liac arteriovenous fistula
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liac Arteriovenous FistulaDue to Spinal Disk SurgeryCauses Severe Hemodynamic Repercussionwith Pulmonary Hypertension
Ivan Machado-Atias, MDOtto Fornes, MDRafael Gonzalez-Bello, MDIvan Machado-Hernandez, MD
Key words: Arteriovenousfistula; hypertension,pulmonary; iatrogenicdisease; surgery, inter-vertebral disk
From: The CardiovascularUnit, Clinica Atias, Caracas,Venezuela; Drs. Machado-Atias and Machado-Hernandez (both cardiol-ogists) and Dr. Gonzalez-Bello (a cardiovascularsurgeon) are affiliated withthe Clinica Atias; Dr Forn6s,the referring physician, is aninternist and cardiologist.
Presented at the 21st annualsymposium of the TexasHeart Institute, titled"Cardiology on the Horizon,"held 15-17 August 1991,Steamboat Springs, Colorado
Address for reprints:Iv,an Machado-Atias, MD,Clinica Atias, Ave. Roosevelt,Caracas, Venezuela
We present a case of a 46-year-old man with a pulsatile mass in the left inferior abdomi-nal quadrant that irradiated a continuous murmur extending to the left lumbar region.Despite an 8-year history of cardiomegaly, he appeared to be asymptomatic except forthe mass and could recollect no traumatic injury or surgery that might have caused it.Near the vertebral column, we found a small scar, the result of spinal disk surgery 11years before. Following chest radiography and electrocardiography, we located the sus-pected arteriovenous fistula by selective angiography of the aorta and its branches: acommunication of the left iliac artery with the left iliac vein had resulted in a very largeleft-to-right shunt and a severely dilated inferior vena cava. We then divided and isolatedthe arterial segment containing the fistula, but left this segment in continuity with theleft iliac vein by over-sewing both ends. To avoid injury to surrounding structures, dissec-tion was limited to the area of maximal thrill. Hemodynamic improvement was immedi-ate, and the postoperative course was uneventful. At the present time, almost 3 yearspostoperatively, the patient is asymptomatic. (Texas Heart Institute Journal 1993;20:60-5)
A pulsatile mass at the abdominal level may appear at any age, with orwithout symptoms, and may have a congenital or acquired origin. Deter-mination of the cause, which can expedite diagnosis and treatment,
sometimes requires persistent inquiry. Surgical intervention, especially if it is early,can both resolve the immediate problem and prevent severe and permanent he-modynamic sequelae affecting the heart. A noteworthy aspect of the present caseis that symptoms resolved despite the lateness of surgical intervention.
In March of 1990, a 46-year-old man was referred to us for clinical evaluation andtreatment of a pulsatile mass in the left inferior abdominal quadrant. Despite an8-year history of cardiomegaly, he was in good general health and appeared to beasymptomatic except for the mass itself, which he had first noted several monthsbefore. The patient could not recollect traumatic injury or surgery that might havecaused the mass. Physical examination revealed a blood pressure of 140-40-0mmHg and bounding pulses, more pronounced at the right femoral artery than atthe left, where the pulse seemed somehow diminished. Palpation of the massproduced pain, and a continuous murmur irradiated from it, extending to the leftlumbar region. In this place, near the vertebral column, we found a very thin,small scar, the result of spinal disk surgery 11 years before, which the patient hadnot mentioned when his history was taken. At aortic and accessory aortic foci,there was a short systolic murmur (grade 2/6). The 2nd heart sound had an in-creased pulmonary component. Chest radiography (Figs. IA and iB) revealedincreased pulmonary vascular marking, an enlarged aorta, and left ventricularhypertrophy. The electrocardiogram (Fig. 2A) showed left and right atrial enlarge-ment, questionable left ventricular hypertrophy, and possible left ventricular dia-stolic overload because of the morphology of the T waves.
With a clinical presumptive diagnosis of arteriovenous fistula, probably iliac-iliac, we decided to perform right-heart catheterization (Fig. 3), which demon-strated severe pulmonary hypertension (systolic pressure, 110 mmHg), and a very
60 Iliac Arteriovenous Fistula Due to Spinal Disk Surgery
V,blume 20, Aiiinber 1, 199.3
Fig. 1 Preoperative chest radiographs in A) frontal and B) lateral views, compared with postoperative chest radiographs inC) frontal and D) lateral views. In preoperative vi'ews, note the increased pulmonary vascular marking, enlarged aorta, and leftventricular hypertrophy. Two months later, left ventricular hypertrophy has diminished.
Fig. 2 A) The preoperative electrocardiogram shows left and right atrial enlargement, questionable left ventricular hypertrophy,and possible left ventricular diastolic overload because of the morphology of the T waves. B) The postoperative electrocardiogramis almost normal.
Iliac Arteriovenous Fistula Due to Spinal Disk Surgery 61Texas Heati Institzitejozirtial
large left-to-right shunt (Qp/Qs = 3.7/1) accompa-nied by a pulmonary oxygen saturation of 93.4% andnormal pulmonary resistance. We also performedleft-heart catheterization (Fig. 3), selective coronaryarteriography, and left ventriculography, findingfunctional mitral insufficiency secondary to left ven-tricular dilatation. The patient had an ejection frac-tion of 50%. We performed thoracic and abdominalaortography, with selective injection of the renal andmesenteric branches, followed by angiography ofthe iliac and femoral arteries. This last demonstratedthe precise site of the suspected fistula: a com-munication of the left iliac artery with the left iliacvein had resulted in a very large left-to-right shuntand a severely dilated inferior vena cava (Fig. 4).On 3 May 1990, the patient underwent a very dif-
ficult surgical procedure. After approach through amidline laparotomy, we found the arteriovenous fis-tula. We then divided and isolated the arterial seg-ment containing the fistula, but left this segment incontinuity with the left iliac vein by over-sewing bothends (Fig. 5). To avoid injury to surrounding struc-tures, dissection was limited to the area of maximalthrill. Arterial continuity was reestablished throughend-to-end anastomosis of an 8-mm GORE-TEX poly-tetrafluoroethylene tube graft, secured with 5-0 Pro- Fig. 4 Illustration of the iliac arteriovenous fistula in relation tonearby vessels and the urinary system. (Illustration by Lee
lene running suture. A Foley catheter was useful in15.19 1)150-65-100 controlling proximal arterial bleeding. No bloodM% / 2)180-80-110 saver was used, and lost blood (on the order of 3 L)
0-25-35 18.25 __ was replaced. To clear the operative field, we used a1735 92.5% 973% j1020-35 disposable suction-drainage system.110317544 Hemodynamic improvement was immediate, and
93% the postoperative course was uneventful. The car-
PCW: 20 1l 4S\\ / / /diac silhouette diminished in size (Figs. iC and 1D),"V": 38 17.07 with corresponding electrocardiographic changes
91% (Fig. 2B). The patient was discharged from the hos-17.39 pital on 10 May 1990, on a regimen of captopril, 12.5mg twice per day, and hydrochlorothiazide, 25 mg927
17(392.6% 18.2597.3% daily. After 1 week, the hydrochlorothiazide was sus-92.6%17.6397
\pended (because of intolerance) in favor of furose-\\94% 1 733 924% 1)150/20 mide, at a dosage of 20 mg 3 times per week. Two
2) 180/24 months later, we discontinued the low-dose furose-17.57 1729 92.2% mide but continued the captopril at 25 mg per day.93.7% When the patient was last evaluated by us, almost
2 years postoperatively, he was asymptomatic, wasleading a normal life, and had a normal electrocar-diogram. His thoracic radiographic and echocardio-
Fig. 3 Cardiac catheterization findings in regard to oxygen graphic results were also normal. On a regimen ofsaturation and pressure. The 2nd level of data given for theaortic arch and the left ventricle is postangiography. Observe 25 mg per day of captopril and a low-salt diet, thethe small differences in oxygen saturation between the aortic patient had normal systemic pressure (120/80), aand pulmonic levels. (Illustration by Lee Rose) normal pulmonic 2nd sound, and no murmur at anyPCW = pulmonary capillary wedge; "V" = V wave level. At the present time, almost 3 years after sur-
gery, we have information from the local physician
62 Iliac Arteriovenous Fistula Due to Spinal Disk Surgery Volume 20, Number 1, 1993
that the patient remains asymptomatic and is lead-ing a normal life.
An arteriovenous fistula can occur at any level, andsometimes is a sequela to intervertebral disk surgery,a procedure that can affect even the urinary tractbecause of the close anatomical relationship. In thisparticular case, the cause of the problem was notsuspected until we saw the scar on the patient'sback. We then explored the possibility of this surgi-cal complication through a review of the literature,conversations with neurosurgeons and a traumatol-ogist, and study of the anatomic relationships at thelevel of the 5th lumbar vertebra (Fig. 6).
Because we did not know the exact site of the fis-tula, we decided to demonstrate it by thoracic andabdominal aortography, selectively injecting the re-nal and mesenteric branches, followed by the iliacand femoral arteries. Although the diagnostic cine-angiograms were clear enough to demonstrate thepresence of iliac-iliac fistula, they were not clearenough for photographic reproduction here, due todilution of the contrast medium in the proximal por-
Fig. 5 Illustration of the surgical technique. See text.(Illustration by Lee Rose)
L5 wavudiscFig. 6 Illustra