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 or

without 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 case

is that symptoms resolved despite the lateness of surgical intervention.

Case Report

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 an

8-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 at

the left, where the pulse seemed somehow diminished. Palpation of the mass

produced 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

CaseReports

V,blume 20, Aiiinber 1, 199.3

"W

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.

A B

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 to

nearby vessels and the urinary system. (Illustration by LeeRose)

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 a

1735 92.5% 973% j1020-35 disposable suction-drainage system.110317544 Hemodynamic improvement was immediate, and93% 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 mg

92717(392.6% 18.2597.3% daily. After 1 week, the hydrochlorothiazide was sus-92.6%17.63

97° \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. Two2) 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, almost2 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.

Discussion

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 wavu§disc

Fig. 6 Illustration of the fistulous connection (arrow) inrelation to the spinal column and other structures.(Illustration by Lee Rose)

Iliac Arteriovenous Fistula Due to Spinal Disk Surgery 63

A

B

C

Texas Hean Instituteiournal

tion of the iliac vein and in the severely dilated infe-rior vena cava.The possible causes of iliac-iliac fistula appear

to be few. Aside from fistulae of apparently sponta-neous origin, there are those associated with con-genital anomaly and those arising from traumatic(piercing) wounds, from intervertebral disk surgery,and from seat-belt (blunt) trauma. In our initialsearch of the international literature, performed priorto surgery on this patient, we found 15 cases in 6different reports. 1-6 The reported mortality rate wasabout 80% in cases of vessels that ruptured, and 10%in cases of vessels that did not rupture. Recently, wesearched the literature more extensively through1992 and found 38 additional cases in 25 adlditionalreports.7t-3

Acknowledgments

We appreciate the assistance given to the medicalillustrator, Mr. Lee Rose, by Drs. Mario Durand andGuillermo Malave, in demonstrating the anatomic sit-uation of the fistula by means of their excellent pre-liminary sketches.

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Y, Ohhara H. Surgical experience in arteriovenous fistulafollowing disc surgery. Nippon Geka Gakkai Zasshi 1986;87(3):350-3.

2. Serrano Hernando FJ, Paredero VM, Solis JV. et al. Iliac arte-riovenous fistula as a complication of lumllbar disc surgery:report of two cases and review of literature. J CardiovascSurg (Torino) 1986;27:180-4.

3. Salander JM, Youkey JR, Rich NM, Olson DW', Clagett GP.VTascular injury related to lumbar clisk surgery. J Trauma1984; 24:628-31.

4. Jue-Denis 1', Kieffer E, Benhamou M, Le-Thoai H, Ricbard T,Natali J. Major vascular injury after disc surgerv [in French].Rev Chir Orthop 1984;70:141-5.

5. Fallahnejad M, Boland BJ, Chait A. Aortoiliac arteriovenousfistula simulating iliac vein thrombosis followving interverte-bral disc surgery. Can J Surg 1983:26:366-7.

6. May ARL, Brewster DC, Darling RC, Browse NL. Arterio-venous fistula following lumbar disc surgery. BrJ SoLrg 1981:68:41-3.

7. Lie TA, Smet HL de. Major vascular injuries following opera-tions for protruded lumbar discs. Plsychiatr Neurol NeLrochir1968;71:71-5.

8. Holscher EC. VasCcular and visceral injuries during lumnbar-disc surgery. J Bone Joint Surg [AIm1] 1968;50:383-93.

9. Davies JM. Ilio-iliac arteriovenous fistula following laimin-ectomy. Clin Radiol 1969;20:103-4.

10. Pelletier LC, Letendre J, Cartier P. Fistule arterio-veineusetraumatique apres discoidectomie: presentation d'on cas etrevue de la litterature [Traumatic arteriovenoUs fistula follow-ing discoidectomy: a case report and a review of the litera-ture]. Can J Surg 1970;13:439-45.

11. Groh P. Hofmann KT, Simonis G. Arteriovenbse Iliacal-Fistelnacb lUmbaler Bandscheiben-Operation [Iliac arteriovenoLsfistula following operation for lumbar prolapsecd interverte-bral disc]. Z Orthop 1973;111:224-9.

12. Ochoa-Bizet LXI. Fernandez-NIontequin JI_ McCook-MartinezJB. Fistula arteriovenosa complicando la cirugia del discolumbar [Arteriovenous fistula complicating lum-ibar disk sur-gervi. Angiologia 1971:23:103-12.

13. Auer Al. Sauer DC. Levin M. Iliac arterio-venous fistula froman aneurysm following seat belt trauma. Angiology 1974;25:21-3.

14. V'ood J1'. Lumrbar clisk surgery: complications. J Am Osteo-patb Assoc 1974;-4:234-40.

15. Ev-ans WE. Arteriovenous fistula following disc surgery. VascSurg 1974;8:33-5.

16. Rossi R, Larcher M, Menghello A. Tovena 1), Cressoni MC.Poppi A. Scompenso cardiaco di fistola artero-venosa iatro-gena [Cardiac inSsufficiency caused by iatrogenic arterio-venous fistula]. G Ital Cardiol 1982;12:676-80.

17. D)u Toit DF Van der Merw,ve I)M, Groenew%vald JH, De RoubaixJAM\. High-output cardiac failure associated xvith an iliac ar-tery aneurysm and arteriovenoLus fiStulal: a case report. S AfrM\Ied.j 1983:63:293-4.

18. Langer B. Aun R, Kauffimian P, Albers MNIT, Bouabci AS,Manasterski J. Fistula arteriovenosa CoC)io coniplicaV'ao decirLrgia cle hbrnia de clisco intervertebral [abs. in English][Arteriox-enous fiStula as a complication of intervertebral diskbernia surgery]. Rev Paul Med 1983;101:228-30.

19. McAllister CJ. Spontaneous fistula between a right commoniliac artery and iliac vein [letter]. JANIA 1984;252:1684-5.

20. Natali J. Jue-Denis P. Kieffer E, et al. Arteriovenous fistulaeof the internal iliac vessels. J Cardiovasc Surg (Torino) 1984;25: 165-72.

21. Harvey CF. Barros DSa AAB. Acute arteriovenous fistulacomiiplicating left iliac artery aneurysm. J R Coll Surg Edinb1984:29:119-21.

22. Jue-D)enis P. Kieffer E, Benhamou M, Le-Thoai H. Richard T.Natali J. Traumatismes des v-aisseaux abdominaux apre.s chir-urgie de la hernie discale [abs. in English] [Injuries to ah-clominal vessels after surgery of disk herniation]. Rev ChirOrtbop 1984;70:141-5.

23. Quigley, TM. Stoney Rl. ArteriovenoLuS fistlas followving lum-bar laminectomy: the anatomy defined. J Vasc Surg 1985;2:828-33.

24. Possati F. Spigonardo F, Calafiore AM, Di Nardo E, Landi PG.So on caso di fistola artero venosa complicata [abs. in Eng-lish] [A case of a conmplicated arteriovenoLIs fistilal. MIinervaChir 1985:40:793-7.

25. McAuley CE, Peitzmiazn AB. cleVries FJ, Silver MIR. Steed DL,Webster MINW. The syndrome of spontaneouS iliac arterio-venouLs fistula: a distinct clinical and pathophbsiologic en-tity. Surgery 1986;99:373-7.

26. Bialy T, Gooch AS, Slbabriari A. High-output congestive fail-ure dole to arteriovenoLS fistula resulting from lumbar discSurgery-a case report. Angiology 1988;39:616-9.

27. Wevrich G. Beck A. Traumllatic fistula between internal iliacarterv and external iliac vein. Radiat Med 1990;8:215-8.

28. Brewster DC, Cambria RP, Moncure AC, et al. Aortocaval andiliac arteriovenouLs fistullas: recognition and treatment. J VascSurg 1991;13:253-65.

29. Gregoric ID, Jacobs NMJ, Reul GJ, Rochelle DG. SpontaneouScoimmon iliac arteriovenous fistula manifested hy acute re-nal failure: a case report. J. Vasc SLrg 1991;14:92-7.

30. Stellbrink C, Kunze KR' Lambertz H, Urbahn R, Hanrath P. Aiatrogenic arteriovenous fistula following laminectomy. Arare differential cliagnosis of heart failure. Dtsch MedWrochenschr 1991:116:11-41-3.

31. DUqUe AC, MIerlo I. Janeiro MIJ, Madeira EN, Pinto-Ribeiro R.Postlaminectomv arteriovenous fiStula: the Brazilian experi-ence. J Cardiovasc Siorg (Torino) 1991;32:783-6.

64 Iliac Arteriovenous Fistula Due to Spinal Disk Surgery tbliiiiie 20, Number 1, 199-3

Editorial Comment

In this paper, Dr. Machado's group presents the caseof a 46-year-old man with a major iliac arteriovenousfistula with serious hemodynamic consequences,secondary to intervertebral disk surgery 11 years ear-lier. This infrequent complication of disk surgery isrecognized in the surgical literature, but is poorly ap-preciated in medical and cardiology circles.

I became aware of this surgical complicationwhenmy mentor, Dr. Thomas W. Mattingly, Col. MC, iden-tified 2 examples at Walter Reed General Hospital.'Only 9 prior cases had been published in the Englishliterature, the 1st in 1945.2 The actual occasion of thevascular injury-often trivial and overlooked by thesurgeon and the anesthesiologist-can occur in thehands of even the most competent of surgeons, fullyaware of this potential complication.3 This increasesthe importance of securing a complete surgical aswell as trauma history when evaluating a patientwith features of an arteriovenous fistula. "Listen overevery scar" is a caveat attributed to Dr. HowardBurchell, another outstanding bedside clinician: ad-

vice that would help us to notice continuous mur-murs associated with arteriovenous fistula, the resultof prior trauma.

Dr. Machado and his colleagues are to be compli-mented for bringing to the attention of our medicalreadership another example of this surgical compli-cation.

RobertJ. Hall, MD,Editor-in-Chief

References1. Smith VM, Hughes CW, Sapp 0, Joy RJT, Mattingly, TW.

High-output circulatory failure due to arteriovenous fistula:complication of intervertebral-disk surgery. Arch Intern Med1957; 100:833-41.

2. Linton RR, White PD. Arteriovenous fistula between the rightcommon iliac artery and the inferior vena cava: report of acase of its occurrence following an operation for a rupturedintervertebral disk with cure by operation. Arch Surg 1945;50:6-13.

3. Holscher EC. Vascular complication of disc surgery. J BoneJoint Surg [Am] 1948;30A:968-70.

Iliac Arteriovenous Fistula Due to Spinal Disk Surgery 65Texas Hearl Instittitejotirnal