Renal Arteriovenous Fistula Treated by EndofistulorrhaEndofistulorrhaphy Richard M. Ehrlich, MD
A renal arteriovenous fistula responsible for diastolic hypertension was repaired without sacrificing renal parenchyma by
endofistulorrhaphy,
a
unique surgical technique.
The fistula site was localized preoperatively by selective renal arteriography. The renal artery was incised and the ostium of the efferent venous channel suture-ligated from within the depths of the artery. The fistula was successfully interrupted, and the patient has remained normotensive. Postoperative arteriography confirmed the absence of the fistula. Vascular surgical procedures sparing renal parenchyma are relatively new, as the most common treatment for this condition had been nephrectomy.
Hunter1 is credited with the first descrip¬ tion of an arteriovenous fistula in 1757, and Varelareported the first intrarenal fistula in 1923. Over 125 cases of renal arteriovenous fistulas have now been documented, but until recently nephrectomy had been the primary sur¬
William gical
treatment.
vascular surgical techniques has examples of renal-sparing proce¬ dures have been reported. This article presents an arteriovenous fistula cured by endofistulorrhaphy, a unique method of interruption of the malformation that obviates the necessity for ablation of renal parenchyma. As
experience with
broadened,
numerous
REPORT OF A CASE A 36-year-old man was referred to UCLA Medical Center with the diagnosis of an arteriovenous fistula. Diastolic hypertension of 160/100 mm Hg and tachycardia, plus a loud, continuous, midepi-
Accepted
for publication Feb 11, 1975. From the Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles. Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, Calif, Jan 19, 1975. Reprint requests to Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles, CA 90024 (Dr. Ehrlich).
gastric bruit, prompted artériographie studies. These revealed a markedly dilated and tortuous right renal artery, immediate fill¬ ing of the renal vein and inferior vena cava on early x-ray films, and an arteriovenous communication in the distal portion of the right renal artery (Fig 1). Renin determinations were nondiagnostic for right renal ischemia: the distal part of the vena cava, 1.08 ng/ml/hr; right renal vein, 1.32 ng/ml/hr; left renal vein, 1.28 ng/ml/hr; and atrial blood, 1.64 ng/ml/hr. increase in cardiac diame¬ urea nitro¬ and creatinine determinations were within normal
A chest roentgenogram revealed ter. Results of
gen (BUN) limits.
urinalysis
were
an
normal, and the blood
Surgical exploration via a flank approach was performed. A marked continuous thrill was palpable over the entire kidney, re¬ nal vein, and vena cava. The arterial vessels were readily dis¬ sected from within the hilum of the kidney, but the actual flstulous communication could not be delineated as multiple veins coursed around the dilated artery. Manual compression over the suspected fistula site caused a definite slowing of the pulse from 100 to 82 beats per minute (Branham sign),' which returned to normal on release of the artery. The renai vein reduced in diame¬ ter from 3 to 1.7 cm during this maneuver. Electromagnetic flowmeter measurement of blood flow within the artery was 400 ml/min, which reduced to 285 ml/min after the repair. The main renal artery was occluded with a vascular clamp, the renal artery was incised, and the ostium of the efferent venous branch was identified. Interrupted vascular 3-0 cardiovascular su¬ tures were placed and tied, resulting in complete disappearance of the thrill within the kidney and renal vein (Fig 2). Several addi¬ tional interrupted sutures of loose intima above the fistulorrhaphy were placed. The kidney remained pink, but the lower pole was somewhat softer than before. The total ischemie time was 20 minutes; 250 ml of blood was lost. The postoperative course was unremarkable, and four months later a second arteriogram (Fig 3) showed a decrease in the cali¬ ber of the renal artery and an absence of the arteriovenous fis¬ tula. The patients blood pressure is currently 120/80 mm Hg and his pulse is 80 beats per minute. He remains asymptomatic two years later.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/02/2015
Fig 1.—Selective right renal arteriogram showing dilated right renal artery, and immediate opacification of renal vein and infe¬ rior vena cava. Exact fistulous site is readily identified.
Fig 2.—Endofistulorrhaphy was performed by opening dilated artery, identifying ostium of venous efferent channel, and suturing fistulous tract from within. renal
COMMENT The causes of arteriovenous fistulas are myriad. Prior to the widespread utilization of percutaneous renal biopsy examinations for diagnostic purposes, congenital and idiopathic fistulas were the most common cause. At present, acquired fistulas from biopsy examinations, trauma, sur¬ gery, neoplasia, and inflammation are being increasingly
reported. The diagnosis is often suggested by cardiovascular manifestations, classically outlined by Holman' in 1940 and reaffirmed by Maldonado et al" and McAlhany et al." The constellation of cardiomegaly or congestive heart fail¬ ure, and diastolic hypertension, is the most common pre¬
sentation with an intra-abdominal bruit present in over three fourths of the patients. The bruit is usually loud, high-pitched, and continuous with systolic accentuation.7 A thrill may be palpable. Other clinical signs, such as hematuria, tachycardia, sys¬ tolic cardiac murmur, and pain, are often found but are less common. In postnephrectomy arteriovenous fistulas, the pathophysiologic findings differ from those associated with a functioning ipsilateral kidney. In the former, the he¬ modynamic consequences of increased cardiac output, in¬ creased venous return, and decreased peripheral resist¬ ance may lead to systolic hypertension, low diastolic blood pressure, and a wide pulse pressure." In the latter instance, with a functioning ipsilateral kidney and arteriovenous fistula, the circulatory changes are the summation of the effects of the Goldblatt phenom¬ enon with those of a peripheral fistula." The diastolic hy-
Fig 3.—Postoperative arteriogram showing right renal artery to be smaller in diameter. Fistula has been successfully interrupted. Renal parenchyma is completely preserved.
pertension, as with the case reported herein, is due to seg¬
mentai renal ischemia distal to the fistula and renininduced vasoconstriction that leads to an increase in pe¬ ripheral resistance. However, the diastolic pressure may be decreased, increased, or even unchanged depending on the size of the fistula and the magnitude of the peripheral effect on the circulation.1" Maldonado et aV' were the first to document segmental renal ischemia distal to an arteriovenous fistula by renography and renal function studies. They reported patho¬ logic confirmation of incomplete renal infarction and histologie changes suggestive of prolonged ischemia. Juxtaglomerular cell counts were considerably higher in the
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/02/2015
kidney distal renchyma.
to the fistula than
surrounding normal
pa¬
As Holman and
Taylor11 suggested, the systemic effects largely dependent on the size of the fistula. In those instances with minimal arteriovenous shunting, the fis¬ tula may produce no symptoms if the distal ischemia is correspondingly small and circulatory effects are minimal. This is seen with percutaneous renal biopsy examination, where most fistulas are small, disappear spontaneously, and have no recognizable systemic effects. The diagnostic work-up should include intravenous ur¬ ography or nephrotomography or both, which may show an irregular filling defect in the affected renal pelvis or ca¬ lix caused by compression from dilated vessels.12 The de¬ finitive diagnostic procedure, however, is arteriography, utilizing selective renal artery studies combined with im¬ age intensification and subtraction x-ray films. Early re¬ nal vein or vena cavai opacification is usually present and diagnostic. The exact point or points of fistulization can most often be delineated with these sophisticated roent¬ genographic techniques and the afferent feeding vessels mapped preoperatively. Complementary studies, such as radioactive scans and renograms, dye dilution procedures, and split renal func¬ tion studies, are often helpful. Renal vein renin sampling may be performed but is usually nondiagnostic in that the renin increase from the affected underperfused kidney may be substantially diluted by the arterialized blood are
from the fistula.13 Measurements of cardiac output, circu¬ lation time, and venous oxygen saturation are additional indices of the circulatory state. Utilizing microspheres la¬ beled with iodinated I 131 serum albumin aggregated, the degree of arteriovenous shunting may be quantitated.14 The treatment of arteriovenous fistulas is dictated by the severity of the symptoms and the effects on the cir¬ culatory dynamics of the patient. In an asymptomatic pa¬ tient, when kidney parenchyma is not at risk, noninter¬ vention may be the wisest course.15 As previously mentioned, fistulas after percutaneous re¬ nal biopsy examination will usually close spontaneously.16 O'Conor et al,'T however, state that approximately 4% per¬ sist and they reported on the necessity for surgical inter¬ vention due to the possibility of rupture. Other authors be¬ lieve that rupture of an arteriovenous fistula is rare,18 but several cases have been reported. 19,2° Symptoms of cardiac decompensation, pain, and hematuria caused by the malformation eroding renal substance, or hypertension not easily controlled with medical ther¬ apy, are unquestioned indications for surgical interven¬ tion. Progressive enlargement of the fistula places both the involved kidney and patient at risk and in this setting should be surgically corrected.21,22 Most surgically treated arteriovenous fistulas have led to nephrectomy, and Tynes et al23 believe that congenital or cirsoid fistulas with multiple vascular ramifications will continue to be so treated. The first reported case of renal salvage by partial ne¬ phrectomy was performed by Edsman24 in 1957, and since
that time increasing numbers of cases have been handled by either partial2"27 or segmental resection,13 excision of the fistula,22-28 afferent arterial ligation, or a combination of these techniques. Cosgrove et al2a listed nine cases sur¬ gically treated without resection of renal tissue and added three cases of branch renal artery ligation. From an extensive review of the literature, I have been able to find seven additional cases1617'21'22-30"32 with com¬ plete renal preservation by the utilization of precise vas¬ cular surgical techniques, and I have added the present case to the growing number. Several interesting examples of surgical ingenuity within this group deserve comment. Waterhouse et al33 performed a nephrotomy over the malformation and oblit¬ erated the fistulous sac. Merritt and Middleton28 subtotally excised an arteriovenous aneurysm, and Merkel and Sako30 obliterated the fistula through the efferent venous channel. The technique detailed in this case report (Fig 2) shows the advantage of precise preoperative mapping of renal vascular architecture. The exact point of fistulization was identified, thus making fistulorrhaphy from within the di¬ lated renal artery an uncomplicated task. To my knowl¬ edge, this unique approach is unreported, but it is pat¬ terned after the original description of arteriorrhaphy by Matas in 1903.34 The Doppler flowmeter is an additional aid that is often helpful in localizing the fistula and ensuring that all vas¬ cular channels have been interrupted.21-35 In those patients who are considered to be poor surgical risks and in whom treatment seems necessary, selective arterial embolization techniques using autologous clots, muscle fragments, or absorbable gelatin sponge have been reported to be successful.36 3? This, however, must be un¬ dertaken with caution in large fistulas without an inter¬ vening capillary bed, as pulmonary emboli can result. Recent advances in renal preservation,38 workbench sur¬ gery,39 and autotransplantation,40-48 will no doubt be uti¬ lized in fistula surgery with greater frequency in the fu¬ ture, rendering renal parenchymal salvage the rule, rather than the exception. Terence J. Fitzpatrick, MD, Southern California Permanente Medical Los Angeles, referred this patient.
Group,
Nonproprietary Iodinated I 131
bumotope-LS,
Name and Trademarks of
Drug
albumin aggregated—Albumotope-H, AlMAA 11318 Human, Macroscan-131. serum
References 1. Hunter W: The history of an aneurysm of the aorta, with some remarks on aneurysms in general. Med Observations Inquiries 1:323, 1757. 2. Varela ME: Aneurisma arteriovenoso de los vasos renales y asistolia consecutiva. Rev Med Lat Am 14:3244-3266, 1928. 3. Fry WJ: Surgical considerations in congenital arteriovenous fistula. Surg Clin North Am 54:165-174, 1974. 4. Holman E: The anatomic and physiologic effects of an arteriovenous fistula. Surgery 8:362, 1940. 5. Maldonado JE, Sheps SG, Bernatz PE, et al: Renal arteriovenous fistula: A reversible cause of hypertension and heart failure. Am J Med
37:499-513, 6.
1964.
McAlhany JC,
Black HC Jr, Hanback LD, et al: Renal arteriovenous
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/02/2015
fistula as a cause of hypertension. Am J Surg 122:117-120, 1971. 7. Diaz-Buxo JA, Kopen DF, Donadio JV Jr: Renal allograft arteriovenous fistula following percutaneous biopsy. J Urol 112:577-580, 1974. 8. Shirey EK: Cardiac disease secondary to post-nephrectomy arteriovenous fistula: Report of a case. Cleve Clin Q 26:188-200, 1959. 9. Grace JT, Staubitz W, Lessmann F, et al: Intrarenal arteriovenous fistula. Arch Surg 81:718-722, 1960. 10. Esquivel EL Jr, Grabstald H: Renal arteriovenous fistula following nephrectomy for renal cell cancer. J Urol 92:367-373, 1964. 11. Holman E, Taylor A: Problems in dynamics of blood flow: II. Pressure relations at site of arteriovenous fistula. Angiology 3:415, 1952. 12. Po JB, Ehrlich RM, Arndt MD, et al: Arteriovenous malformations: The value of renal angiography for a filling defect in the renal pelvis. J Urol, to be published. 13. Nelson BD, Brosman SA, Goodwin WE: Renal arteriovenous fistulas. J Urol 109:779-784, 1973. 14. Siegel ME, Giargiana FA Jr, Wagner HN Jr: Verification and quanitification of anatomic arteriovenous shunting in a hypernephroma. J Urol 112:16-18, 1974. 15. Kaufman JJ, Gordon A, Maxwell MH: Intrarenal arteriovenous fistula following needle biopsy of the kidney. Calif Med 103:350-354, 1965. 16. Leiter E, Gribetz D, Cohen S: Arteriovenous fistula after percutaneous needle biopsy: Surgical repair with preservation of renal function. N Engl J Med 287:971-972, 1972. 17. O'Conor VJ Jr, Bergan JJ: Surgical repair in a solitary kidney of a large intrarenal arteriovenous fistula resulting from needle biopsy. J Urol 109:934-937, 1973. 18. Tunner WS, Middleton RG, Watson RW, et al: Repair of an intrarenal arteriovenous fistula with preservation of the kidney. J Urol 103:286\x=req-\ 289, 1970. 19. Sauter KE, Sargent JW: Spontaneous rupture of intrarenal arteriovenous fistula: Report of a case. J Urol 83:17, 1960. 20. Sanoudos GM, Berenbaum E, Clauss RH: Ruptured renal arteriovenous fistula. JAMA 219:1581, 1972. 21. Gibbons RP, Correa RJ Jr, Tremann JA: Management of intrarenal vascular malformations. Urology 1:136-140, 1973. 22. Kostiner AI, Burnett LL: Intrarenal arteriovenous fistula: Documented increase in size during an eight-year interval in one case and surgical treatment with renal salvage in another. Radiology 109:531, 1973. 23. Tynes WV, Devine CJ Jr, Devine PC, et al: Surgical treatment of renal arteriovenous fistulas: Report of five cases. J Urol 103:692-698, 1970. 24. Edsman G: Angionephrography and suprarenal angiography. Acta Radiol 155:110, 1957. 25. Boijsen E, Kohler R: Renal arteriovenous fistulae. Acta Radiol 57:433, 1962. 26. Milloy F Jr, Fell EH, Dillon RF, et al: Intrarenal arteriovenous fistula with hypertensive cardiovascular disease. Am J Surg 96:3-11, 1958. 27. Palmer JM, Connolly JE: Intrarenal arteriovenous fistula: Surgical excision under selective renal hypothermia with kidney survival. J Urol
96:599-605, 1966. 28. Merritt BA, Middleton RG: Repair of a huge renal arteriovenous aneurysm with preservation of the kidney. J Urol 107:521-523, 1972. 29. Cosgrove MD, Mendez R, Morrow JW: Branch artery ligation for renal arteriovenous fistula. J Urol 110:632-638, 1973. 30. Merkel FK, Sako Y: Surgical treatment for traumatic renal arteriovenous fistulas. Arch Surg 101:438-441, 1970. 31. Javadpour N, Dellon AL, Vermess M, et al: Intrarenal arteriovenous fistula: Early surgical repair with preservation of renal parenchymal. Urology 1:457-459, 1973. 32. Wise HA II, Winter CC, Molner W, et al: Management of renal arte-
riovenous fistula and carcinoma in the opposite kidney: An unusual combination. J Urol 112:433-437, 1974. 33. Waterhouse K, Wesolowski SA, McGoan AJ Jr: Intrarenal arteriovenous fistula: Surgical treatment with salvage of the kidney. J Urol 92:256-260, 1964. 34. Matas R: An operation for the radical cure of aneurysm based upon
arteriorrhaphy.
Ann Surg 37:161-196, 1903. 35. Lichti EL, Erickson TG: Traumatic arteriovenous fistula: Clinical evaluation and intraoperative monitoring with the Doppler ultrasonic flowmeter. Am J Surg 127:333-335, 1974. 36. Bookstein JJ, Goldstein HM: Successful management of post-biopsy arteriovenous fistula with selective arterial embolization. Radiology 109:535, 1973. 37. Ring EJ, Waltman AC, Athanasoulis C, et al: Angiography in pelvic trauma. Surg Gynecol Obstet 139:375-380, 1974. 38. Sacks SA, Petritsch PH, Kaufman JJ: Canine kidney preservation using a new perfusate. Lancet 1:1024-1028, 1973. 39. Milsten R, Neifield J, Koontz WW Jr: Extracorporeal renal surgery. J Urol 112:425-427, 1974. 40. Marshall VF, Whitsell J, McGovern JH, et al: The practicality of renal autotransplantation in humans. JAMA 196:1154, 1966. 41. Martinez-Pi\l=n~\eiro JA, Sicilia LS: Kidney autotransplantation for the treatment of renal artery stenosis: Report of two cases. J Urol 108:35-39, 1972. 42. Lim RC Jr, Eastman AB, Blaisdell FW: Renal autotransplantation. Arch Surg 105:847-852, 1972. 43. Rhame RC: Application of renal autotransplantation to the treatment of simultaneous bilateral ureteral tumors. Br J Urol 45:388, 1973. 44. Clune GJA, Hartley LCJ, Collins GM, et al: Renovascular hypertension: The place of renal autotransplantation. Br J Surg 60:562, 1973. 45. Orcutt TW, Foster JH, Richie RE, et al: Bilateral ex vivo renal artery reconstruction with autotransplantation. JAMA 228:493, 1974. 46. Hodges CV, Lawson RK, Pearse HD, et al: Autotransplantation of the kidney. J Urol 110:20-23, 1973. 47. Lawson RK, Hodges CV: Extracorporeal renal artery repair and autotransplantation. Urology 4:532-539, 1974. 48. Pfister RR, Husberg B: Renal salvage through autotransplantation. Urology 4:703-705, 1974.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/02/2015