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Traumatic thoracic aorta-innominate vein fistula: A case report
CASE REPORT trauma, fistula, aorta-innominate vein; traumatic thoracic aorta-innominate vein fistula
Traumatic Thoracic Aorta.lnnominate Vein Fistula: A Case Report Traumatic thoracic aorta-innominate vein fistulae are very rare. We present the case of a 20-year-old woman who sustained a stab wound to the left side of the chest. The physical examination was unremarkable. A chest radiograph showed a widened mediastinum, and arteriography demonstrated an arterio-venous fistula involving the thoracic aorta and the irmominate vein. Operative repair was accomplished and the patient recovered. [Szymanski TJ, Llera JL: Traumatic thoracic aorta-innominate vein fistula: A case report. Ann Emerg Med April 1986;15:466-469.] INTRODUCTION The occurrence of a traumatic arteriovenous fistula between the thoracic aorta and the left innominate vein was first reported by Proctor in 1950.1 Since that time only nine other cases have been reported.2-to We report the eleventh known case.
CASE REPORT A 20-year-old w o m a n was admitted to the emergency department after having sustained mukiple stab wounds. The assailant had approached her from behind and stabbed her once in the left chest, once in the back, and twice in the left arm. Paramedics found her unresponsive with a palpable systolic blood pressure of 220 m m Hg. Two large-bore IV catheters of normal saline were started, and the patient was transported immediately to the hospital. On arrival the patient's blood pressure was 130/70 m m Hg, pulse was 140, and respirations were 28. Physical examination revealed an obese, lethargic woman who answered questions appropriately. There was a strong odor of alcohol on her breath. The head and neck examination was unremarkable. Examination of the chest revealed a 1-cm horizontal stab wound just inferior to the left clavicle and 2 cm from the sternal border. No crepitance or bruits were noted at the wound site. The trachea was midline, and neck veins were not distended. The lungs were clear to auscultation. There were no murmurs or gallops. Peripheral pulses were present and equal symmetrically in all extremities. Blood pressure was the same in both arms. The abdomen was soft and nontender, with no guarding or rigidity. Bowel sounds were normal, and rectal examination was normal with guaiacnegative stools. There was a very superficial stab wound in the left lumbar region and there were two superficial lacerations on the left forearm. The neurological examination was normal. Laboratory evaluation revealed a hematocrit of 34.4%, hemoglobin of 11.1 g/mL, and a white blood cell count of 19,700, with a differential of 23% polymorphonuclear leukocytes, 4% stabs, and 72% lymphocytes. BUN was 9 mg/dL; sodium, 137 mEq/L; potassium, 3.4 mEq/L; chloride, 109 mEq/mL., CO 2, 13.5 mEq/L; and creatinme, 1.0 mg/dL. Platelet count, and prothrombin and partial thromboplastin times were normal. The serum ethanol level was 190 mg/dL. Urinalysis was normal. Shortly after arrival, the patient's blood pressure fell to 85/40 m m Hg. Examination revealed no changes in heart sounds, nor was there any pulsus paradoxus or neck vein distension. Military antishoek trousers were inflated, and the patient received 1,000 mL Ringer's lactate. Her blood pressure subse15:4 April 1986
Annals of Emergency Medicine
Ted J Szymanski, DO* Jacksonville, Florida Jorge L Liera, MDt Tacoma, Washington From the Department of Emergency Medicine, University Hospital of Jacksonville, Jacksonville, Florida;* and the Department of Emergency Medicine, St Joseph Hospital, Tacoma, Washington.t Received for publication March 1, 1984. Revision received September 23, 1985. Accepted for publication October 18, 1985. Address for reprints: Jorge L Llera, MD, Department of Emergency Medicine, St Joseph Hospital, 1718 South I Street, Tacoma, Washington 98405.
466/133
AORTA-tNNOMiNAfE VEIN FISTULA Szymanski & Llera
FIGURE 1. Expiratory upright chest radiograph demonstrating a widened mediastinurn. quently increased to 118/40 m m Hg. Portable upright (inspiratory and expiratory) chest radiographs revealed a wide mediastinum but no pneumothorax (Figure 1). An arch-aortogram demonstrated an arteriovenous fistula between the thoracic aorta proximal to the base of the left common carotid and the left innominate vein (Figures 2 and 3). Following angiography, the patient was taken to the operating room, and a median sternotomy was performed. There was a small tear in the thoracic aorta at the takeoff of the left common carotid. The thoracic aorta was repaired. The estimated blood loss during surgery was ten units, and 12 units were reinfused. The patient was taken to the recovery room in satisfactory condition with a mediastinal chest tube in place. In the recovery room, she was placed on a respirator with arterial blood gases of pH, 7.43; PCO2, 40.3 m m Hg; and PO2, 90.5 on 0.40 FiO 2. The chest tube drainage was 118 mL overnight and urine output was normal. The patient was extubated the following day. She was alert and responsive and her lungs were clear on chest radiograph. The remainder of the patient's hospital course was complicated by low-grade fever. Cultures of blood, urine, and s p u t u m were negative. On the 24th postoperative da~ bronchoscopy was performed and the patient was found to have diffuse edema in the left mainstem bronchus. She received IV penicillin and amikacin, became afebrile the following day, and was discharged on the 31st postoperative day in good condition. The patient did not return and was lost to followup. DISCUSSION The occurrence of traumatic arteriovenous fistulae (AVF) involving the thoracic aorta and innominate vein is rare. We were able to find only ten reported cases. Ho Mediastinal structures are particularly at risk to penetrating neck and chest wounds. The high mortality of aortic wounds accounts for the few patients who survive to manifest complications of posttraumatic thoracic 134/467
aneurysms or AVE Kollmeyer found that traumatic AVF comprise approximately 7% of all acute arterial injuries studied. The etiology of injury for these traumatic AVF were gunshot wounds (56.5%), shotgun wounds (11.6%), stab wounds (13%), blunt trauma (17.4%), and iatrogenic causes (1.3%).11 During the Viet Nam War, 7,500 vascular injuries were sustained by Americans. Only 7% resulted in AVF and/or false aneurysms, and none involved the thoracic aorta.12 The patient's history usually is not helpful in diagnosing AVF; however, physical examination is of value when a bruit or thrill is noted.llA 3 Kollmeyerl2 noted that bruits were present in 55% of acute AVF and 92% of chronic AVF in a series of 69 patients. Auscultation is an important part of the examination of any wound in the proximity of a major vessel. A high index of suspicion must be maintained because this injury might not be accompanied by the usual signs of major arterial injury; therefore, the diagnosis can be overlooked during the initial examination. 13 Typically the wound appears insignificant, but the patient presents with massive blood loss or an extensive hematoma over the wound site. The presence of pulses and evidence of perfusion distal to the injury may obscure the diagnoses of arterial injury. For this reaAnnals of Emergency Medicine
son, arteriography is recommended in any hemodynamically stable patient when traumatic AVF is considered, tl Kollmeyer identified 45% of unsuspected AVF by angiography in patients whose only evidence for an AVF on physical examination was a wound in the proximity of a major vessel.11 Also, arteriography can identify the exact location and size of the AVE which helps the surgeon select the best operative approach and treatment. Acute AVF, like other vascular injuries, should be repaired immediately. Definitive repair should be done as soon as is feasible after the injury is recognized, thus avoiding the danger of delayed hemorrhage or the development of false aneurysms. 1a-16 Furthermore, the lesion is easier to repair acutely prior to the development of fibrosis or of collateral vessels. Disparity in the size of the vessels proximal and distal to the fistula will not be seen in acute AVF, as it is in many chronic fistulas. Early repair prevents potential cardiovascular side effects (ie, congestive heart failure) and complications of increased venous pressure and venous insufficiency that commonly occur with chronic AVF.17-19
SUMMARY We reported the llth known case of traumatic thoracic aorta-innominate 15:4 April 1986
FIGURE 2. Arch-aortogram demon-
strating filling of aorta and suggestive of superior vena cava and innominate vein filling. 3. S u b t r a c t i o n archaortogram revealing AVE There is filling with contrast of the aorta arch and innominate vein with fistula just proximal to the base of the left common carotid artery. FIGURE
vein fistula. A 20-year-old w o m a n sustained a stab wound to the chest, resulting in a fistula between the thoracic aorta and the left i n n o m i n a t e vein. She u n d e r w e n t operative repair and recovered.
REFERENCES 1. Proctor WH: Arteriovenous fistula of the aortic arch. JAMA 1950;144:818-819. 2. McCook WW: Arteriovenous fistula of the aortic arch. J Thorac Surg 1952j23: 299-302. 3. Scaly WC, Fawcett B: Arteriovenous fistula of ascending aorta and left innomihate vein. Ann Surg 1955;142:302-303. 4. Conrad JK, Cartwright RS, Mostyn EM: Arteriovenous fistula of the aortic arch. N Engl J Med 1962;267:15-18. 5. Beall AC, Roof WR, DeBakey ME: Suecessful surgical management of through and through stab wound of the aortic arch. Ann Surg 1962;156:823-826. 6. Borst HG, Schaudig A, Rudolph W: Arteriovenous fistula of the aortic arch; repair during deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg 1964;48:443-447. 7. Giraud RM: Arteriovenous fistula of aortic arch complicating stab wound of the neck. S Air Med l 1965;39:474. 8. Tarlov E, Greenfield LJ: Post-traumatic aortic arch aneurysm with arteriovenous fistula to the innominate vein. J Thorac Cardiovasc Surg 1968;55:134-140. 9. Symbas PN, Sehdeva JS: Penetrating wounds of the thoracic aorta. Ann Surg 19701171:441-449. 10. Treiman RL, Cohen JL, Gaspard DJ, et al: Early surgical repair of acute post-traumatic arteriovenous fistulas. Arch Surg 1971;102:559-561. 11. Kollmeyer KR, Hunt JL, Ellman BA, et al: Acute and chronic traumatic arteriovenous fistulae in civilians. Arch Surg 1981; 116:697-702. 12. Martinez E, Meller J, Godoy M, et al: Arteriovenous fistulae of the thoracic aorta: Report of a case presenting with superior vena caval obstruction. Thorax 1981;36:315-318. 15:4 April 1986
Annals of Emergency Medicine
468/135
AORTA-INNOMINATE VEIN FISTULA Szymanski & Llera
13. Hewitt RL, Smith AD, Drapanas T: Acute traumatic arteriovenous fistulas. ] Trauma 1973;13:901-906. 14. Beall AC Jr, Harrington OB, Crawford ES, et al: Surgical management of traumatic arteriovenous aneurysms. A m J Surg 1963; 106:610-618. 15. Hewitt RL, Collins PJ: Acute arteriovenous fistulas in war injuries. Ann Surg
136/469
1969; 169:447-449.
tion 1965;32:1001-1009.
16. Drapanas T, Hewitt RL, Weichert RF, et al: Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 1970;172:351-360.
18. Hughes CW, Jahnke EJ: The surgery of traumatic arteriovenous fistulas and aneurysms. A five year follow up study of 215 lesions. Ann Surg 1959;148:790-797.
17. Holman E: Abnormal arteriovenous communications. Great variability of effects with particular reference to delayed development of cardiac failure. Circula-
19. Pate JW, Sherman RT, Jackson T, et al: Cardiac failure following traumatic arteriovenous fistulae: A report of 14 cases. J Trauma 1965;5:398-403.
Annals of Emergency Medicine
15:4 April 1986
Traumatic Thoracic Aorta.lnnominate Vein Fistula: A Case Report Traumatic thoracic aorta-innominate vein fistulae are very rare. We present the case of a 20-year-old woman who sustained a stab wound to the left side of the chest. The physical examination was unremarkable. A chest radiograph showed a widened mediastinum, and arteriography demonstrated an arterio-venous fistula involving the thoracic aorta and the irmominate vein. Operative repair was accomplished and the patient recovered. [Szymanski TJ, Llera JL: Traumatic thoracic aorta-innominate vein fistula: A case report. Ann Emerg Med April 1986;15:466-469.] INTRODUCTION The occurrence of a traumatic arteriovenous fistula between the thoracic aorta and the left innominate vein was first reported by Proctor in 1950.1 Since that time only nine other cases have been reported.2-to We report the eleventh known case.
CASE REPORT A 20-year-old w o m a n was admitted to the emergency department after having sustained mukiple stab wounds. The assailant had approached her from behind and stabbed her once in the left chest, once in the back, and twice in the left arm. Paramedics found her unresponsive with a palpable systolic blood pressure of 220 m m Hg. Two large-bore IV catheters of normal saline were started, and the patient was transported immediately to the hospital. On arrival the patient's blood pressure was 130/70 m m Hg, pulse was 140, and respirations were 28. Physical examination revealed an obese, lethargic woman who answered questions appropriately. There was a strong odor of alcohol on her breath. The head and neck examination was unremarkable. Examination of the chest revealed a 1-cm horizontal stab wound just inferior to the left clavicle and 2 cm from the sternal border. No crepitance or bruits were noted at the wound site. The trachea was midline, and neck veins were not distended. The lungs were clear to auscultation. There were no murmurs or gallops. Peripheral pulses were present and equal symmetrically in all extremities. Blood pressure was the same in both arms. The abdomen was soft and nontender, with no guarding or rigidity. Bowel sounds were normal, and rectal examination was normal with guaiacnegative stools. There was a very superficial stab wound in the left lumbar region and there were two superficial lacerations on the left forearm. The neurological examination was normal. Laboratory evaluation revealed a hematocrit of 34.4%, hemoglobin of 11.1 g/mL, and a white blood cell count of 19,700, with a differential of 23% polymorphonuclear leukocytes, 4% stabs, and 72% lymphocytes. BUN was 9 mg/dL; sodium, 137 mEq/L; potassium, 3.4 mEq/L; chloride, 109 mEq/mL., CO 2, 13.5 mEq/L; and creatinme, 1.0 mg/dL. Platelet count, and prothrombin and partial thromboplastin times were normal. The serum ethanol level was 190 mg/dL. Urinalysis was normal. Shortly after arrival, the patient's blood pressure fell to 85/40 m m Hg. Examination revealed no changes in heart sounds, nor was there any pulsus paradoxus or neck vein distension. Military antishoek trousers were inflated, and the patient received 1,000 mL Ringer's lactate. Her blood pressure subse15:4 April 1986
Annals of Emergency Medicine
Ted J Szymanski, DO* Jacksonville, Florida Jorge L Liera, MDt Tacoma, Washington From the Department of Emergency Medicine, University Hospital of Jacksonville, Jacksonville, Florida;* and the Department of Emergency Medicine, St Joseph Hospital, Tacoma, Washington.t Received for publication March 1, 1984. Revision received September 23, 1985. Accepted for publication October 18, 1985. Address for reprints: Jorge L Llera, MD, Department of Emergency Medicine, St Joseph Hospital, 1718 South I Street, Tacoma, Washington 98405.
466/133
AORTA-tNNOMiNAfE VEIN FISTULA Szymanski & Llera
FIGURE 1. Expiratory upright chest radiograph demonstrating a widened mediastinurn. quently increased to 118/40 m m Hg. Portable upright (inspiratory and expiratory) chest radiographs revealed a wide mediastinum but no pneumothorax (Figure 1). An arch-aortogram demonstrated an arteriovenous fistula between the thoracic aorta proximal to the base of the left common carotid and the left innominate vein (Figures 2 and 3). Following angiography, the patient was taken to the operating room, and a median sternotomy was performed. There was a small tear in the thoracic aorta at the takeoff of the left common carotid. The thoracic aorta was repaired. The estimated blood loss during surgery was ten units, and 12 units were reinfused. The patient was taken to the recovery room in satisfactory condition with a mediastinal chest tube in place. In the recovery room, she was placed on a respirator with arterial blood gases of pH, 7.43; PCO2, 40.3 m m Hg; and PO2, 90.5 on 0.40 FiO 2. The chest tube drainage was 118 mL overnight and urine output was normal. The patient was extubated the following day. She was alert and responsive and her lungs were clear on chest radiograph. The remainder of the patient's hospital course was complicated by low-grade fever. Cultures of blood, urine, and s p u t u m were negative. On the 24th postoperative da~ bronchoscopy was performed and the patient was found to have diffuse edema in the left mainstem bronchus. She received IV penicillin and amikacin, became afebrile the following day, and was discharged on the 31st postoperative day in good condition. The patient did not return and was lost to followup. DISCUSSION The occurrence of traumatic arteriovenous fistulae (AVF) involving the thoracic aorta and innominate vein is rare. We were able to find only ten reported cases. Ho Mediastinal structures are particularly at risk to penetrating neck and chest wounds. The high mortality of aortic wounds accounts for the few patients who survive to manifest complications of posttraumatic thoracic 134/467
aneurysms or AVE Kollmeyer found that traumatic AVF comprise approximately 7% of all acute arterial injuries studied. The etiology of injury for these traumatic AVF were gunshot wounds (56.5%), shotgun wounds (11.6%), stab wounds (13%), blunt trauma (17.4%), and iatrogenic causes (1.3%).11 During the Viet Nam War, 7,500 vascular injuries were sustained by Americans. Only 7% resulted in AVF and/or false aneurysms, and none involved the thoracic aorta.12 The patient's history usually is not helpful in diagnosing AVF; however, physical examination is of value when a bruit or thrill is noted.llA 3 Kollmeyerl2 noted that bruits were present in 55% of acute AVF and 92% of chronic AVF in a series of 69 patients. Auscultation is an important part of the examination of any wound in the proximity of a major vessel. A high index of suspicion must be maintained because this injury might not be accompanied by the usual signs of major arterial injury; therefore, the diagnosis can be overlooked during the initial examination. 13 Typically the wound appears insignificant, but the patient presents with massive blood loss or an extensive hematoma over the wound site. The presence of pulses and evidence of perfusion distal to the injury may obscure the diagnoses of arterial injury. For this reaAnnals of Emergency Medicine
son, arteriography is recommended in any hemodynamically stable patient when traumatic AVF is considered, tl Kollmeyer identified 45% of unsuspected AVF by angiography in patients whose only evidence for an AVF on physical examination was a wound in the proximity of a major vessel.11 Also, arteriography can identify the exact location and size of the AVE which helps the surgeon select the best operative approach and treatment. Acute AVF, like other vascular injuries, should be repaired immediately. Definitive repair should be done as soon as is feasible after the injury is recognized, thus avoiding the danger of delayed hemorrhage or the development of false aneurysms. 1a-16 Furthermore, the lesion is easier to repair acutely prior to the development of fibrosis or of collateral vessels. Disparity in the size of the vessels proximal and distal to the fistula will not be seen in acute AVF, as it is in many chronic fistulas. Early repair prevents potential cardiovascular side effects (ie, congestive heart failure) and complications of increased venous pressure and venous insufficiency that commonly occur with chronic AVF.17-19
SUMMARY We reported the llth known case of traumatic thoracic aorta-innominate 15:4 April 1986
FIGURE 2. Arch-aortogram demon-
strating filling of aorta and suggestive of superior vena cava and innominate vein filling. 3. S u b t r a c t i o n archaortogram revealing AVE There is filling with contrast of the aorta arch and innominate vein with fistula just proximal to the base of the left common carotid artery. FIGURE
vein fistula. A 20-year-old w o m a n sustained a stab wound to the chest, resulting in a fistula between the thoracic aorta and the left i n n o m i n a t e vein. She u n d e r w e n t operative repair and recovered.
REFERENCES 1. Proctor WH: Arteriovenous fistula of the aortic arch. JAMA 1950;144:818-819. 2. McCook WW: Arteriovenous fistula of the aortic arch. J Thorac Surg 1952j23: 299-302. 3. Scaly WC, Fawcett B: Arteriovenous fistula of ascending aorta and left innomihate vein. Ann Surg 1955;142:302-303. 4. Conrad JK, Cartwright RS, Mostyn EM: Arteriovenous fistula of the aortic arch. N Engl J Med 1962;267:15-18. 5. Beall AC, Roof WR, DeBakey ME: Suecessful surgical management of through and through stab wound of the aortic arch. Ann Surg 1962;156:823-826. 6. Borst HG, Schaudig A, Rudolph W: Arteriovenous fistula of the aortic arch; repair during deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg 1964;48:443-447. 7. Giraud RM: Arteriovenous fistula of aortic arch complicating stab wound of the neck. S Air Med l 1965;39:474. 8. Tarlov E, Greenfield LJ: Post-traumatic aortic arch aneurysm with arteriovenous fistula to the innominate vein. J Thorac Cardiovasc Surg 1968;55:134-140. 9. Symbas PN, Sehdeva JS: Penetrating wounds of the thoracic aorta. Ann Surg 19701171:441-449. 10. Treiman RL, Cohen JL, Gaspard DJ, et al: Early surgical repair of acute post-traumatic arteriovenous fistulas. Arch Surg 1971;102:559-561. 11. Kollmeyer KR, Hunt JL, Ellman BA, et al: Acute and chronic traumatic arteriovenous fistulae in civilians. Arch Surg 1981; 116:697-702. 12. Martinez E, Meller J, Godoy M, et al: Arteriovenous fistulae of the thoracic aorta: Report of a case presenting with superior vena caval obstruction. Thorax 1981;36:315-318. 15:4 April 1986
Annals of Emergency Medicine
468/135
AORTA-INNOMINATE VEIN FISTULA Szymanski & Llera
13. Hewitt RL, Smith AD, Drapanas T: Acute traumatic arteriovenous fistulas. ] Trauma 1973;13:901-906. 14. Beall AC Jr, Harrington OB, Crawford ES, et al: Surgical management of traumatic arteriovenous aneurysms. A m J Surg 1963; 106:610-618. 15. Hewitt RL, Collins PJ: Acute arteriovenous fistulas in war injuries. Ann Surg
136/469
1969; 169:447-449.
tion 1965;32:1001-1009.
16. Drapanas T, Hewitt RL, Weichert RF, et al: Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 1970;172:351-360.
18. Hughes CW, Jahnke EJ: The surgery of traumatic arteriovenous fistulas and aneurysms. A five year follow up study of 215 lesions. Ann Surg 1959;148:790-797.
17. Holman E: Abnormal arteriovenous communications. Great variability of effects with particular reference to delayed development of cardiac failure. Circula-
19. Pate JW, Sherman RT, Jackson T, et al: Cardiac failure following traumatic arteriovenous fistulae: A report of 14 cases. J Trauma 1965;5:398-403.
Annals of Emergency Medicine
15:4 April 1986