Diagnostic Radiology
Spontaneous Closure of Traumatic Arteriovenous Fistula 1
CASE REPORT A 17-year-old Thai girl had been shot in the right clavicular area three weeks prior to admission. Physical examination demonstrated marked edema about the right shoulder with several small entrance wounds in the right clavicular area. Regional superficial veins were dilated and a continuous murmur was heard in the midclavicular region. Diminution of the brachial and radial pulsations was present; however, sensation and movement of the right upper extremity were normal. Blood pressure in the right arm was 110/70 mm Hg and in the left 130/60 mm Hg. Radiographs of the right clavicle revealed multiple metallic foreign bodies in the infraclavicular region. A comminuted fracture of the right clavicle with separation of fracture fragments and an impacted fracture of the coracoid process of the scapula were present. 'Percutaneous transfemoral right subclavian arteriography on 4 April 1974, demonstrated a large false aneurysm of the subclavian artery at the site of the clavicular fracture, with early filling of the subclavian vein and superior vena cava (Fig. 1). The patient was scheduled for surgery, but left the hospital without treatment and did not return until four months later. Re-examination at this time showed normal motion and sensation. The previously described right midclavicular murmur was no longer present and a blood volume study was normal. Repeat selective right subclavian arteriography was performed on 2 August 1974 (Fig. 2) and the subclavian and axillary artery and their branches were well visualized and appeared normal. One metallic bullet fragment was superimposed over the subclavian artery proximal to the thoraco-acromial and superior thoracic arteries. The previously seen false aneurysm and early draining subclavian vein were no longer present. The midclavicular fracture had good callus formation and was healing well.
Chirotchana Suchato, M.D., Chinda Suwanraks, M.D., Chanchamduang Sukapanpotharam, M.D., and Siricha Sukumalanandana, M.D. A case of spontaneous closure of traumatic arteriovenous fistula with large false aneurysm is reported. The diagnosis was proved by follow-up angiographic study. The closure of the aneurysm is explained by thrombosis followed by fibrosis with occlusion at the venous orifice. INDEX TERMS:
Arteries, wounds and injuries. Fistula; subclavian
Radiology 118:291-292, February 1976
arteriovenous fistulas have been noted to close spontaneously. This has usually occurred in small vessels following renal biopsies (1-5). However, the spontaneous closure of a large traumatic arteriovenous fistula in peripheral vessels is uncommon (6). The pathophysiological and clinical .manifestations of arteriovenous fistulas have been well documented elsewhere (7). Arteriography is essential in the diagnosis and location of the site of the fistula with or without false aneurysm. In the past six years, we have found occasional cases of traumatic arteriovenous fistula at the Ramathibodi Hospital Medical School. There has been only one case of spontaneous closure of a traumatic fistula with associated false aneurysm. This was located in the subclavian vessels and confirmed by serial angiographic studies.
T
RA UMA TIC
Fig. 1. Subtraction film, early phase of selective subclavian arteriography. The subclavian artery ( [> ) communicates with the subclavian vein (J---+) through a large arteriovenous fistula with a false aneurysm (--"). Superior vena cava (e». 1 From the Departments of Radiology (C. Such, C. Suk, S. S.) and Surgery (C. Suw.), Faculty of Medicine, Ramathibodi University Hospital, Bangkok, Thailand. Revised edition accepted for publication in June 1975. elk
291
292
February 1976
CHIROTCHANA SUCHATO AND OTHERS
The angiographic studies show spontaneous closure of the false aneurysm and arteriovenous fistula of the right subclavian vein. The closure occurred secondary to thrombosis of the axlllary vein with extension to the site of the fistUla and false aneurysm. The patient was discharged without surgery.
DISCUSSION
Fig. 2. Repeat selective right subclavian arteriogram four months after initial examination. Note the subclavian artery (e» and adjacent metallic bullet. The distal subclavian artery and axillary artery ([» are intact. No evidence of previously seen false aneurysm or early draining subclavian vein is seen.
Arteriography is essential for diagnosis as well as localization of the site of the fistula, anatomic detail, and hemodynamic evaluation of the injury. Surgical correction of the aneurysm is usually indicated. Spontaneous closure of arteriovenous fistula of large peripheral vessels is a rare condition. In a review of the literature, Schumacher (8) found only 8 cases of spontaneous closure in 119 cases discussed. Only 5 cases were described in a series of 245 arteriovenous fistulas reported in World War II (8). Recently, Billings et el. (6) reported a case with spontaneous closure. The incidence of spontaneous closure of arteriovenous fistula with false aneurysm is higher than that with arteriovenous fistula alone. This may be explained by the sudden change in pressure from the arterial site to the false aneurysm (2). Decreased blood flow allows clot propagation and progressive fibrosis gradually completes the process. The spontaneous closure was shown on serial arteriographic and venographic studies. Department of Radiology Faculty of Medicine, Ramathibodi Hospital Rama VI Road. Bangkok, Thailand
REFERENCES
Fig. 3. Right upper extremity venography demonstrates occlusion of the cephalic ( [» and axillary veins (t» by thrombus to the level of the metallic bullet. Collateral veins are visualized with opacification of the subclavian vein and superior vena cava.
Venographic study of the right upper extremity was performed by rapid injection of 25 ml of 50 % Hypaque into a cubital vein with serial filming of the right clavicular region at 1 film every 2 sec. for 20 sec. (Fig. 3). The cephalic and axillary veins were occluded by thrombus up to the level of the metallic bullet fragment. Venous drainage was by way of collateral veins to the right subclavian vein and the superior vena cava.
1. Bennett AR, Wiener SN: Intrarenal arteriovenous fistula and aneurysm. A complication of percutaneous renal biopsy. Am J RoentgenoI95:372-382, Oct 1965 2. Halpern M: Spontaneous closure of traumatic renal arteriovenous fistulas. Am J Roentgenol 107:730-736, Dec 1969 3. Ekelund L, Lindholm T: Arteriovenous fistulae following percutaneous renal biopsy. Acta Radiol [Diagn] 11:38-48, Jan 1971 4. Ekelund L: Arteriovenous fistulae secondary to renal biopsy. An experimental study in the rabbit. Acta Radiol [Diagn] 10:218224, May 1970 5. Nilsson CG, Ross RJ: Bilateral renal arteriover.ous fistulas and decreased blood pressure following renal biopsies. J Urol 97: 176-179, Feb 1967 6. Billings KJ. Nasca RJ, Griffin HA: Traumatic arteriovenous fistula with spontaneous closure. J Trauma 13:741-743, Aug 1973 7. Gomes MMA, Bernatz PE: Arteriovenous fistulas: a review and ten-year experience at the mayo clinic.' Mayo Clin Proc 45:81102, Feb 1970 8. Schumacher HB Jr: Arterial aneurysms and arteriovenous fistulas: spontaneous cures. [In] Vascular Surgery in World War Elkin DC, De Bakey ME, eds. Medical Department, U. S. Army, Washington D. C., 1955, pp 361-374
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Spontaneous Closure of Traumatic Arteriovenous Fistula 1
CASE REPORT A 17-year-old Thai girl had been shot in the right clavicular area three weeks prior to admission. Physical examination demonstrated marked edema about the right shoulder with several small entrance wounds in the right clavicular area. Regional superficial veins were dilated and a continuous murmur was heard in the midclavicular region. Diminution of the brachial and radial pulsations was present; however, sensation and movement of the right upper extremity were normal. Blood pressure in the right arm was 110/70 mm Hg and in the left 130/60 mm Hg. Radiographs of the right clavicle revealed multiple metallic foreign bodies in the infraclavicular region. A comminuted fracture of the right clavicle with separation of fracture fragments and an impacted fracture of the coracoid process of the scapula were present. 'Percutaneous transfemoral right subclavian arteriography on 4 April 1974, demonstrated a large false aneurysm of the subclavian artery at the site of the clavicular fracture, with early filling of the subclavian vein and superior vena cava (Fig. 1). The patient was scheduled for surgery, but left the hospital without treatment and did not return until four months later. Re-examination at this time showed normal motion and sensation. The previously described right midclavicular murmur was no longer present and a blood volume study was normal. Repeat selective right subclavian arteriography was performed on 2 August 1974 (Fig. 2) and the subclavian and axillary artery and their branches were well visualized and appeared normal. One metallic bullet fragment was superimposed over the subclavian artery proximal to the thoraco-acromial and superior thoracic arteries. The previously seen false aneurysm and early draining subclavian vein were no longer present. The midclavicular fracture had good callus formation and was healing well.
Chirotchana Suchato, M.D., Chinda Suwanraks, M.D., Chanchamduang Sukapanpotharam, M.D., and Siricha Sukumalanandana, M.D. A case of spontaneous closure of traumatic arteriovenous fistula with large false aneurysm is reported. The diagnosis was proved by follow-up angiographic study. The closure of the aneurysm is explained by thrombosis followed by fibrosis with occlusion at the venous orifice. INDEX TERMS:
Arteries, wounds and injuries. Fistula; subclavian
Radiology 118:291-292, February 1976
arteriovenous fistulas have been noted to close spontaneously. This has usually occurred in small vessels following renal biopsies (1-5). However, the spontaneous closure of a large traumatic arteriovenous fistula in peripheral vessels is uncommon (6). The pathophysiological and clinical .manifestations of arteriovenous fistulas have been well documented elsewhere (7). Arteriography is essential in the diagnosis and location of the site of the fistula with or without false aneurysm. In the past six years, we have found occasional cases of traumatic arteriovenous fistula at the Ramathibodi Hospital Medical School. There has been only one case of spontaneous closure of a traumatic fistula with associated false aneurysm. This was located in the subclavian vessels and confirmed by serial angiographic studies.
T
RA UMA TIC
Fig. 1. Subtraction film, early phase of selective subclavian arteriography. The subclavian artery ( [> ) communicates with the subclavian vein (J---+) through a large arteriovenous fistula with a false aneurysm (--"). Superior vena cava (e». 1 From the Departments of Radiology (C. Such, C. Suk, S. S.) and Surgery (C. Suw.), Faculty of Medicine, Ramathibodi University Hospital, Bangkok, Thailand. Revised edition accepted for publication in June 1975. elk
291
292
February 1976
CHIROTCHANA SUCHATO AND OTHERS
The angiographic studies show spontaneous closure of the false aneurysm and arteriovenous fistula of the right subclavian vein. The closure occurred secondary to thrombosis of the axlllary vein with extension to the site of the fistUla and false aneurysm. The patient was discharged without surgery.
DISCUSSION
Fig. 2. Repeat selective right subclavian arteriogram four months after initial examination. Note the subclavian artery (e» and adjacent metallic bullet. The distal subclavian artery and axillary artery ([» are intact. No evidence of previously seen false aneurysm or early draining subclavian vein is seen.
Arteriography is essential for diagnosis as well as localization of the site of the fistula, anatomic detail, and hemodynamic evaluation of the injury. Surgical correction of the aneurysm is usually indicated. Spontaneous closure of arteriovenous fistula of large peripheral vessels is a rare condition. In a review of the literature, Schumacher (8) found only 8 cases of spontaneous closure in 119 cases discussed. Only 5 cases were described in a series of 245 arteriovenous fistulas reported in World War II (8). Recently, Billings et el. (6) reported a case with spontaneous closure. The incidence of spontaneous closure of arteriovenous fistula with false aneurysm is higher than that with arteriovenous fistula alone. This may be explained by the sudden change in pressure from the arterial site to the false aneurysm (2). Decreased blood flow allows clot propagation and progressive fibrosis gradually completes the process. The spontaneous closure was shown on serial arteriographic and venographic studies. Department of Radiology Faculty of Medicine, Ramathibodi Hospital Rama VI Road. Bangkok, Thailand
REFERENCES
Fig. 3. Right upper extremity venography demonstrates occlusion of the cephalic ( [» and axillary veins (t» by thrombus to the level of the metallic bullet. Collateral veins are visualized with opacification of the subclavian vein and superior vena cava.
Venographic study of the right upper extremity was performed by rapid injection of 25 ml of 50 % Hypaque into a cubital vein with serial filming of the right clavicular region at 1 film every 2 sec. for 20 sec. (Fig. 3). The cephalic and axillary veins were occluded by thrombus up to the level of the metallic bullet fragment. Venous drainage was by way of collateral veins to the right subclavian vein and the superior vena cava.
1. Bennett AR, Wiener SN: Intrarenal arteriovenous fistula and aneurysm. A complication of percutaneous renal biopsy. Am J RoentgenoI95:372-382, Oct 1965 2. Halpern M: Spontaneous closure of traumatic renal arteriovenous fistulas. Am J Roentgenol 107:730-736, Dec 1969 3. Ekelund L, Lindholm T: Arteriovenous fistulae following percutaneous renal biopsy. Acta Radiol [Diagn] 11:38-48, Jan 1971 4. Ekelund L: Arteriovenous fistulae secondary to renal biopsy. An experimental study in the rabbit. Acta Radiol [Diagn] 10:218224, May 1970 5. Nilsson CG, Ross RJ: Bilateral renal arteriover.ous fistulas and decreased blood pressure following renal biopsies. J Urol 97: 176-179, Feb 1967 6. Billings KJ. Nasca RJ, Griffin HA: Traumatic arteriovenous fistula with spontaneous closure. J Trauma 13:741-743, Aug 1973 7. Gomes MMA, Bernatz PE: Arteriovenous fistulas: a review and ten-year experience at the mayo clinic.' Mayo Clin Proc 45:81102, Feb 1970 8. Schumacher HB Jr: Arterial aneurysms and arteriovenous fistulas: spontaneous cures. [In] Vascular Surgery in World War Elkin DC, De Bakey ME, eds. Medical Department, U. S. Army, Washington D. C., 1955, pp 361-374
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