CASE REPORT

Arteriovenous Fistula of Internal Thoracic VesselsYuzo UCHIDA, Hiroaki KAWANO,Yuji KOIDE, Genji TODAand Katsusuke YANO

Abstract

Arteriovenous fistula of internal thoracic vessels israre. We report a case of a 77-year-old womanwith a fis-tula between the left internal thoracic artery and veinafter a mediastinal needle biopsy through the anteriorchest wall. The incidence of internal thoracic arterio-

venous fistulas seems to be increasing because the num-ber of cardiac and thoracic surgical procedures is in-creasing. It is important to consider an internal thoracicarteriovenous fistula as part of the differential diagnosisin patients with continuous murmurin the parasternalarea.(Internal Medicine 42: 987-990, 2003)

Key words: arteriovenous fistula, internal thoracic artery, bi-opsy, continuous murmur

Introduction

Arteriovenous fistulas involving the systemic, coronary,

or pulmonaryvessels represent the most commoncauses ofcontinuous heart murmurs. However, fistulas of the internalthoracic vessels are extremely rare (1). These fistulas can

usually be classified as either congenital, inflammatory, trau-matic, neoplastic, or iatrogenic in origin (1, 2). Wepresent apatient with an internal thoracic arteriovenous fistula that de-veloped as a complication of a mediastinal needle biopsythrough the anterior chest wall.

Case ReportA 77-year-old womanwas admitted to our ward for theassessment of a heart murmur in September 2002. She hadundergone a mediastinal needle biopsy via the left anteriorchest wall at the second intercostal space because of a sus-pected mediastinal tumor in September 2001 (Fig. 1). The

biopsy was performed without complications, such as bleed-ing or pneumothorax. A heart murmur had never been de-tected in this patient prior to the biopsy. No family history ofcongenital malformations was present. She had no symptomsof heart failure. Her blood pressure was 118/64 mmHg, andher pulse rate was 72 beats/min. A grade 3/6 continuous ma-chinery murmur was heard over the left second intercostalspace along the left sternal border. The results of a chest X-ray and electrocardiogram were within the normal limits. Anechocardiogram revealed a normal cavity size and LVwallmotion, mild aortic stenosis and no abnormalintracardiacleft-right communication.Cardiac catheterization revealednormalpressures in the right atrium, right ventricle, pulmo-nary artery, pulmonary capillary wedge pressure, left ventri-cle and aorta without evidence of intracardiac shunting. Aleft ventriculogram, and right and left coronary arteriogramswere normal. A computed tomography (CT) examinationusing contrast mediumshowed a dilated left internal thoracicartery and veins, comparedwith the results of a similar ex-amination performed about one year earlier (Fig. 2). Magne-tic resonance imaging (MRI) and MRangiography alsorevealedthedilatationoftheleftinternalthoracic artery and

veins (Fig. 3). Selective angiography of the left internal tho-racic artery revealed a communication between the left inter-nal thoracic artery and veins (Fig. 4), with the left internal

thoracic veins draining into the superior vena cava.Ultrasonography and echo-Doppler studies showed an en-

larged left interthoracic vein and shunt flow from the leftinterthoracic artery (Fig. 5). We decided to observe the pre-

sent patient because the fistula in the internal thoracic vesselswas small and the patient did not have any complications as-sociated with the fistula or symptoms or signs of heart fail-

ure.

Discussion

Only 14 cases of iatrogenic arteriovenous fistulas of theinternal thoracic vessels have been reported (3-14). Amongthesecases, 12 were caused by a parasternal wire after a

From Department of Cardiovascular Medicine, Course of Medical and Dental Sciences, Graduate School of Biomedical Sciences, Nagasaki University,

NagasakiReceived for publication January 14, 2003; Accepted for publication July 5, 2003

R

eprint requests should be addressed to Dr. Hiroaki Kawano, Department of Cardiovascular Medicine, Course of Medical and Dental Sciences, GraduateSchool of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8501

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UCHIDAet al

Figure 1. Computed tomography shows the position and direc-tion of the biopsy needle (arrowhead) in the mediastinal tumor(arrow).

sternotomy (3-13), 1 was caused by pericardiocentesis afterthe insertion of a catheter into the pericardial cavity using thesubxiphoid approach in a patient with uremic pericarditis(14), and 1 was caused by the insertion of a chest tube intothe right parasternal region through the third intercostalspace (13). The present case is the first report of the forma-tion of a fistula caused by a needle biopsy through the ante-

rior chest wall in the parasternal region. In the previous twocases caused by the chest tube or catheter insertion, thearteriovenous fistulas that formed in the internal thoracicvessels were located at the site of insertion. The internal tho-racic artery and veins are located in the parasternal and

subxiphoid regions. Thus, the needle puncture in the presentcase and the tube and catheter insertion in the previously re-ported cases are the most likely causes of fistula formation.Therefore, transthoracic maneuvers, including the insertionof tubes or needles in the parasternal region, must be care-fully performed to prevent the formation of arteriovenousfistulas in the internal thoracic vessels.Diagnosing an arteriovenous fistula in an internal thoracicvessel is difficult because of the relative scarcity of this con-dition and its variable and often subclinical presentation. Thepresence of an internal thoracic fistula should be consideredif a characteristic continuous, machinery murmuris presentin the parasternal area. Although CT and MRI examinationsusually provide useful information for the diagnosis of an in-ternal thoracic fistula, the gold standard is a selectiveangiography. Fistula was also detected by ultrasonography inthe present case. Ultrasonography and echo-Doppler studiesseem to be useful for the observation of fistulas in internalthoracic vessels.

Internal thoracic arteriovenous fistulas can be associatedwith complications like congestive heart failure, bacterial

endocarditis, rupture, and proximal arterial degeneration, an-eurysm, and compression of adjacent tissues (1, 13, 15-19).However,the spontaneous closure of small fistulas mayalsooccur (4). Management of this condition may include surgi-cal closure, transcatheter embolization, or observation (20-22). Congestive heart failure as a result of an internal tho-

Figure 2. Computedtomography examination using contrast mediumshows dilated left internal thoracic artery and veins(arrow) (B), compared with the results of a similar examination performed about one year earlier (arrow) (A).

988 Internal Medicine Vol. 42, No. 10 (October 2003)

AVFistula of Internal Thoracic Vessels

Figure 3. Magnetic resonance imaging (A) and angiography (B) show the enlarged left internal thoracic artery and veins(arrow).

Figure 4. Selective angiography shows a communication be-tween the enlarged left internal thoracic artery (arrow) andveins (arrowheads). The left internal thoracic artery is in thecenter and internal thoracic veins are on the sides of the artery.

Figure 5. Ultrasonography shows the enlarged left Internal tho-racic vein and shunt flow from the left internal thoracic artery(arrow).

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racic arteriovenous fistula seems to be related to the durationand size of the fistula. Although arteriovenous fistulas of the internal thoracicvessels are rare, their incidence is likely to increase becauseof the increasing number of cardiac and thoracic surgicalprocedures. The possibility of an internal thoracic fistulashould be considered as part of a differential diagnosis in pa-tients with a continuous murmur in the parasternal area andwho have previously undergone a surgical procedure orpuncture

of the anterior chest wall.

References

1) Senno A, Schweitzer P, Merrill C, Clauss R. Arteriovenous fistulas of the internal mammary artery. Review of the literature. J Cardiovasc Surg 16: 296-301, 1975. 2) Hearne SF, Burbank MK. Internal mammary artery-to-pulmonary ar- tery fistulas. Case report and review of the literature. Circulation 62: 1131-1135, 1980. 3) Longmaid HE 3rd, Jay M, Phillips D. Angiographic evaluation of post- sternotomy arteriovenous fistula of the internal mammary artery and vein. Cardiovasc Intervent Radiol 3: 150-152, 1980. 4) Monrand P, Masson D, Charbonnier B, Lavigne G, Brehier J. Iatrogenic arteriovenous fistula from the internal mammary artery. Spontaneous closure. Arc Mai Coeur Vaiss 74: 105-110, 1981 (in French). 5) Maher TD, Glenn JF, Magovern GJ. Internal mammary arteriovenous fistula after sternotomy. Arch Surg 117: 1 100-1 101, 1982. 6) Deuvaert FE, Dumont N, Van Nooten G, De Paepe J, Primo G. Poststernotomy arteriovenous fistula of internal mammary origin with pseudoaneurysmal subcutaneous extension. J Cardiovasc Surg (Torino) 28: 343-344, 1987. 7) Bentivegna PE, Humphrey CB. Arteriovenous fistula of internal mam- mary artery after median sternotomy. J Cardiovasc Surg (Torino) 30: 375-377, 1989. 8) Thiel R, Bircks W. Arteriovenous fistulas after median sternotomy: re- port of 2 cases and review of the literature. Thorac Cardiovasc Surg 38: 195-197, 1990. 9) Sapoval M, Jebara V, Raynaud A, Renaudin JM, Fabiani JN, Gaux JC. Internal mammary arteriovenous fistula. An unusual complication of sternotomy treated by embolization. J Radiol 74: 297-299, 1993 (in French).

10) Silva J, Gonzalez-Santos J, Perez M, Ruiz M, Vallejo JL. Iatrogenicmammaryarteriovenous fistula caused by sternal wire. Ann ThoracSurg 66: 1398-1399, 1998.

ll) Saad RA, Zaidi A, Pugh ND, Haaverstad R. Iatrogenic mammaryarteriovenous fistula caused by a sternal wire. Ann Thorac Surg 68:626, 1999.

1

2) Braun P, Holtgen R, Stroh E, et al. Coil embolization of an AV-fistulabetween the left thoracic artery and vein after coronary artery bypasssurgery. Z Kardiol 88: 812-814, 1999 (in German).

1

3) Hassan A, Campbell DR, Bethune DC, Ali IS. Fistulae of the internalthoracic vessels: report of two cases. Eur J Cardiothorac Surg 21: 358-360, 2002.

14) Silverstein R, Crumbo D, Long DL, Kokko JP, Hull AR, Vergne-Marini P. Iatrogenic arteriovenous fistula. An unusual complication ofindwelling pericardial catheter and intrapericardial steroid instillationfor the treatment of uremic pericarditis. Arch Intern Med 138: 308-3 10,1978.

1

5) Glauss IH, Rowe RD, Duckworth JWA. Congenital arteriovenous fistu-las between the left internal thoracic artery and the ductus venosus; un-usual cause of congestive heart failure in the newborn heart. Pediatrics26: 604-607, 1960.

16) Sanchez FW, Freeland PN, Bailey GT, Vujic I. Embolotherapy ofmycotic pseudoaneurysm of the internal mammary artery in chronicgranulomatous disease. Cardiovasc Intervent Radiol 8: 43-45, 1985.

1

7) Sako Y, Varco RL. Arteriovenous fistula: results of management ofcongenital and acquired forms, blood flow measurements, and observa-tions on proximal arterial degeneration. Surgery 67: 40-61, 1970.

1

8) Boontje AH, Kruyswijk HH. Arteriovenous fistula of the internal mam-mary vessels. J Thorac Cardiovasc Surg 62: 618-623, 1971.

19) Halldorsson A, Hunter GC, Mclntyre KE, Bernhard VM. Internalmammaryartery subclavian vein fistula following internal jugular veincatheterization. A case report and review of the literature. J CardiovascSurg 32: 376-379, 1991.

20) Keller FS, Rosch J, Banner RL, Dotter CT. Iatrogenic internal mam-mary artery-to-innominate vein fistula: percutaneous nonsurgical clo-

sure. Chest 255-257, 1982.21.) Seshadri PA, Parker JO, Tomalty DR. Congenital arteriovenous fistula

of internal thoracic artery: successfully managed by transcatheterembolization. Cathet Cardiovasc Diagn 43: 198-200, 1998.

22) Sapoval MR, Jebara VA, Raymaud AC, et al. Percutaneousembolization of an arteriovenous fistula of the internal mammarypedicle following sternal wire insertion. Cathet Cardiovasc Diagn 28:339-341, 1993.

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