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TRAUMATIC RENAL ARTERIOVENOUS FISTULA: REPORT OF 12 CASES MALCOLM D. COSGROVE, ROBERT MEl\DEZ
AND
.JAMES W MORRO\V
From the Department of Urology, Los Angeles Cuunty/Unit•erslty of Southern California Medical Center, Los Angeles, California
Renal arteriovenous (A-V) fistula is an important clinical entity. More than 100 cases have been reported in the urological literature since the first case reported in 192:3 by Varela. 1 · 3 The number of reports of this condition has mounted because of the increasing use of renal arteriography, the rise in violence and consequent renal trauma cases and the popularity of percutaneous needle biopsy of the kidney. Etiologically, most A-V fistulas are: 1) congenital, 2) idiopathic, :3) in association with renal cell carcinoma, 4) post-nephrectomy, in which case the fistula results from communication between the stumps of the ligated artery and vein and 5) following renal trauma. We report herein our experience with renal A-V fistulas of traumatic origin from 1965 to 1972. MATERIAL
Twelve patients satisfied the 3 criteria necessary for inclusion in the study. Antecedent trauma. All patients had a proved history of trauma to the affected kidney before detection of the fistula: 6 had a stabbing injury, :3 TABLE
10 patients there was continuing massive hematuria. In 1 patient (W. W.) there was intermittent gross hematuria with evidence of a mass increasing in size in the kidney. In 1 patient (C. W.) hypertension was attributed to the fistula. MANAGEMENT
Each patient was evaluated and treated in the manner appropriate to the clinical status of the case. Experience in this institution has supported a policy of performing renal angiography in all cases of penetrating renal trauma and in instituting conservative management of renal trauma cases whenever possible. 4 Therefore, all 12 patients were initially treated expectantly. Operations were performed only when non-operative management was unsuccessful. Four definitive modes of treatment were used: 1) nephrectomy (4 cases), 2) completely non-operative (:3 cases), 3) expectant after laparotomy (:2 cases) and 4) branch ligation of renal artery (3 cases). Nephrectomy group. All 4 patients in this group
1. Patients with renal A- V fistulas treated by nephrectomy ConservatiYe
Pt.
Cause
Side
HG MW BG
Stab Stab Stab Stab
Lt.
cw
Lt.
Lt. LL
Clinical Problem
Treatmen1 Failed at Failed at Failed at Failed at
Bleeding Bleeding
Bleeding H_ypertension
18 days 4:l days* 14 days 2 years*
Conservative Operation
Outcome
Not attempted Not attempterl Not possible Not possible
Good Good Good Good
* Patients had renal laceration sutured soon after injury.
had gunshot wounds, :2 had sustained blunt trauma and 1 had undergone percutaneous needle biopsy. Arteriographic demonstration. All patients had evidence on selective renal arteriography of the area of A-V communication and all displayed abnormally early visualization of the renal vein. clinical problems. All patients were significantly disabled as a result of the fistula. In Accepted for publication July 6, 1973. Read at annual meeting of American Urological Association, New New York, May 13-17, 1973. 1 McAlhany, ,J. Jr., Black, H. C., ,Jr., Hanback. L. D., Jr. and Yarbrough, D. R., Ill: Renal arteriovenous fistula as a cause of hypertension. Amer. J. Surg .. 122: 117, 1971. 'Merritt, B. A. and Middleton, R. G.: Repair of a huge renal arteriovenous aneurysm with preservation of the kidney. J. Urol., 107: 521, 1972. 'Varela, M. E.: Aneurisma arteriovenoso de los vasos renales y asistolia consecutiva. Rev. Med. Latino-Amer., 14: 3244, 1928.
had stab injuries to the kidney (table 1). Coincidentally, perhaps, the left kidney was involved in all 4 cases. Non-operative management failed in all cases. Two patients (M. W. and C. W.) underwent suturing of the renal laceration within a few days of injury. In M. Vv. had to be performed subsequently for exsanguinating hemorrhage after 43 In C. W. the was controlled but of 17 4/104 developed during the next 2 years. A conservative was not possible because of the size and central location of the fistula (fig. 1) and nephrectomy was performed. the blood pressure remained steady at 130/80. H. G. underwent nephrectomy after 18 days because of continuous massive hemorrhage. B. G. underwent exploration after 14 days because of continued bleeding and multiple renal lacerations made nephrectomy mandatory (fig. 2). 4 Morrow, J. W. and Mendez, R.: Renal trauma. J. Urol., 104: 649, 1970.
627
628
COSGROVE, MENDEZ AND MORROW TABLE
2. Patients with renal A- V fistulas treated
expectantly without operation
FIG. 1. C. W. Arteriogram shows large centrally located renal A- V fistula.
FIG. 2. B. G. Straight arrow shows point of A-V communication. Curved arrow shows early venous filling.
In all 4 patients, the outcome is listed as good since they survived with good renal function. The hemorrhage stopped in 3 cases and hypertension was reversed in C. W.
Pt.
Cause
Clinical Problem
JS TL DS
Blunt trauma Blunt trauma Gunshot wound
Bleeding Bleeding Bleeding
Therapy Duration Side (days)
Outcome
Rt. Lt. Rt.
Good Good Good
11
17 9
Non-operative group. The 3 patients in this group had significant gross hematuria after renal trauma and were found on angiography to have renal A-V fistulas (table 2). On expectant treatment with bedrest and fluid replacement, bleeding ceased in all 3 cases within 2 weeks. Renal function and vital signs remained stable and these patients were discharged from the hospital within :3 weeks. At followup angiography the fistulas had closed. J. S., a 45-year-old woman, had a fistula as a result of a severe physical beating on the right side. An A-V fistula was readily seen in the lower pole of the kidney supplied by the inferior of 2 main renal arteries (fig. 3, A). At 5-month followup arteriography the fistula was no longer present and the patient was clinically in good health (fig. 3, B). D. S., a 19-year-old man, had an A-V fistula as a result of a gunshot wound to the right kidney (fig. 4, A). He had gross hematuria. The bleeding resolved within 4 days with bedrest and the patient was discharged from the hospital at 9 days. He remained in good health and at 8-month followup arteriography the fistula had resolved completely, leaving slight scarring of the lower pole of the kidney (fig. 4, B). Laparotomy group. Two patients who suffered extensive gunshot wounds had gross hematuria because of penetrating renal injury with A- V fistula ( table 3). These patients underwent laparotomy because of the intraperitoneal visceral injuries. The retroperitoneal area was not entered since it was thought that such a maneuver might provoke more hematuria and possibly necessitate nephrectomy. In both patients the hematuria cleared within a week and at followup arteriography the fistulas had resolved. S. M., a 19-year-old man, had gunshot wounds to the liver and right kidney. Arteriography demonstrated an A-V fistula in the lower pole of the kidney (fig. 5, A). At laparotomy the liver laceration was sutured but the kidney was not exposed. Clinically, the patient had no postoperative urologic problems. Excretory urography showed normal bilateral systems at 10 days. Hematuria had cleared completely by 15 days. At 3-month followup arteriography the fistula was no longer present, although there was scarring of the lower pole of the kidney (fig. 5, B). Vessel ligation group. Three patients in whom a significant A-V fistula developed after penetrating renal injury were treated by ligation of the branch
FIG. 3. J. S. A, selective arteriogram on inferior renal artery. Straight arrow shows point of A-V communication. Curved arrow shows early venous filling. B, selective arteriogram on inferior renal artery 5 months later. No evidence of A-V fistula. Reproduced by permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.
FIG. 4. D. S. A, curved arrow shows early filling of renal vein. Straight arrow shows a vascular area at site of trauma. B, arteriogram 8 months later shows no evidence of A-V fistula. Reproduced by permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.
630
COSGROVE, MENDEZ AND MORROW
FIG. 5. S. M. A, arteriogram shows A-V fistula in lower pole. Arrows point to early v_enous filling. B, arteriogram 3 months later shows absence of A-V fistula. Scarring of lower pole. Reproduced by perm1ss10n ot the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.
TABLE
3. Patients with renal A-V fistulas treated expectantly after laparotomy
Pt.
Cause
Clinical Problem
HF SM
Gunshot wound Gunshot wound
Bleeding Bleeding
Therapy Duration Side (days)
Outcome
Lt. Rt.
Good Good
37
28
In all ;3 cases the outcome was good. The patients survived with retention of good function by both kidneys. Hematuria stopped in all cases and the fistula was no longer visualized at followup arteriography. All patients have been followed for more than a year postoperatively and did not have any undesirable sequela, such as hypertension. DISCUSSION
TABLE 4.
Pt.
Patients with renal A-V fistulas treated by branch artery ligation
Cause
Clinical Problem
Side
Treatment
Outcome
Conservative
WW Needle biopsy Stabbing TB
Mass bleeding
Rt.
Not considered
Good
Bleeding
Rt.
Good
Stabbing
Bleeding
Lt.
Failed at 11 days Failed at 19 days*
BR
Good
* Patient had renal laceration sutured soon after injury.
artery feeding the fistula (table 4). These cases have been reported in another article. 5 Non-operative treatment was not considered in W. W. because the fistula was so large. Continuing l,emorrhage in T. B. made exploration of the kidney mandatory. B. R. underwent suturing of a renal laceration in another hospital within a few hours of sustaining a stab wound to the left kidney. Two weeks later, severe bleeding from the kidney necessitated operative intervention. .s Cosgrove, M. D., Mendez, R. and Morrow, J. W.: Branch artery ligation for renal arteriovenous fistula. J. Urol., 110: 632, 1973.
Analysis of the data on these 12 cases leads to several observations. The nature of the trauma causing the fistula is important. Stab wounds of the kidney seem to cause the most severe problem when associated with an A-V fistula. Not one of the 6 stab wound patients responded to expectant therapy-all required an operation. Although all patients with stab wounds of the kidney need not undergo exploration, they should have angiography. However, patients with stab wounds associated with A-V fistula should be operated upon. If a conservative procedure such as vessel ligation, excision of the fistula or segmental resection of the kidney is not feasible, then nephrectomy should be considered. Over-sewing a renal laceration is not recommended. Three of the cases reported, thus treated, subsequently required a secondary operation. In 2 instances the result was nephrectomy. If the laceration is sufficiently severe to warrant exploration, a more definitive operation is indicated. Patients with A-V fistulas associated with blunt trauma and gunshot wounds, in general, did well without recourse to an operation. However, it is essential that such patients be observed carefully
531 until the clinical and manifestations of the fistula have Although approximately 700 percutaneous needle biopsies of the kidney were performed at this center during the 7-year period, only 1 case of renal A-V fistula resulting from the biopsy met the criteria for inclusion in this series. This fact tends to corroborate the findings of Ekelund and Lindholm' that although A-V fistula is common after percutaneous needle biopsy of the kidney (approximately 15 per cent), most of these fistulas cause no problems and heal spontaneously. Clinically, 11 of the 12 patients presented with gross hematuria and 1 presented with diastolic hypertension. These findings disagree with those of McAlhany and associates I who, on reviewing 84 cases of A-V fistula, found that 50 per cent presented with diastolic hypertension and only 33 per cent had hematuria. They also observed that 74 per cent of the cases had an audible bruit. In our series only 3 of the 12 cases had bruits. The angiographic size of the fistula seems to have no relation to the extent of bleeding it may cause. The 3 patients who underwent nephrectomy because of bleeding had small fistulas. In such cases, the bleeding could be related to the communication between blood vessel and collecting system rather than to the A-V fistula. The size of the fistula may be important in cases
Twelve cases of traumatic renal arteriovenous fistula occurring during a 7-year period are described. All patients had significant clinical problems: severe hemorrhage in 11 and diastolic hypertension in L Only 4 patients required nephrectomy. The remaining 8 patients responded to a conservative operation or non-operative management. In general fistulas from stabbing injuries presented the most severe problems. It is recommended that patients with such fistulas undergo exploration.
6 Ekelund. Land Lindholm, T.: Arteriovenous fistulae following percutaneous renal biopsy. Acta RadioL, l 1: 38, 197L
7 Halpern, :\1.: Spontaneous closure of traumatic renal arteriovenous fistulas. Amer. J. Roentgen., 107: 730, 1969.
with significant disturbance resulting from the communication. In our series the only patient in whom hypertension was attributable to the fistula had a large fistula. Halpern observed that some traumatic A-V fistulas close spontaneously. 7 However, 7 of our 12 patients required an operation. It is recommended that if operation is indicated and if it is feasible a conservative procedure should be done. There is unfortunately no secure angiographic criteria for determining whether operation will be required. Since an angiographically established fistula which does not immediately require operation might increase in size, arteriography should be repeated at intervals until the fistula has closed. SUMMARY