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Iatrogenic arteriovenous fistula unveiling aberrant left renal vein
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Iatrogenic arteriovenous fistula unveiling aberrant left renal vein Radhakrishnan Raju, MCh, Vishnukumar Venkatesan, MS, MRCS, Kapil Mathur, MCh, and Ayyappan Makkathai Kanakasabai, MS, MCh, FRCS, Chennai, India A 28-year-old man with L4 to L5 laminectomy done 3 years ago presented with history of breathlessness, abdominal pain, and discoloration of the left leg. A palpable thrill was felt in the abdomen with normally felt pedal pulses. He had features of high output cardiac failuredtachycardia, generalized rales in the chest, bilateral moderate pleural effusion, ascites, hepatomegaly, and a large cardiac shadow. Echocardiogram revealed a dilated right atrium, with increased pulmonary arterial pressure and a left ventricular ejection fraction of 45%. Computed tomographic angiogram revealed an arteriovenous fistula between the right common iliac artery and the left common iliac vein (CIV) (A). The CIV and the inferior vena cava were massively dilated with an incidental anomalous left renal vein draining into the left CIV (B/ Cover). Written informed consent was obtained from the patient for publication of this case report and any accompanying images. In view of the proximity of the fistula to the aortic bifurcation with a relatively small aortic diameter of 14 mm we preferred surgical repair and proceeded with a midline laparotomy. The infrarenal aorta and bilateral common iliac arteries were controlled and the fistula tract was dissected and disconnected. The iliac artery and vein were repaired primarily using 6-0 polypropylene sutures. The patient’s central venous pressure normalized rapidly after disconnection (C). Postoperatively the patient had prolonged paralytic ileus but was symptomatically better at discharge. Iatrogenic arteriovenous fistulae between the iliac artery and vein resulting from laminectomy are uncommon with a prevalence of 1 to 5 per 10,000 surgeries1 but can result in serious manifestations including high-output cardiac failure. They are usually caused when the anterior spinal ligament is penetrated and the adjacent artery and vein perforated during instrumentation.2 Immediate bleeding seldom occurs from the laminectomy wound because it can be tamponaded in the retroperitoneal space. Most present later with complications resulting from the iatrogenic arteriovenous fistula. Thorough history might be the only indicator in these patients. Patients have presented as late as 9 years after laminectomy with symptoms of cardiac failure, often being misdiagnosed. The clinical presentation with a history of lumbar disc surgery and the finding of a machinery bruit in the abdomen should clinch the diagnosis.3 We would like to acknowledge the assistance provided by Prof T. R. Muralidharan, Professor of Cardiology, Sri Ramachandra University, Chennai, in the management of this case.
From the Department of Vascular Surgery, Sri Ramachandra University, Porur. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg: Venous and Lym Dis 2016;4:343-4 2213-333X Copyright Ó 2016 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvsv.2015.12.005
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JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS July 2016
REFERENCES 1. Papadoulas S, Konstantinou D, Kourea HP, Kritikos N, Haftouras N, Tsolakis JA. Vascular injury complicating lumbar disc surgery. A systematic review. Eur J Vasc Endovasc Surg 2002;24:189-95. 2. Quigley TM, Stoney RJ. Arteriovenous fistulas following lumbar laminectomy: the anatomy defined. J Vasc Surg 1985;2:828-33. 3. Brewster DM, Cambria RP, Moncure AC, Darling RC, LaMuraglia GM, Geller SC, et al. Aortocaval and iliac arteriovenous fistulas: Recognition and treatment. J Vasc Surg 1991;13:253-65. Submitted Dec 18, 2015; accepted Dec 28, 2015.
Iatrogenic arteriovenous fistula unveiling aberrant left renal vein Radhakrishnan Raju, MCh, Vishnukumar Venkatesan, MS, MRCS, Kapil Mathur, MCh, and Ayyappan Makkathai Kanakasabai, MS, MCh, FRCS, Chennai, India A 28-year-old man with L4 to L5 laminectomy done 3 years ago presented with history of breathlessness, abdominal pain, and discoloration of the left leg. A palpable thrill was felt in the abdomen with normally felt pedal pulses. He had features of high output cardiac failuredtachycardia, generalized rales in the chest, bilateral moderate pleural effusion, ascites, hepatomegaly, and a large cardiac shadow. Echocardiogram revealed a dilated right atrium, with increased pulmonary arterial pressure and a left ventricular ejection fraction of 45%. Computed tomographic angiogram revealed an arteriovenous fistula between the right common iliac artery and the left common iliac vein (CIV) (A). The CIV and the inferior vena cava were massively dilated with an incidental anomalous left renal vein draining into the left CIV (B/ Cover). Written informed consent was obtained from the patient for publication of this case report and any accompanying images. In view of the proximity of the fistula to the aortic bifurcation with a relatively small aortic diameter of 14 mm we preferred surgical repair and proceeded with a midline laparotomy. The infrarenal aorta and bilateral common iliac arteries were controlled and the fistula tract was dissected and disconnected. The iliac artery and vein were repaired primarily using 6-0 polypropylene sutures. The patient’s central venous pressure normalized rapidly after disconnection (C). Postoperatively the patient had prolonged paralytic ileus but was symptomatically better at discharge. Iatrogenic arteriovenous fistulae between the iliac artery and vein resulting from laminectomy are uncommon with a prevalence of 1 to 5 per 10,000 surgeries1 but can result in serious manifestations including high-output cardiac failure. They are usually caused when the anterior spinal ligament is penetrated and the adjacent artery and vein perforated during instrumentation.2 Immediate bleeding seldom occurs from the laminectomy wound because it can be tamponaded in the retroperitoneal space. Most present later with complications resulting from the iatrogenic arteriovenous fistula. Thorough history might be the only indicator in these patients. Patients have presented as late as 9 years after laminectomy with symptoms of cardiac failure, often being misdiagnosed. The clinical presentation with a history of lumbar disc surgery and the finding of a machinery bruit in the abdomen should clinch the diagnosis.3 We would like to acknowledge the assistance provided by Prof T. R. Muralidharan, Professor of Cardiology, Sri Ramachandra University, Chennai, in the management of this case.
From the Department of Vascular Surgery, Sri Ramachandra University, Porur. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg: Venous and Lym Dis 2016;4:343-4 2213-333X Copyright Ó 2016 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvsv.2015.12.005
343
344 Raju et al
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS July 2016
REFERENCES 1. Papadoulas S, Konstantinou D, Kourea HP, Kritikos N, Haftouras N, Tsolakis JA. Vascular injury complicating lumbar disc surgery. A systematic review. Eur J Vasc Endovasc Surg 2002;24:189-95. 2. Quigley TM, Stoney RJ. Arteriovenous fistulas following lumbar laminectomy: the anatomy defined. J Vasc Surg 1985;2:828-33. 3. Brewster DM, Cambria RP, Moncure AC, Darling RC, LaMuraglia GM, Geller SC, et al. Aortocaval and iliac arteriovenous fistulas: Recognition and treatment. J Vasc Surg 1991;13:253-65. Submitted Dec 18, 2015; accepted Dec 28, 2015.