mm-diameter Amplatzer II plug was deployed beyond the AVF in the distal right deep femoral artery, and an 18-mm-diameter Amplatzer II plug was deployed within the AVF.
Completion arteriography demonstrated successful occlusion of the AVF with maintained patency of the proximal deep femoral artery and the superficial femoral artery (Fig 3). Repeat duplex scan on postoperative day one demonstrated no evidence of AVF with normal ankle-brachial indices bilaterally. The patient was discharged home on postoperative day two. The patient went on to have uncomplicated urethral repair. At seven-month follow-up, CT angiography demonstrated an excluded AVF without flow. The iliac venous system had returned to normal diameter. The previously seen dilatation of the external iliac artery was unchanged (Fig 4).
Fig 3.
A, Mid-procedure angiography demonstrating proximal deep femoral arterial branches (arrow) filling the AVF and adjacent vein via collateral branches. B, Completion angiography following embolization of the AVF with maintained flow via the deep femoral artery branches and absence of flow in the adjacent veins.
Fig 4.
Follow-up computed tomography angiogram demonstrating lack of contrast in, and normalization in diameter of, right external iliac vein (long arrow). Note persistent dilation of the right external iliac artery (short arrow) in comparison to normal contralateral external iliac artery (arrowhead).
Discussion
With the widespread use of catheter-based diagnostic and therapeutic technologies, most secondary AVF diagnosed today are due to iatrogenic trauma. These AVF are generally benign with a fairly standardized management algorithm.2 However, the clinical course for AVF due to violent trauma is less predictable, with a wide variation in management practices. It should be noted that this condition should not be confused with primary or congenital AVF, which would be treated in a different fashion. In a retrospective review, Melliere et al reported that the mean time from the inciting trauma to the eventual diagnosis and treatment of AVF was 20 years and 7 months (range, 7-43 years). These authors also observed that the clinical course appeared to be related to the relative flow state of the AVF. They noted that low-flow AVF were usually uncomplicated and might occasionally close spontaneously, while high-flow AVF were associated with early cardiac complications that usually necessitated surgical correction before the onset of arterial dilatation. However, medium-flow AVF were associated with proximal arterial dilatation generally discovered later with or without concomitant cardiac complication.5 Our patient would appear to represent this latter group, 50 years after his gunshot wound and consequent AVF, with aneurysmal dilatation of the feeding iliac and femoral arteries. The patient had no florid congestive heart failure, but his pulmonary hypertension may have been a reflection of evolving cardiac overload.
Aneurysmal dilatation of the artery proximal to a chronic AVF after arterial injury has been well documented.5, 6, 7, 8 In at least one case, arteriomegaly continued to progress despite successful occlusion of the AVF.8 There are several proposed mechanisms for arterial dilatation proximal to significant AVF, including the effect of increased shear force on the endothelium secondary to the increased flow. However, this would not explain why aneurysmal dilatation would continue to progress even after occlusion of the AVF.5, 6, 8, 9 In any event, the data would support early repair of noniatrogenic traumatic AVF.
Direct surgical repair of long-standing traumatic AVF can be challenging due to the obvious venous hypertension and the surrounding scar tissue. The development of endovascular technology may offer potential alternative options for occlusion of these AVF.10 We chose to use Amplatzer plugs instead of coils in order to reduce the risk of coil migration/pulmonary embolization due to the relatively large vessel diameter and high flow state. Others have utilized Amplazter plugs for AVF due to the same concerns.11 In our case, patient anatomy compromised endovascular repair alone, so a combination of open and endovascular treatment was employed. While the AVF has been resolved in this patient, further follow-up will be necessary to determine whether there will be progression or resolution of his iliac and femoral arterial dilatation.
Author contributions
References
- . Traumatic arteriovenous fistula: experience with 202 patients. Br J Surg. 1994;81:1296–1299
- . Traumatic arteriovenous fistulas. In: Rutherford R editors. Vascular surgery. 6th ed.. Philadelphia: Elsevier Saunders; 2005;p. 1619–1625
- . Intermittent claudication secondary to a traumatic arteriovenous fistula. Vasa. 2007;36:285–287
- High-output heart failure resulting from an obscure traumatic arteriovenous fistula. J Chin Med Assoc. 2008;71:428–430
- . Proximal arterial dilatation developing after surgical closure of long-standing posttraumatic arteriovenous fistula. Ann Vasc Surg. 1997;11:391–396
- . Aneurysmatic dilatation of popliteal and femoral artery due to long-standing traumatic arteriovenous fistula. Vasa. 1990;19:79–81
- . Late arterial aneurysm proximal to corrected post-traumatic arteriovenous fistula. J Cardiovasc Surg (Torino). 1987;28:510–515
- . Extensive arterial aneurysm developing after surgical closure of long-standing post-traumatic popliteal arteriovenous fistula. J Vasc Surg. 2004;39:889–892
- . The arteriovenous fistula. J Am Soc Nephrol. 2003;14:1669–1680
- . Endovascular repair of a traumatic arteriovenous fistula 34 years after the injury: report of a case. Surg Today. 2007;37:78–81
- . Use of an amplatzer vascular plug for transcatheter embolization of a renal arteriovenous fistula. Vascular. 2009;17:40–43
competition of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.
PII: S0741-5214(09)02453-7
doi:10.1016/j.jvs.2009.11.080
© 2010 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
