High-output heart failure due to post-traumatic peroneal arteriovenous fistula Daisuke Imai, MD,a,b Shinsuke Mii, MD, PhD,b Kiyoshi Tanaka, MD, PhD,b Takuya Matsumoto, MD, PhD,a and Yoshihiko Maehara, MD, PhD,a Fukuoka, Japan
A 69-year-old man was admitted because of increasing respiratory distress with 74% of a cardiothoracic ratio on chest X ray. He was diagnosed with high-output heart failure classified as New York Heart Association classification II from the hemodynamic data, showing 3.84 L/min/m2 of a cardiac index and detection of a patent foramen ovale. He had a history of left tibia fracture 50 years prior; thereafter, the arteriovenous fistula (AVF) had been noted. He had never had any symptoms except for a markedly swollen left leg. He took warfarin for atrial fibrillation and a calcium channel blocker for hypertension. Three-dimensional computed tomography and selective angiography revealed the peroneal AVF just distal to the origin of the peroneal artery and a remarkable dilation of vein and artery cephalad to the AVF with saccular aneurysmal change of the vein at the AVF (A and B). The peroneal artery distal to the AVF, the anterior tibial artery, and posterior tibial artery were perfectly patent. The patient in a prone position underwent direct suture of the fistula following opening the aneurysmal vein through a posterior approach (C). Reefing of the aneurysmal vein was performed to prevent thrombus formation and pulmonary embolism. The patient’s heart failure improved immediately after surgery. One month after surgery, his hemodynamic data were improved (cardiac index, 2.68L/min/m2; cardiothoracic ratio, 62%), and the patent foramen ovale was closed. Disappearance of the AVF was revealed in computed tomography (D). The patient suffered from difficulty in extending the left knee in the short term following surgery, which disappeared 2 months postsurgery. Currently, the patient lives an independent daily life without any limitation. DISCUSSION Recently, the endovascular approach for post-traumatic AVF and pseudoaneurysm has been developed; many cases, even tibial arteries, have been reported.1,2 This includes coil embolization and/or the deployment of covered stent grafts. In this case, the endovascular approach was thought to be difficult for the following reasons. (1) The diameter of the AVF was too large, and the length of the AVF was too short for coil embolization. (2) The difference in diameter of arteries (between proximal and distal to the fistula) was too large for the placement of a covered stent; this not an approved health insurance treatment in Japan.
From the Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu Universitya; and the Vascular Disease Center, Steel Memorial Yawata Hospital.b 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 JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:1121-2 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.06.091
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REFERENCES 1. Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Laganà D, Carrafiello G, et al. Stent graft repair of peroneal arteriovenous fistula. Cardiovasc Intervent Radiol 2007;30:133-5. 2. Albrecht RJ, Parra JR. Traumatic peroneal artery pseudoaneurysm: use of preoperative coil embolization. J Vasc Surg 2004;39:912. Submitted Mar 18, 2013; accepted Jun 30, 2013.
JOURNAL OF VASCULAR SURGERY April 2014
A 69-year-old man was admitted because of increasing respiratory distress with 74% of a cardiothoracic ratio on chest X ray. He was diagnosed with high-output heart failure classified as New York Heart Association classification II from the hemodynamic data, showing 3.84 L/min/m2 of a cardiac index and detection of a patent foramen ovale. He had a history of left tibia fracture 50 years prior; thereafter, the arteriovenous fistula (AVF) had been noted. He had never had any symptoms except for a markedly swollen left leg. He took warfarin for atrial fibrillation and a calcium channel blocker for hypertension. Three-dimensional computed tomography and selective angiography revealed the peroneal AVF just distal to the origin of the peroneal artery and a remarkable dilation of vein and artery cephalad to the AVF with saccular aneurysmal change of the vein at the AVF (A and B). The peroneal artery distal to the AVF, the anterior tibial artery, and posterior tibial artery were perfectly patent. The patient in a prone position underwent direct suture of the fistula following opening the aneurysmal vein through a posterior approach (C). Reefing of the aneurysmal vein was performed to prevent thrombus formation and pulmonary embolism. The patient’s heart failure improved immediately after surgery. One month after surgery, his hemodynamic data were improved (cardiac index, 2.68L/min/m2; cardiothoracic ratio, 62%), and the patent foramen ovale was closed. Disappearance of the AVF was revealed in computed tomography (D). The patient suffered from difficulty in extending the left knee in the short term following surgery, which disappeared 2 months postsurgery. Currently, the patient lives an independent daily life without any limitation. DISCUSSION Recently, the endovascular approach for post-traumatic AVF and pseudoaneurysm has been developed; many cases, even tibial arteries, have been reported.1,2 This includes coil embolization and/or the deployment of covered stent grafts. In this case, the endovascular approach was thought to be difficult for the following reasons. (1) The diameter of the AVF was too large, and the length of the AVF was too short for coil embolization. (2) The difference in diameter of arteries (between proximal and distal to the fistula) was too large for the placement of a covered stent; this not an approved health insurance treatment in Japan.
From the Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu Universitya; and the Vascular Disease Center, Steel Memorial Yawata Hospital.b 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 JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:1121-2 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.06.091
1121
1122 Imai et al
REFERENCES 1. Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Laganà D, Carrafiello G, et al. Stent graft repair of peroneal arteriovenous fistula. Cardiovasc Intervent Radiol 2007;30:133-5. 2. Albrecht RJ, Parra JR. Traumatic peroneal artery pseudoaneurysm: use of preoperative coil embolization. J Vasc Surg 2004;39:912. Submitted Mar 18, 2013; accepted Jun 30, 2013.
JOURNAL OF VASCULAR SURGERY April 2014
