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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 19-21

Surgical treatment of traumatic arteriovenous fistula after failed endovascular treatment


1 Department of Vascular Surgery, Affiliated Hospital of Jining Medical University, Jining 272029, China
2 Department of Ultrasound, Affiliated Hospital of Jining Medical University, Jining 272029, China

Date of Submission05-Jan-2021
Date of Decision09-Feb-2021
Date of Acceptance10-Feb-2021
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Song Jin
Department of Vascular Surgery, Affiliated Hospital of Jining Medical University, No. 89, Guhuai Road, Jining 272029
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT-D-21-00002

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  Abstract 


Endovascular interventional therapy is the first choice for the treatment of the traumatic arteriovenous fistula (AVF) because of its small trauma, fast recovery, exact effect, and low incidence of complications. However, surgery is still an important option for patients with contraindications to endovascular treatment or failure of endovascular treatment. We present the case of a 64-year-old male who was carried out with traumatic AVF and given endovascular treatment in other hospital 10 years ago. However, AVF did not disappear after surgery, and symptoms of venous hypertension such as lower limb swelling and ulcers appeared. We removed the stent and repaired the AVF with opening surgery. AVF did not recur after 1-year follow-up.

Keywords: Covered stent, endovascular treatment, surgery, traumatic arteriovenous fistula


How to cite this article:
Cai H, Li K, Sun Z, Jin S. Surgical treatment of traumatic arteriovenous fistula after failed endovascular treatment. Vasc Invest Ther 2021;4:19-21

How to cite this URL:
Cai H, Li K, Sun Z, Jin S. Surgical treatment of traumatic arteriovenous fistula after failed endovascular treatment. Vasc Invest Ther [serial online] 2021 [cited 2021 Apr 11];4:19-21. Available from: https://www.vitonline.org/text.asp?2021/4/1/19/309886




  Introduction Top


Traumatic arteriovenous fistula (AVF) refers to the abnormal arteriovenous communication that occurs after trauma in the sites adjacent to the artery and vein. Endovascular interventional therapy is the first choice for the treatment of AVF after trauma owing to its small trauma, fast recovery, exact effect, and low incidence of complications.[1] However, surgery remains an important option for patients with contraindications to endovascular treatment or failure of endovascular treatment.


  Case Report Top


A 64-year-old male was admitted to the hospital with the chief complaint of swelling of the right lower limb for 10 years and exacerbated by skin darkening with skin ulcerations during the last 3 years. The patient had a history of a stab wound in the right thigh which was debrided and sutured 30 years ago. He developed swelling of the right lower limb 10 years ago, which became evident after the activity, and relieved after rest. Examinations in other hospital revealed an AVF of the right lower extremity, and a covered stent was placed to isolate it. He stated that there was still swelling in the right lower limbs after the stent placement. The patient developed darkening of the skin in the distal right leg and right ankle progressing to areas of ulceration 3 years ago.

On physical examination, there was swelling diffusely in the right lower extremity and particularly in the right leg with an increased circumference and diameter compared to the left leg, and additionally enlarged varicose veins were present. Skin ulcers on the medial malleolus of the right leg had healed, and the surrounding skin was pigmented [Figure 1]. The skin temperature of the right lower extremity was increased. No palpable thrill was present in the right thigh, but at auscultation an audible bruit was present. At the right foot, the right Dorsalis Pedis artery and right Posterior Tibial artery were palpable 4/5.
Figure 1: Ulcer and pigmentation of the right lower limb before surgery

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Computed tomography angiogram (CTA) demonstrated a stent was placed in the right superficial femoral artery (SFA), but there was still an AVF from the right SFA to the superficial femoral vein. Compared to the left lower extremity, the vessels at the proximal end of the fistula were significantly dilated [Figure 2]. Cardiac ultrasound showed dilated left ventricle and main pulmonary artery. The left ventricular ejection fraction was 62%.
Figure 2: Computed tomography angiography demonstrating the stent and arteriovenous fistula at the level of the right superficial femoral artery (a, b and c). The stent didn't equal the diameter of the dilated Superficial Femoral artery (red arrow) in (b)

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The patient underwent open surgery under general anesthesia. After control of the vessels, we first removed the stent in the SFA [Figure 3], and then removed the AVF. Because the expansion was evident, the vessels were directly sutured. Postoperative CTA showed AVF disappeared and arteries of the right lower extremity were unobstructed [Figure 4]. The patient postoperativeley was placed on 100 mg of Aspirin daily and compression stockings. Swelling and pigmentation of the right lower limb were dramatically relieved after 3 months of follow-up [Figure 5]. Ultrasound at 1 year showed no recurrence of the AVF, but deep venous insufficiency of the right lower limb still existed.
Figure 3: Stent removed during the operation

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Figure 4: Computed tomography angiography demonstrating disapperance of the arteriovenous fistula after surgery (a, b and c)

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Figure 5: Healed ulcers and reduced pigmentation after 3 months

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  Discussion Top


Common causes of traumatic AVF include puncture wounds, gunshot wounds, fractures, and severe blunt trauma.[1] The mechanism of most injuries is penetrative. It has been reported that stab wounds (62%) are more frequent than gunshot wounds (26%).[2] 29% and 16% of all traumatic AVFs happened in the femoral and iliac arteries, respectively.[3] The traumatic AVF was caused by a stab wound in the right lower extremity in our report. Traumatic AVF usually does not show noticeable manifestations of vascular damage at an early stage, so it is often delayed in diagnosis. A retrospective study showed that 33% of patients with traumatic AVF had delayed diagnosis.[2] Delayed diagnosis after injury could be up to 52 years.[4] The diagnosis of AVF is mainly based on medical history, physical examination, and color Doppler ultrasound. Typical early symptoms include increased skin temperature, palpable thrill, and persistent bruit on auscultation. Late symptoms contain arterial and venous dilatation, distal ischemia, venous congestion, and congestive heart failure.[5],[6] In this case, arterial and venous dilatation and venous congestion of the right lower limb were found. Although there was the absence of manifestation of heart failure, the color Doppler ultrasound showed that the left ventricle and the main pulmonary artery were all dilated. Angiography is the most accurate method of diagnosis. It can identify the location of the fistula, understand the status of surrounding blood vessels and provide a reliable assessment basis for the selection of surgical options.[2] Due to the invasive nature of angiography and CTA can achieve the same diagnostic purpose, CTA is currently more and more widely used.

The treatment of AVF includes endovascular treatment and open surgery. Endovascular treatment includes covered stent graft and coil embolization. Due to its minimal trauma, fast recovery, exact effect and low incidence of complications, endovascular treatment is the first choice for surgeons to treat AVF.[7],[8] However, surgery remains an important option for patients with contraindications to endovascular treatment or failure of endovascular treatment.[9] The reason for the failure of the patient in the initial endovascular treatment may be that the selected stent did not match the diameter of the artery and the fistula was not adequately covered, which was demonstrated to be the case in [Figure 2]b. We first removed the stent in the SFA and then removed the AVF. Because the expansion was evident, the vessels were directly sutured.

We should pay attention to the presence of traumatic AVF when dealing with trauma patients with vascular disease. Endovascular treatment can be the primary choice for AVF, but open surgery is equally important. We need to choose a reasonable treatment based on the overall status of the patient, the exact situation of AVF, the skills of the doctor and the conditions of the hospital.

Declaration of patient consent

The authors certify that they have obtained the patient consent form. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

PhD Research Foundation of Affiliated Hospital of Jining Medical University (Project ID: 2020-BS-012).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Şahin M, Yücel C, Kanber EM, İlal Mert FT, Bıçakhan B. Management of traumatic arteriovenous fistulas: A tertiary academic center experience. Ulus Travma Acil Cerrahi Derg 2018;24:234-8.  Back to cited text no. 1
    
2.
Robbs JV, Carrim AA, Kadwa AM, Mars M. Traumatic arteriovenous fistula: Experience with 202 patients. Br J Surg 1994;81:1296-9.  Back to cited text no. 2
    
3.
Rich NM, Hobson RW 2nd, Collins GJ Jr., Traumatic arteriovenous fistulas and false aneurysms: A review of 558 lesions. Surgery 1975;78:817-28.  Back to cited text no. 3
    
4.
Chaudry M, Flinn WR, Kim K, Neschis DG. Traumatic arteriovenous fistula 52 years after injury. J Vasc Surg 2010;51:1265-7.  Back to cited text no. 4
    
5.
Rerkasem K. Venous insufficiency due to chronic traumatic arteriovenous fistula: Two case reports. Int J Low Extrem Wounds 2005;4:249-51.  Back to cited text no. 5
    
6.
Young CJ, Dardik A, Sumpio B, Indes J, Muhs B, Ochoa Chaar CI. Venous ulcer: Late complication of a traumatic arteriovenous fistula. Ann Vasc Surg 2015;29:836.  Back to cited text no. 6
    
7.
Mylankal KJ, Johnson B, Ettles DF. Iatrogenic arteriovenous fistula as a cause for leg ulcers: A case report. Ann Vasc Dis 2011;4:139-42.  Back to cited text no. 7
    
8.
O'Brien J, Buckley O, Torreggiani W. Hemolytic anemia caused by iatrogenic arteriovenous iliac fistula and successfully treated by endovascular stent-graft placement. AJR Am J Roentgenol 2007;188:W306.  Back to cited text no. 8
    
9.
Mellière D, Barres G, Saada F, Becquemin JP. Late arterial aneurysm proximal to corrected post-traumatic arteriovenous fistula. J Cardiovasc Surg (Torino) 1987;28:510-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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