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ACQUIRED ARTERIOVENOUS FISTULA FOLLOWING PRESCALENE LYMPH NODE BIOPSY
ACQUIRED ARTERIOVENOUS FISTULA PRESCALENE LYMPH NODE BIOPSY
FOLLOWING
Florencio A. Hipona, M.D.* and Timothy S. Harrison, M.D.,** New Haven, Conn. of lymph nodes in the prescalene region is frequently helpful as a B diagnostic procedure in patients with chronic pulmonary disease. In patients with malignant tumors of the lung, a small but appreciable percentage of IOPSY
occult metastases have been detected by this method. In general, complications reported from prescalene lymph node biopsy are few,1'2 but we are aware of lymphatic duct fistulas, transient phrenic nerve paralysis, air embolism, and delayed hemorrhage into the wound following the biopsy. This paper concerns a previously unreported complication of prescalene lymph node biopsy: arteriovenous fistula. CASE REPORT E. H. No. 443740. The patient was a 76-year-old Swedish male sheet-metal worker who was admitted to the Grace-New Haven Hospital on J a n . 19, 1961. He complained of a nonproductive cough of 6 months' duration. Physical examination and laboratory data showed no significant abnormality. Chest x-ray examination revealed a nodular density in the right upper lobe. Bronchoscopy was unremarkable and cytologic examinations of the bronchial aspirate and of three sputa were negative for tumor cells. On J a n . 21, 1961, a right prescalene lymph node biopsy was performed with removal of a generous amount of fat and associated lymphatic tissue. The base of the fat pad was secured with a large catgut ligature. There was no tumor identified in the histologic sections of the excised lymph nodes. On J a n . 26, 1961, an uneventful right upper lobeetomy was performed. The tumor proved to be a small primary broncho-alveolar cell carcinoma confined to the right upper lobe and without involvement of hilar lymph nodes. Postoperatively the patient's course was smooth and he was discharged. On May 12, 1961, the patient was seen on a routine follow-up visit. At this time he complained of a "hum" in the right lower neck. There was a vague fullness underneath the prescalene scar and a bruit was heard. On readmission to the hospital a forward aortogram was performed, with 100 c.c. of 90 per cent Hypaque being rapidly injected into the right atrium through a No. 9 N I H catheter. Films centered over the right prescalene area demonstrated a highly vascular Prom the Departments of Radiology and Surgery, Yale University School of Medicine, and Radiological and Surgical Services of Grace-New Haven Community Hospital, New Haven, Conn. Supported by U. S. Public Health Service, Grant HTS 5429 (C). Received for publication Jan. 2, 1963. ♦Cardiovascular Fellow, Yale University School of Medicine. ••Instructor in Surgery, Yale University School of Medicine. 824
Vol. 45, No. 6 June. 1963
ACQUIRED ABTERIOVENOUS F I S T U L A
825
• * i f ^ . a . 4.:;i,,l|
Fig. 1.—The arteriogram demonstrates the vascular mass (arrow) which consists of numerous collateral vessels with some degree of "tumor stain." The venous system is outlined on the roentgenogram ; the numbers refer to the sites of blood sampling during catheterization (Table I ) .
mass consisting of several tortuous vessels in the arterial phase of the examination (Fig. 1). There was residual " s t a i n " at the site of the mass in the venous phase. Catheterization from the right arm showed an increase in pressure and oxygen content at the midsubclavian vein which was the level of the suspected arteriovenous fistula (Table I ) .
Fig. 2.—An injection cast of the surgical specimen illustrates several tortuous vessels.
H I P O N A AND HARRISON
826
TABLE I. BLOOD SAMPLE*
POSITION
J. Thoracic and Cardiovas. Surg.
CATHETERIZATION DATA 0 2 SATURATION
(%)
1 High superior vena cava 91.8 2 Right mid-subclavian vein 88.1 3 Right mid-axillary vein 84. •Refer to Fig. 1 for localization of catheter position.
PRESSURE (MM. SALINE)
85 75 40
On J u n e 2, 1961, exploration of the right lower neck under general anesthesia revealed a mass, 3.0 cm. in diameter, consisting of numerous small tortuous vessels and scar tissue. Prominent vascular connections were identified to this mass, i.e., a branch of the thyrocervical a r t e r y and a t r i b u t a r y of t h e anterior jugular vein. The blood in the anterior jugular vein was well oxygenated. There was definite arterial pulse in the anterior jugular vein which could be obliterated b y occlusion of the arterial branch from the thyrocervical t r u n k leading into the mass. The mass of scar tissue and vessels was removed in toto, with many fine venous tributaries to the subclavian vein being ligated as they were encountered. Special examination of t h e specimen by injection of Vinylite plastic medium was done as further proof of its n a t u r e (Fig. 2). Postoperatively the bruit was gone. When last seen on Dec. 19, 1961, the patient was well. COMMENT
The complications of prescalene lymph node biopsy are infrequent in our experience and those which we have encountered can usually be attributed to technical accidents. In rare instances, a vascular tumor may contain small arteriovenous connections.3 On histologic section of the supraclavicular mass in this case, no evidence of tumor was found. This is the only arteriovenous fistula which followed prescalene lymph node biopsy of which we are aware. It was probably secondary to mass ligation of the incompletely dissected prescalene fat pad, with inclusion of both an artery and a vein in the ligature. SUMMARY
An acquired arteriovenous fistula secondary to prescalene lymph node biopsy is described. REFERENCES 1. Harken, D. E., Black, H., Clauss, R., and F a r r a n d , R. E.: A Simple Cervico-Mediastinal Exploration for Tissue Diagnosis of Intra-Thoracic Disease, New England J . Med. 251: 1041-1044, 1954. 2. Cruze, K., Hoffman, R. F., Hayden, W. B., and Byron, F . X.: Pre-Scalene Node Biopsy, Ann. Surg. 148: 895-898, 1958. 3. Capps, J . H., and Hipona, F . A.: D a t a to be published.
FOLLOWING
Florencio A. Hipona, M.D.* and Timothy S. Harrison, M.D.,** New Haven, Conn. of lymph nodes in the prescalene region is frequently helpful as a B diagnostic procedure in patients with chronic pulmonary disease. In patients with malignant tumors of the lung, a small but appreciable percentage of IOPSY
occult metastases have been detected by this method. In general, complications reported from prescalene lymph node biopsy are few,1'2 but we are aware of lymphatic duct fistulas, transient phrenic nerve paralysis, air embolism, and delayed hemorrhage into the wound following the biopsy. This paper concerns a previously unreported complication of prescalene lymph node biopsy: arteriovenous fistula. CASE REPORT E. H. No. 443740. The patient was a 76-year-old Swedish male sheet-metal worker who was admitted to the Grace-New Haven Hospital on J a n . 19, 1961. He complained of a nonproductive cough of 6 months' duration. Physical examination and laboratory data showed no significant abnormality. Chest x-ray examination revealed a nodular density in the right upper lobe. Bronchoscopy was unremarkable and cytologic examinations of the bronchial aspirate and of three sputa were negative for tumor cells. On J a n . 21, 1961, a right prescalene lymph node biopsy was performed with removal of a generous amount of fat and associated lymphatic tissue. The base of the fat pad was secured with a large catgut ligature. There was no tumor identified in the histologic sections of the excised lymph nodes. On J a n . 26, 1961, an uneventful right upper lobeetomy was performed. The tumor proved to be a small primary broncho-alveolar cell carcinoma confined to the right upper lobe and without involvement of hilar lymph nodes. Postoperatively the patient's course was smooth and he was discharged. On May 12, 1961, the patient was seen on a routine follow-up visit. At this time he complained of a "hum" in the right lower neck. There was a vague fullness underneath the prescalene scar and a bruit was heard. On readmission to the hospital a forward aortogram was performed, with 100 c.c. of 90 per cent Hypaque being rapidly injected into the right atrium through a No. 9 N I H catheter. Films centered over the right prescalene area demonstrated a highly vascular Prom the Departments of Radiology and Surgery, Yale University School of Medicine, and Radiological and Surgical Services of Grace-New Haven Community Hospital, New Haven, Conn. Supported by U. S. Public Health Service, Grant HTS 5429 (C). Received for publication Jan. 2, 1963. ♦Cardiovascular Fellow, Yale University School of Medicine. ••Instructor in Surgery, Yale University School of Medicine. 824
Vol. 45, No. 6 June. 1963
ACQUIRED ABTERIOVENOUS F I S T U L A
825
• * i f ^ . a . 4.:;i,,l|
Fig. 1.—The arteriogram demonstrates the vascular mass (arrow) which consists of numerous collateral vessels with some degree of "tumor stain." The venous system is outlined on the roentgenogram ; the numbers refer to the sites of blood sampling during catheterization (Table I ) .
mass consisting of several tortuous vessels in the arterial phase of the examination (Fig. 1). There was residual " s t a i n " at the site of the mass in the venous phase. Catheterization from the right arm showed an increase in pressure and oxygen content at the midsubclavian vein which was the level of the suspected arteriovenous fistula (Table I ) .
Fig. 2.—An injection cast of the surgical specimen illustrates several tortuous vessels.
H I P O N A AND HARRISON
826
TABLE I. BLOOD SAMPLE*
POSITION
J. Thoracic and Cardiovas. Surg.
CATHETERIZATION DATA 0 2 SATURATION
(%)
1 High superior vena cava 91.8 2 Right mid-subclavian vein 88.1 3 Right mid-axillary vein 84. •Refer to Fig. 1 for localization of catheter position.
PRESSURE (MM. SALINE)
85 75 40
On J u n e 2, 1961, exploration of the right lower neck under general anesthesia revealed a mass, 3.0 cm. in diameter, consisting of numerous small tortuous vessels and scar tissue. Prominent vascular connections were identified to this mass, i.e., a branch of the thyrocervical a r t e r y and a t r i b u t a r y of t h e anterior jugular vein. The blood in the anterior jugular vein was well oxygenated. There was definite arterial pulse in the anterior jugular vein which could be obliterated b y occlusion of the arterial branch from the thyrocervical t r u n k leading into the mass. The mass of scar tissue and vessels was removed in toto, with many fine venous tributaries to the subclavian vein being ligated as they were encountered. Special examination of t h e specimen by injection of Vinylite plastic medium was done as further proof of its n a t u r e (Fig. 2). Postoperatively the bruit was gone. When last seen on Dec. 19, 1961, the patient was well. COMMENT
The complications of prescalene lymph node biopsy are infrequent in our experience and those which we have encountered can usually be attributed to technical accidents. In rare instances, a vascular tumor may contain small arteriovenous connections.3 On histologic section of the supraclavicular mass in this case, no evidence of tumor was found. This is the only arteriovenous fistula which followed prescalene lymph node biopsy of which we are aware. It was probably secondary to mass ligation of the incompletely dissected prescalene fat pad, with inclusion of both an artery and a vein in the ligature. SUMMARY
An acquired arteriovenous fistula secondary to prescalene lymph node biopsy is described. REFERENCES 1. Harken, D. E., Black, H., Clauss, R., and F a r r a n d , R. E.: A Simple Cervico-Mediastinal Exploration for Tissue Diagnosis of Intra-Thoracic Disease, New England J . Med. 251: 1041-1044, 1954. 2. Cruze, K., Hoffman, R. F., Hayden, W. B., and Byron, F . X.: Pre-Scalene Node Biopsy, Ann. Surg. 148: 895-898, 1958. 3. Capps, J . H., and Hipona, F . A.: D a t a to be published.