- Email: [email protected]
MR of superior mesenteric arteryrenal vein fistula
Computrrixd Radio/. Vol. IO, No. 6, pp. 279-282, Printed in the U.S.A. All rights reserved
19X6 Copyright
MR OF SUPERIOR MESENTERIC RENAL VEIN FISTULA DEWEYJ. CONCESJR, DONALD Department
(Received
of Radiology,
5 February
L.
KREIPKE
and
Indiana University Medical Center, Indianapolis, IN 46223, U.S.A.
1986; in revised form
0
0730-4862/X6 $3.00 + 0.00 1987 Pergamon Journals Ltd.
ARTERY-
ROBERT
D.
TARVER
926 West Michigan
9 July 1986; received for publicarion
Street,
5 August
1986)
Abstract-Traumatic arteriovenous fistulas involving the superior mesenteric artery are rare. Diagnosis is most commonly made shortly after the injury. Symptoms, when present, are usually related to intestinal ischemia. Angiography has heen the conventional modality used in diagnosing arteriovenous fistulas. We report a patient with a superior mesenteric artery to left renal vein fistula who presented in overt heart failure five years after a gun shot wound. The fistula was evaluated with magnetic resonance imaging. Magnetic vascular
resonance
imaging
Fistula,
arteriovenous
Arteries,
mesenteric
Veins,
renal
Trauma,
INTRODUCTION
Traumatic arteriovenous fistulas (AVF) are rare; those involving the aorta and left renal vein are very rare [1, 21. We report a case of superior mesenteric artery @MA) to left renal vein fistula secondary to a gun shot wound. In this patient, the fistulcus communication was evaluated using magnetic resonance (MR) imaging.
CASE
REPORT
A 29-year-old man presented with a two month history of extertional dyspnea. Five years prior to admission, the patient had suffered a gun shot wound to the abdomen. Physical examination revealed a systolic ejection murmur. A systolic and diastolic bruit was heard throughout the abdomen. Cardiomegaly and increased pulmonary vasculature were demonstrated on the admitting chest radiograph. Cardiac catheterization revealed a left to right shunt of approximately 5: 1. No intracardiac shunt was demonstrated. Oximetry revealed 45% saturation in the superior vena cava and 93% saturation in the inferior vena cava (IVC). An abdominal aorta injection at that time showed a huge shunt from the aorta to the IVC. A cut film aortogram showed what appeared to be a large fistulous communication between the aorta and left renal vein (Fig. 1). Selective injections of the renal arteries failed to demonstrate a fistula. A selective injection of the SMA was not performed. MR imaging was performed using a Technicare (Cleveland, Ohio) 0.15 resistive unit. A multislice spin echo pulse sequence with a TE of 30 msec and TR of 500 msec was used. Images were obtained in the transverse, coronal and sagittal planes. The MR images demonstrate a markedly enlarged left renal vein and IVC (Fig. 2). The sagittal slice through the SMA demonstrated an apparent communication between the SMA and left renal vein (Fig. 3). At surgery, a fistula from the proximal SMA to the superior aspect of the left renal vein was found. The AVF was repaired, and the patient was doing well on follow up. Please address reprint requests and correspondence University Hospital, X-64, 926 West Michigan Street,
to: Dewey J. Conces Jr, M.D., Indianapolis, IN 46223, U.S.A. 279
Department
of Radiology,
Indiana
DEWEY J. CONCES JR et al.
280
Fig. 1. Abdominal
aortogram
demonstrating arteriovenous fistula. Communication the aorta and left renal vein.
appeared
to be between
DISCUSSION Arterioj renous fistulas involving the superior mesenteric vessels are uncommon; only 31 case:s have been repot :ted [l]. The fistulas resulted from either previous surgery (14 cases) or trauma (17 cases). Traumatic fistulas are caused by simultaneous injury to adjacent arteries and veins. In most cases, the causat ive agent is either a bullet or a knife.
Fig. 2. Transverse
MR slice at the level of the left renal vein. Left renal vein (V) and inferior are markedly dilated.
vena cava (C)
MR of superior
mesenteric
artery
281
Fig. 3. Sagittal MR slice through the superior mesenteric artery. Superior mesenteric artery (arrow) is seen draped over dilated left renal vein. Fistula (arrowhead) between vessels is located on the superior aspect of the left renal vein.
Traumatic mesenteric fistulas are usually diagnosed within weeks of the initial injury [l]. Some patients, as in this case, may not be diagnosed until years after the injury. A patient with a traumatic SMA fistula may initially be asymptomatic. Ischemia of the bowel distal to the fistula may develop as the shunt through the fistula gradually increases. The patient may then experience nausea, vomiting, diarrhea and abdominal pain [3]. Cardiac failure has been reported in patients with mesenteric AVF’s [4]. In our case, symptoms of cardiac failure were the presenting complaint. In fistulas between the superior mesenteric artery and vein, portal venous hypertension may develop from the high blood flow [3]. In our case, there was elevated venous pressure in the IVC and left renal vein, resulting in marked dilatation of these vessels. The left renal was dilated back to the renal pelvis. The high flow rate in the left renal vein does not appear to have interfered with the function of the left kidney. A DTPA renal scan showed satisfactory function. Angiography has been the conventional diagnostic procedure in the evaluation of arteriovenous fistulas. In this patient, aortography and selective renal artery injections did not precisely locate the site of the fistula. This is unusual since angiography typically provides excellent depiction of the fistulous anatomy. In this case the failure to precisely localize the fistula may be due in part to the extreme proximal location of the fistula in the SMA. Also, additional injections such as a selective injection of the SMA may have provided better localization of the fistula. MR imaging is a potentially useful modality in the evaluation of AVF’s. Previous reports have shown that MR can image abdominal vascular pathology [5-71. The natural contrast provided by the absence of signal in moving blood allows easy identification of enlarged draining veins, which in turn helps to localize the fistula location. The ability to image blood vessels without needing to administer an intravascular contrast agent may prove useful in those patients in whom contrast administration is contraindicated or must be kept to a minimum. Angiography, however, remains the procedure of choice in the evaluation of arteriovenous fistulas. SUMMARY A case of superior mesenteric artery to left renal vein fistula is presented. Magnetic resonance imaging was used to evaluate the fistula. Arteriovenous fistulas involving the superior mesenteric artery are discussed. REFERENCES 1. M. Wood and P. W. Nykamp, (I 980).
Traumatic
arteriovenous
fistula of the superior
mesenteric
vessels, J. Trcrum~ 20, 378~ 382
282
DEWEYJ. CONCESJR et al
2. V. K. Mittal, A. Diaz-Velez, J. A. Cortez and V. K. Puri, Traumatic aorto-left renal vein fistula, ht. Surg. 67, 367-369 (1982). 3. J. T. Diehl and E. G. Beven, Arteriovenous fistulas of the mesenteric vessels, J. Curdiouusc. Surg. 23, 33&337 (1982). 4. D. Paloyan, P. A. Collins and F. P. Washburn, Superior mesenteric arteriovenous fistula, Am. Surg. 40, 481484 (1974). 5. C. B. Higgins, H. Goldberg, H. Hricak, L. E. Crooks, L. Kaufman and R. Brasch, Nuclear magnetic resonance imaging of vasculature of abdominal viscera: normal and pathologic features, Am. J. Roentg. 140, 1217-1225 (1983). 6. E. G. Amparo, C. B. Higgins and H. Hricak, Primary diagnosis of abdominal arteriovenous fistula by MR imaging, J. Comput. assist. Tomogr. 8, 114&l 142 (1984). 7. H. Hricak, E. Amparo, M. R. Fisher, L. Crooks and C. B. Higgins, Abdominal venous system: assessment using MR, Radiology 156, 415422 (1985). About the Author-DEWEY J. CONCES JR graduated from Creighton University School of Medicine in 1977. Following an internship and residency in Internal Medicine at Indiana University Medical Center he completed a residency in Radiology at the same institution. Currently he is an Assistant Professor of Radiology at Indiana University School of Medicine. His current responsibilities are in chest radiology and mammography at Indiana University Hospital. About the Author-DONALD L. KREIPKEgraduated from Indiana University School of Medicine in 1976. He completed his radiology residency at Indiana University Medical Center in 1980. He is currently an Assistant Professor of Radiology at Indiana University School of Medicine. He is Director of Emergency and ENT Radiology at Wishard Memorial Hospital, Indianapolis. About the Author-ROBERT D. TARVERgraduated from West Virginia University School of Medicine in 1979. Following a radiology residency at Indiana University Medical Center he completed a fellowship in chest radiology at Duke University. Currently he is an Assistant Professor of Radiology at Indiana University School of Medicine. His current responsibilities are in chest radiology at Wishard Memorial Hospital, Indianapolis.
19X6 Copyright
MR OF SUPERIOR MESENTERIC RENAL VEIN FISTULA DEWEYJ. CONCESJR, DONALD Department
(Received
of Radiology,
5 February
L.
KREIPKE
and
Indiana University Medical Center, Indianapolis, IN 46223, U.S.A.
1986; in revised form
0
0730-4862/X6 $3.00 + 0.00 1987 Pergamon Journals Ltd.
ARTERY-
ROBERT
D.
TARVER
926 West Michigan
9 July 1986; received for publicarion
Street,
5 August
1986)
Abstract-Traumatic arteriovenous fistulas involving the superior mesenteric artery are rare. Diagnosis is most commonly made shortly after the injury. Symptoms, when present, are usually related to intestinal ischemia. Angiography has heen the conventional modality used in diagnosing arteriovenous fistulas. We report a patient with a superior mesenteric artery to left renal vein fistula who presented in overt heart failure five years after a gun shot wound. The fistula was evaluated with magnetic resonance imaging. Magnetic vascular
resonance
imaging
Fistula,
arteriovenous
Arteries,
mesenteric
Veins,
renal
Trauma,
INTRODUCTION
Traumatic arteriovenous fistulas (AVF) are rare; those involving the aorta and left renal vein are very rare [1, 21. We report a case of superior mesenteric artery @MA) to left renal vein fistula secondary to a gun shot wound. In this patient, the fistulcus communication was evaluated using magnetic resonance (MR) imaging.
CASE
REPORT
A 29-year-old man presented with a two month history of extertional dyspnea. Five years prior to admission, the patient had suffered a gun shot wound to the abdomen. Physical examination revealed a systolic ejection murmur. A systolic and diastolic bruit was heard throughout the abdomen. Cardiomegaly and increased pulmonary vasculature were demonstrated on the admitting chest radiograph. Cardiac catheterization revealed a left to right shunt of approximately 5: 1. No intracardiac shunt was demonstrated. Oximetry revealed 45% saturation in the superior vena cava and 93% saturation in the inferior vena cava (IVC). An abdominal aorta injection at that time showed a huge shunt from the aorta to the IVC. A cut film aortogram showed what appeared to be a large fistulous communication between the aorta and left renal vein (Fig. 1). Selective injections of the renal arteries failed to demonstrate a fistula. A selective injection of the SMA was not performed. MR imaging was performed using a Technicare (Cleveland, Ohio) 0.15 resistive unit. A multislice spin echo pulse sequence with a TE of 30 msec and TR of 500 msec was used. Images were obtained in the transverse, coronal and sagittal planes. The MR images demonstrate a markedly enlarged left renal vein and IVC (Fig. 2). The sagittal slice through the SMA demonstrated an apparent communication between the SMA and left renal vein (Fig. 3). At surgery, a fistula from the proximal SMA to the superior aspect of the left renal vein was found. The AVF was repaired, and the patient was doing well on follow up. Please address reprint requests and correspondence University Hospital, X-64, 926 West Michigan Street,
to: Dewey J. Conces Jr, M.D., Indianapolis, IN 46223, U.S.A. 279
Department
of Radiology,
Indiana
DEWEY J. CONCES JR et al.
280
Fig. 1. Abdominal
aortogram
demonstrating arteriovenous fistula. Communication the aorta and left renal vein.
appeared
to be between
DISCUSSION Arterioj renous fistulas involving the superior mesenteric vessels are uncommon; only 31 case:s have been repot :ted [l]. The fistulas resulted from either previous surgery (14 cases) or trauma (17 cases). Traumatic fistulas are caused by simultaneous injury to adjacent arteries and veins. In most cases, the causat ive agent is either a bullet or a knife.
Fig. 2. Transverse
MR slice at the level of the left renal vein. Left renal vein (V) and inferior are markedly dilated.
vena cava (C)
MR of superior
mesenteric
artery
281
Fig. 3. Sagittal MR slice through the superior mesenteric artery. Superior mesenteric artery (arrow) is seen draped over dilated left renal vein. Fistula (arrowhead) between vessels is located on the superior aspect of the left renal vein.
Traumatic mesenteric fistulas are usually diagnosed within weeks of the initial injury [l]. Some patients, as in this case, may not be diagnosed until years after the injury. A patient with a traumatic SMA fistula may initially be asymptomatic. Ischemia of the bowel distal to the fistula may develop as the shunt through the fistula gradually increases. The patient may then experience nausea, vomiting, diarrhea and abdominal pain [3]. Cardiac failure has been reported in patients with mesenteric AVF’s [4]. In our case, symptoms of cardiac failure were the presenting complaint. In fistulas between the superior mesenteric artery and vein, portal venous hypertension may develop from the high blood flow [3]. In our case, there was elevated venous pressure in the IVC and left renal vein, resulting in marked dilatation of these vessels. The left renal was dilated back to the renal pelvis. The high flow rate in the left renal vein does not appear to have interfered with the function of the left kidney. A DTPA renal scan showed satisfactory function. Angiography has been the conventional diagnostic procedure in the evaluation of arteriovenous fistulas. In this patient, aortography and selective renal artery injections did not precisely locate the site of the fistula. This is unusual since angiography typically provides excellent depiction of the fistulous anatomy. In this case the failure to precisely localize the fistula may be due in part to the extreme proximal location of the fistula in the SMA. Also, additional injections such as a selective injection of the SMA may have provided better localization of the fistula. MR imaging is a potentially useful modality in the evaluation of AVF’s. Previous reports have shown that MR can image abdominal vascular pathology [5-71. The natural contrast provided by the absence of signal in moving blood allows easy identification of enlarged draining veins, which in turn helps to localize the fistula location. The ability to image blood vessels without needing to administer an intravascular contrast agent may prove useful in those patients in whom contrast administration is contraindicated or must be kept to a minimum. Angiography, however, remains the procedure of choice in the evaluation of arteriovenous fistulas. SUMMARY A case of superior mesenteric artery to left renal vein fistula is presented. Magnetic resonance imaging was used to evaluate the fistula. Arteriovenous fistulas involving the superior mesenteric artery are discussed. REFERENCES 1. M. Wood and P. W. Nykamp, (I 980).
Traumatic
arteriovenous
fistula of the superior
mesenteric
vessels, J. Trcrum~ 20, 378~ 382
282
DEWEYJ. CONCESJR et al
2. V. K. Mittal, A. Diaz-Velez, J. A. Cortez and V. K. Puri, Traumatic aorto-left renal vein fistula, ht. Surg. 67, 367-369 (1982). 3. J. T. Diehl and E. G. Beven, Arteriovenous fistulas of the mesenteric vessels, J. Curdiouusc. Surg. 23, 33&337 (1982). 4. D. Paloyan, P. A. Collins and F. P. Washburn, Superior mesenteric arteriovenous fistula, Am. Surg. 40, 481484 (1974). 5. C. B. Higgins, H. Goldberg, H. Hricak, L. E. Crooks, L. Kaufman and R. Brasch, Nuclear magnetic resonance imaging of vasculature of abdominal viscera: normal and pathologic features, Am. J. Roentg. 140, 1217-1225 (1983). 6. E. G. Amparo, C. B. Higgins and H. Hricak, Primary diagnosis of abdominal arteriovenous fistula by MR imaging, J. Comput. assist. Tomogr. 8, 114&l 142 (1984). 7. H. Hricak, E. Amparo, M. R. Fisher, L. Crooks and C. B. Higgins, Abdominal venous system: assessment using MR, Radiology 156, 415422 (1985). About the Author-DEWEY J. CONCES JR graduated from Creighton University School of Medicine in 1977. Following an internship and residency in Internal Medicine at Indiana University Medical Center he completed a residency in Radiology at the same institution. Currently he is an Assistant Professor of Radiology at Indiana University School of Medicine. His current responsibilities are in chest radiology and mammography at Indiana University Hospital. About the Author-DONALD L. KREIPKEgraduated from Indiana University School of Medicine in 1976. He completed his radiology residency at Indiana University Medical Center in 1980. He is currently an Assistant Professor of Radiology at Indiana University School of Medicine. He is Director of Emergency and ENT Radiology at Wishard Memorial Hospital, Indianapolis. About the Author-ROBERT D. TARVERgraduated from West Virginia University School of Medicine in 1979. Following a radiology residency at Indiana University Medical Center he completed a fellowship in chest radiology at Duke University. Currently he is an Assistant Professor of Radiology at Indiana University School of Medicine. His current responsibilities are in chest radiology at Wishard Memorial Hospital, Indianapolis.