Renal Arteriovenous Fistula after Nephrectomy Arlindo Matos, MD, Alexandre Moreira. MD, Mergulhao Mendon~a, MD,
Porto, Portugal
Postnephrectomy renal arteriovenous fistulas are rare. An arteriovenous fistula of the right renal pedicle was discovered in a 37-year-old woman who had undergone nephrectomy for renal tuberculosis nine months previously, after she had complained of dyspnea and pain in the right flank. The fistula was confirmed on arteriograms. Proximal ligation of the artery and distal ligation of the vein were followed by an uneventful recovery. Twelve months later, the patient was asymptomatic. Even though complete excision of the fistula represents the ideal treatment of this type of lesion, simple ligation can provide good results when the size of the fistula contraindicates embolization. (Ann Vasc Surg 1992;6:378-380). KEY WORDS: Arteriovenous fistula; renal artery; renal vein; postoperative complications; nephrectomy.
A n o m a l o u s communication between the renal artery and vein constitutes a rare pathological condition, described for the first time by William Hunter in 1757 [1]. Between that date and 1980, 200 congenital or acquired renal fistulas have been reported in the literature [2]. Excluding fistula secondary to trauma, carcinoma, arteritis, or following percutaneous biopsy {2], p o s t n e p h r e c t o m y arteriovenous fistula remains an exceptional clinical entity. Reviews found in the world literature have included 33 cases in 1973 [3], 46 cases in 1978 [4], 54 cases in 1979 [5], and 62 cases in 1985 [6]. It follows that p o s t n e p h r e c t o m y arteriovenous fistula is a rare complication of an otherwise frequently performed operation [7,8].
From the Department of Vascular Surgeo', Hospital Geral de Santo Antonio, Porto, Portugal. Reprint requests: Dr. A. Moreira, Department of Vascular Surgery, Hospital Geral de Santo Antonio, Largo do Prof. Abel Salazar, 4000 Porto, Port,gal.
CASE REPORT A 37-year-old woman, having undergone a right nephrectomy for tuberculosis nine months previously, was admitted for workup of mild dyspnea and the discovery of a systolic-diastolic bruit in the right flank. Upon clinical examination, a thrill was found in the right flank. Cardiac auscultation, electrocardiogram, and sonograms were not contributive and, notably, no signs or symptoms of cardiac failure were found. Standard thoracic films showed an increased cardiothoracic ratio. Kidney function was normal. The diagnosis of arteriovenous fistula of the renal pedicle was confirmed by transfemoral retrograde aortograms (Fig. 1), which showed a large communication between a single renal artery and vein through a distal false aneurysm. Double ligation of the right renal artery and vein was performed through a midline laparotomy. Postoperative recovery was uneventful, and the patient was discharged on day 7 with tuberculostatic treatment. Twelve months after operation, the patient was asymptomatic. DISCUSSION P o s t n e p h r e c t o m y arteriovenous fistula of the renal pedicle is found more often on the right (75% of cases) [4] and after en bloc ligation of the renal
378
VOLUME 6 No 4 - 1992
379
R E N A L A R T E R I O V E N O U S FISTULA
Fig. 1. Aortography demonstrating a large communication between a single renal artery and vein through a distal false aneurysm.
pedicle. Arteriovenous fistula develops most often after nephrectomy for infection or carcinoma [9]. Tuberculosis was the indication for nephrectomy in the patient described herein. Diagnosis of renal arteriovenous fistula is occasionally made late, as some cases have been reported up to 40 years after nephrectomy (mean 14.5 years). The diagnosis is usually suggested when a patient experiences heart failure or complains of atypical pain. Fistulas have also been discovered by chance [10]. Early discovery is usually dependent on the caliber of the fistula. The larger arteriovenous fistulas can be responsible for increased heart flow and decreased peripheral resistance which lead to diastolic overload and then to high flow heart failure [7]. At the time of diagnosis, 90% of patients have a bruit which can be heard over the corresponding flank, 80% have cardiomegaly, 50% have signs of heart failure and 40% experience pain [11]. While diagnosis is essentially clinical, complementary investigations remain useful. Thoracic films can show cardiomegaly. Abdominal films can show small calcifications in the wall of the arteriovenous communication. Sonograms, pulsed Doppler combined with sonograms, and abdominal computed tomographic (CT) scan can suggest or confirm the diagnosis. Aortography is the mainstay of preoperative investigations, visualizing all the feeding and drainage pedicles of the fistula, as well as the contralaterat kidney and its pedicle [2,9,12,13]. Postnephrectomy arteriovenous fistula should be treated because of pain, the risk of rupture, but above
all because of the risk of heart failure. Three therapeutic modalities are available including complete excision of the fistulous tract, simple ligation of the arterial and venous pedicles, and embolization. The treatment of choice remains complete excision of the arteriovenous fistula, after control of the aorta and the inferior vena cava. Simple ligation of the renal artery and vein, advocated by several authors [13], presents the risk of recurrence, related to the possible collateral vascularization by the diaphragmatic or suprarenal vessels [12]. Selective embolization with coils [14], detachable balloons [15], or even cyanacrylate [16] can be used in the case of solitary, small caliber, arteriovenous fistula whenever there is no risk that the embotization material will course through the fistula without being stopped. Our therapeutic choice was simple ligation. Both of the other techniques were contraindicated because the fistula was too large to allow embolization safely and excision was hazardous due to inflammation surrounding the fistula. In conclusion, by the choice of an adapted strategy, therapeutic efficacy in the treatment of postnephrectomy arteriovenous fistula attains the 97% level [ 12].
REFERENCES 1. BUNTER W. The history of an aneurysm of the aorta with some remarks on aneurysms in general. Med Observ Inquiries 1757:/:323. 2. TYNES WV. Unusual renovascular disorders. Urol Clin N Ant t984:11:529-54l. 3. I,ACOMBE M. NUSSAUME O. BRONSTEIN M. JUNGERS P. Les fistules arterio-veineuses du pedicule renal apres nephrectomie. Ann Chir Thorac Cardiovasc 1973:/2:91-97. 4. M1LLERET P. COMBE J. DREYFUS A. et al. Fistule artdrioveineuse du p~dicule renal gauche apres nephrectomie. J Chir 1978:115:541-544. 5. LANGERON P. THEVENET A. CROCCEL L, et al. Les fistules artdrio-veineuses du pedicule renal apres nephrectomie. J Mal Vase 1980:5:55-62. 6, LACOMBE M. Renal arteriovenous fistula following nephrectomy. Urology 1985:25:13-16. 7. CUMM1NGS KB, JOLLY PC. GRABER JO, BUMETT LL, Arteriovenous fistula of the renal vessels: surgical management. J Urol 1975:114:776-778. 8. MATEO A. LARRANAGA J, VAQUERO C, et al. Postnephrectomy arteriovenous fistula. J Cardiovasc Surg 1988;29: 491-493, 9. FELDMAN SL. PRESMAN D, KANDEL GI,. Renal arteriovenous fistula following nephrectomy. Br J Urol 1985:57: 592. 10. DUBOST C. PIWN1CA A. MATHIS P, FONTANELLE J. l,es fistules artdrio-veineuses du pedicule r~nal apres nephrectomie. J Chir 1965:89:5-22. 11. MALDONADO JE, SHEPS SG, BERNATZ PE, et al. Renal arteriovenous fistula: a reversible cause of hypertension and heart failure. Am J Med 1964;37:49%513. 12. JOYEUX A, SAINT-AUBERT B, CAMPOS A. Fistule arterio-veineuse du pedicule renal gauche depistde 30 ans apr~s une nephrectomie. J Chir 1984;121:487-490.
380
R E N A L ARTERIOVENOUS FISTULA
13. DZSINICH C, SZABO Z, DLUSTUS B, et al. Arteriovenous fistula after partial nephrectomy: successful surgical repair. Thorac Cardiovasc Sttrg 1984:32:325-328. 14. CASSIDY MJ, HARRIES-JONES EP, YAN ZYL-SMIT R. Post-biopsy renal arteriovenous fistula. Successfully embolized with a Gianturco minicoil, Postgrad Med J 1982:58: 570-572.
mmm
ANNALS OF VASCULARSURGERY
15. COURTHEOUX P, MAIZA D, MANI J, et al. Postnephrectomy arteriovenous fistula of the renal pedicle treated with detachable balloons. Cardiovasc lntervent Radio/ 1988;11: 340-342. 16. KERBER CW, FREENY PC, CROMWELL L, et al. Cyanoacrylate occlusion of a renal arteriovenous fistula. A JR 1977:128:663~65.
Porto, Portugal
Postnephrectomy renal arteriovenous fistulas are rare. An arteriovenous fistula of the right renal pedicle was discovered in a 37-year-old woman who had undergone nephrectomy for renal tuberculosis nine months previously, after she had complained of dyspnea and pain in the right flank. The fistula was confirmed on arteriograms. Proximal ligation of the artery and distal ligation of the vein were followed by an uneventful recovery. Twelve months later, the patient was asymptomatic. Even though complete excision of the fistula represents the ideal treatment of this type of lesion, simple ligation can provide good results when the size of the fistula contraindicates embolization. (Ann Vasc Surg 1992;6:378-380). KEY WORDS: Arteriovenous fistula; renal artery; renal vein; postoperative complications; nephrectomy.
A n o m a l o u s communication between the renal artery and vein constitutes a rare pathological condition, described for the first time by William Hunter in 1757 [1]. Between that date and 1980, 200 congenital or acquired renal fistulas have been reported in the literature [2]. Excluding fistula secondary to trauma, carcinoma, arteritis, or following percutaneous biopsy {2], p o s t n e p h r e c t o m y arteriovenous fistula remains an exceptional clinical entity. Reviews found in the world literature have included 33 cases in 1973 [3], 46 cases in 1978 [4], 54 cases in 1979 [5], and 62 cases in 1985 [6]. It follows that p o s t n e p h r e c t o m y arteriovenous fistula is a rare complication of an otherwise frequently performed operation [7,8].
From the Department of Vascular Surgeo', Hospital Geral de Santo Antonio, Porto, Portugal. Reprint requests: Dr. A. Moreira, Department of Vascular Surgery, Hospital Geral de Santo Antonio, Largo do Prof. Abel Salazar, 4000 Porto, Port,gal.
CASE REPORT A 37-year-old woman, having undergone a right nephrectomy for tuberculosis nine months previously, was admitted for workup of mild dyspnea and the discovery of a systolic-diastolic bruit in the right flank. Upon clinical examination, a thrill was found in the right flank. Cardiac auscultation, electrocardiogram, and sonograms were not contributive and, notably, no signs or symptoms of cardiac failure were found. Standard thoracic films showed an increased cardiothoracic ratio. Kidney function was normal. The diagnosis of arteriovenous fistula of the renal pedicle was confirmed by transfemoral retrograde aortograms (Fig. 1), which showed a large communication between a single renal artery and vein through a distal false aneurysm. Double ligation of the right renal artery and vein was performed through a midline laparotomy. Postoperative recovery was uneventful, and the patient was discharged on day 7 with tuberculostatic treatment. Twelve months after operation, the patient was asymptomatic. DISCUSSION P o s t n e p h r e c t o m y arteriovenous fistula of the renal pedicle is found more often on the right (75% of cases) [4] and after en bloc ligation of the renal
378
VOLUME 6 No 4 - 1992
379
R E N A L A R T E R I O V E N O U S FISTULA
Fig. 1. Aortography demonstrating a large communication between a single renal artery and vein through a distal false aneurysm.
pedicle. Arteriovenous fistula develops most often after nephrectomy for infection or carcinoma [9]. Tuberculosis was the indication for nephrectomy in the patient described herein. Diagnosis of renal arteriovenous fistula is occasionally made late, as some cases have been reported up to 40 years after nephrectomy (mean 14.5 years). The diagnosis is usually suggested when a patient experiences heart failure or complains of atypical pain. Fistulas have also been discovered by chance [10]. Early discovery is usually dependent on the caliber of the fistula. The larger arteriovenous fistulas can be responsible for increased heart flow and decreased peripheral resistance which lead to diastolic overload and then to high flow heart failure [7]. At the time of diagnosis, 90% of patients have a bruit which can be heard over the corresponding flank, 80% have cardiomegaly, 50% have signs of heart failure and 40% experience pain [11]. While diagnosis is essentially clinical, complementary investigations remain useful. Thoracic films can show cardiomegaly. Abdominal films can show small calcifications in the wall of the arteriovenous communication. Sonograms, pulsed Doppler combined with sonograms, and abdominal computed tomographic (CT) scan can suggest or confirm the diagnosis. Aortography is the mainstay of preoperative investigations, visualizing all the feeding and drainage pedicles of the fistula, as well as the contralaterat kidney and its pedicle [2,9,12,13]. Postnephrectomy arteriovenous fistula should be treated because of pain, the risk of rupture, but above
all because of the risk of heart failure. Three therapeutic modalities are available including complete excision of the fistulous tract, simple ligation of the arterial and venous pedicles, and embolization. The treatment of choice remains complete excision of the arteriovenous fistula, after control of the aorta and the inferior vena cava. Simple ligation of the renal artery and vein, advocated by several authors [13], presents the risk of recurrence, related to the possible collateral vascularization by the diaphragmatic or suprarenal vessels [12]. Selective embolization with coils [14], detachable balloons [15], or even cyanacrylate [16] can be used in the case of solitary, small caliber, arteriovenous fistula whenever there is no risk that the embotization material will course through the fistula without being stopped. Our therapeutic choice was simple ligation. Both of the other techniques were contraindicated because the fistula was too large to allow embolization safely and excision was hazardous due to inflammation surrounding the fistula. In conclusion, by the choice of an adapted strategy, therapeutic efficacy in the treatment of postnephrectomy arteriovenous fistula attains the 97% level [ 12].
REFERENCES 1. BUNTER W. The history of an aneurysm of the aorta with some remarks on aneurysms in general. Med Observ Inquiries 1757:/:323. 2. TYNES WV. Unusual renovascular disorders. Urol Clin N Ant t984:11:529-54l. 3. I,ACOMBE M. NUSSAUME O. BRONSTEIN M. JUNGERS P. Les fistules arterio-veineuses du pedicule renal apres nephrectomie. Ann Chir Thorac Cardiovasc 1973:/2:91-97. 4. M1LLERET P. COMBE J. DREYFUS A. et al. Fistule artdrioveineuse du p~dicule renal gauche apres nephrectomie. J Chir 1978:115:541-544. 5. LANGERON P. THEVENET A. CROCCEL L, et al. Les fistules artdrio-veineuses du pedicule renal apres nephrectomie. J Mal Vase 1980:5:55-62. 6, LACOMBE M. Renal arteriovenous fistula following nephrectomy. Urology 1985:25:13-16. 7. CUMM1NGS KB, JOLLY PC. GRABER JO, BUMETT LL, Arteriovenous fistula of the renal vessels: surgical management. J Urol 1975:114:776-778. 8. MATEO A. LARRANAGA J, VAQUERO C, et al. Postnephrectomy arteriovenous fistula. J Cardiovasc Surg 1988;29: 491-493, 9. FELDMAN SL. PRESMAN D, KANDEL GI,. Renal arteriovenous fistula following nephrectomy. Br J Urol 1985:57: 592. 10. DUBOST C. PIWN1CA A. MATHIS P, FONTANELLE J. l,es fistules artdrio-veineuses du pedicule r~nal apres nephrectomie. J Chir 1965:89:5-22. 11. MALDONADO JE, SHEPS SG, BERNATZ PE, et al. Renal arteriovenous fistula: a reversible cause of hypertension and heart failure. Am J Med 1964;37:49%513. 12. JOYEUX A, SAINT-AUBERT B, CAMPOS A. Fistule arterio-veineuse du pedicule renal gauche depistde 30 ans apr~s une nephrectomie. J Chir 1984;121:487-490.
380
R E N A L ARTERIOVENOUS FISTULA
13. DZSINICH C, SZABO Z, DLUSTUS B, et al. Arteriovenous fistula after partial nephrectomy: successful surgical repair. Thorac Cardiovasc Sttrg 1984:32:325-328. 14. CASSIDY MJ, HARRIES-JONES EP, YAN ZYL-SMIT R. Post-biopsy renal arteriovenous fistula. Successfully embolized with a Gianturco minicoil, Postgrad Med J 1982:58: 570-572.
mmm
ANNALS OF VASCULARSURGERY
15. COURTHEOUX P, MAIZA D, MANI J, et al. Postnephrectomy arteriovenous fistula of the renal pedicle treated with detachable balloons. Cardiovasc lntervent Radio/ 1988;11: 340-342. 16. KERBER CW, FREENY PC, CROMWELL L, et al. Cyanoacrylate occlusion of a renal arteriovenous fistula. A JR 1977:128:663~65.
