Traumatic Superior Mesenteric Artery Portal Vein Fistula J. Deitrick, MD, P. McNeill, MD, M.P. Posner, MD, J. Kellum, MD, S. Cho, MD, J. Tisnado, MD, H.M. Lee, MD, Richmond, Virginia
An interesting and rare case of traumatic superior mesenteric artery-to-portal vein arteriovenous fistula is presented. Initial operative control of the bleeding superior mesenteric artery injury required ligation of the superior mesenteric artery at its origin to prevent exsanguination in an extremely unstable patient with multiple injuries. Early postoperative visceral arteriography documented ligation of the superior mesenteric artery with a proximal superior mesenteric artery-to-portal vein arteriovenous fistula. Percutaneous catheter embolization of the arteriovenous fistula was undertaken successfully at this time. Superior mesenteric artery ligation was surprisingly well tolerated. Major arterioportal fistulas require treatment to prevent long-term complications of intestinal ischemia, portal hypertension, and cirrhosis. Although traditional treatment involves ligation of the arteriovenous fistula and arterial bypass, percutaneous embolization is becoming a viable alternative. Arteriography remains the cornerstone of diagnosis and treatment planning. (Ann Vasc Surg 1990;4:72-76) KEY WORDS: trauma.
Arteries; superior mesenteric artery-to-portal vein fistula; fistula;
sion and bowel ischemia, in addition to formidable technical considerations involved in their surgical repair. Our case of a traumatic superior mesenteric artery (SMA) AVF not only demonstrates these points, but also illustrates a nonoperative method of management.
Arteriovenous fistulas (AVF) have long interested vascular surgeons because of their unique pathophysiology and clinical presentation. The physiologic consequences o f a hyperdynamic cardiovascular state and venous hypertension are well described. Etiology is varied and includes aneurysmal erosion, trauma, congenital, neoplastic, and iatrogenic injury [1-3]. Arteriovenous fistulas involving the superior mesenteric artery are particularly unique because of their rarity, inaccessibility and involvement of the central supply to the gut. These latter two features have import with regard to the grave and catastrophic consequences of portal hyperten-
CASE REPORT A 16-year-old black male presented to the emergency room in extremis following a gunshot wound to the mid-epigastrium, the bullet having first passed through his right arm. Blood pressure was 60 mmHg systolic, heart rate 150 beats per minute, and respirations labored. On examination his abdomen was distended, tense, and diffusely tender. A single entrance wound was present in the epigastrium to the right of the midline. Femoral pulses were barely palpable. The patient was resuscitated with four liters of crystalloid and four units of O-negative blood en route to the operating room. Several liters of free blood were found in
From the Divisions of Vascular and General Surgery, Department of Surgeo' and Department of Radiology, Medical College of Virginia, Richmond, Virginia. Reprint requests: Marc P. Posner, MD, Division of Vascular and Transplant Surge~, Box 57, MCV Station, Richmond, Virginia 23298-0057. 72
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Fig. 1. Abdominal aortogram performed after first operative procedure showing early filling of portal vein, suspicious for SMA-portal vein arteriovenous fistula.
Fig. 2. Late film of selective celiac injection demonstrating distal SMA filling through gastroduodenal and pancreaticoduodenal collateral vessels.
the peritoneal cavity. Proximal aortic control was obtained above the celiac axis. The bullet had lacerated the liver, gallbladder, root of the mesentery and head of pancreas, as well as causing multiple enterotomies. The patient's intraoperative course was marked by hemorrhage, hypotension, hypothermia, acidosis and dilutional coagulopathy. Hemostasis was achieved at the base of the mesentery with direct suture ligation of several bleeding vessels. The liver laceration was repaired, gallbladder removed, enterotomies repaired, and drains placed over the pancreas and in both upper quadrants. Although difficult to determine, a major SMA injury was suspected. Due to patient instability, further exploration was felt to be prohibitive. The small and large bowel were viable at the close of this procedure. On postoperative day 1 the patient required transfusion of four units of red blood cells but remained hemodynamically stable on low doses of dopamine. An aortogram was performed because of suspected major visceral vascular injury. It demonstrated SMA-portal vein arteriovenous fistula (Fig. 1). On selective injection of the celiac axis, the superior mesenteric artery filled through gastroduodenal collaterals, with good perfusion of the gut (Fig. 2). Selective SMA injection, however, opacified the SMA-portal venous fistula with no filling of the mesenteric vessels. This large A V F was successfully occluded arteriographically with a percutaneously placed 8 mm Gianturco steel coil (Fig. 3). An initial attempt using a 5 mm coil resulted in the coil embolizing into a distal portal venous branch. On postoperative day 2 the patient manifested acidosis and hemodynamic instability with continued massive
fluid requirements. Laparotomy was performed to assess bowel viability. The bowel was viable both grossly and on inspection with the Woods lamp following intravenous fluorescein injection. A third laparotomy was performed on hospital day 14 for suspected intraabdominal abscess. Liquefaction necrosis was found in the region of the head of the pancreas. There were abscesses in the pelvis and left subphrenic area. There were several small perforations of the cecum thought to be secondary to drain trauma and relative ischemia. Wide drainage of the peritoneal cavity with attention to the pancreas was accomplished along with end ileostomy and tube cecostomy. On hospital day 19 the patient had a fourth laparotomy to drain a pelvic abscess, cecal fistula, and duodenocutaneous fistula. Nutrition was maintained with parenteral hyperalimentation. Two months post-injury he was discharged from the hospital, tolerating a general diet with good iteostomy function. Repeat arteriogram at that time showed filling of the SMA through gastroduodenal and left gastric artery collaterals. No SMA-portal venous fistula could be demonstrated. At one year follow-up the patient has undergone successful ileostomy closure and is maintaining good nutrition without liver function abnormality.
DISCUSSION O u r r e v i e w o f the literature c o n f i r m s that traumatic superior m e s e n t e r i c a r t e r y (main trunk) A V F s are indeed rare injuries, with o n l y sixteen
74
TRAUMA TIC S M A - - P O R T A L VEIN FISTULA
Fig. 3. Late film of aortic injection (lateral view) following successful angiographic occlusion of SMAportal AVF showing position of bullet, occluding coil (upper arrow) and distal reconstitution of SMA by collaterals (lower arrow).
previously reported cases [1,3-15] (Table I). This type of AVF belongs to a larger group of AVFs involving major venous (hepatic vein, portal vein, splenic vein, superior mesenteric vein) and major arterial (aorta, hepatic artery, splenic artery) visceral vessels. The largest collective reviews of these various AVFs include those of Van Way [2], Strodel [3], and Rosenthal [1] involving 61, 36, and 16 cases, respectively. Only a fraction of these cases involve the main trunk of the superior mesenteric artery. Aneurysmal erosion and penetrating trauma account for the greatest number of visceral AVFs. Other etiologies include congenital lesions, neoplasia, and iatrogenic injury (liver biopsy, percutaneous transhepatic cholangiogram, umbilical artery catheters, postsurgical, etc.). Although portal hypertension is a sequelum shared by all of these types of fistulas, superior mesenteric artery involvement poses unique problems with respect to preserving gut viability. Additionally, the surgical approach to the superior mesenteric artery is quite difficult in the setting of portal
ANNALS OF VASCULAR SURGERY
hypertension, or the unstable trauma patient with multiple life-threatening injuries. Surgical inaccessibility compounds the technical difficulties of AVF closure and preservation of gut viability, making treatment of this injury particularly challenging. Presentation of traumatic SMA-portal arteriovenous fistula may be immediate or delayed. During the initial exploration for penetrating abdominal trauma, severe intraabdominal hemorrhage or retroperitoneal and mesenteric hematomas mandate direct exclusion of significant visceral vascular injury. AVFs may be missed if they are small or if the routine exploration of "central" posterior hematomas is not done. Presentation may then be delayed for months to years with subsequent sequelae of bowel ischemia, secondary cirrhosis, or portal hypertension. Operative intervention at this point is particularly hazardous because of dilated, "arterialized'" mesenteric collaterals and their propensity for massive hemorrhage if entered inadvertently. Presenting symptoms are varied and often nonspecific. The most common clinical findings in 17 reported cases of SMA-AVF include a history of penetrating trauma (17/17), and presence of a bruit or thrill (15/17). Abdominal pain is the next most frequent complaint (10/17), in addition to signs and symptoms of portal hypertension or liver failure (4/17), or diarrhea (4/17) [1,3-15,23] (Table I). Of interest is that immediate (early) diagnosis was made in only four of 17 cases and that there were three early deaths, due to uncontrollable hemorrhage or sepsis. Immediate treatment goals include arresting hemorrhage, eradication of the fistula, and preservation of gut viability. Specific treatment modalities will depend on the clinical situation, local anatomy, associated injuries, and whether the diagnosis is made intra- or postoperatively. Because of its anatomical location, control of hemorrhage from the SMA may require temporary supraceliac aortic clamping either directly through an anterior approach through the lesser sac just below the diaphragm or through a left retroperitoneal approach after performing a Maddox maneuver. In the presence of a massive supramesenteric central hematoma with ongoing hemorrhage, the safest option may well be thoracoabdominal extension of the incision to allow supradiaphragmatic thoracic aortic control. Once the injured vessel is identified, the clamp may then be moved to obtain more specific and direct control and thereby limit the period of total visceral ischemia induced by supraceliac aortic occlusion. Fistulas to non-critical venous structures (splenic vein, inferior mesenteric vein, middle colic vein) may be treated by venous ligation and primary repair of the artery with or without vein patch. More essential venous structures (portal vein, superior mesenteric vein) generally require direct re-
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TABLE I.mReview of reported cases of superior mesenteric arterynportal vein fistula Author Nusselt [4] Rabhan [5] Sumner [6]
Year 1947 1962 1963
Injury Shrapnel GSW GSW
Interval 24 months -3 months
Signs/Symptoms B B/D/P/A/GB/PHTN B/P
Spellman [7] Hunt [8] Hunt [8] Fullen [9]
1963 1971 1971 1971
GSW GSW GSW GSW
1 month Immediate -Immediate
B/P B/P/D
Brunner [10] Bole [11] Nicolas [12] Yaw [13] Wood [14]
1973 1973 1974 1974 1980
GSW GSW GSW GSW GSW
17 days 7 days 20 months Immediate 8 days
B/P B B/P/D/A/PHTN
Imbert [15] Hennessey [23]
1983 1986
GSW GSW
-17 months
P/B B/PHTN/GB/D/P/A
Rosenthal [1]
1987
GSW
3 weeks
B/P
Strodel [3]
1987
GSW
3 days
B
MCV
Present
GSW
Immediate
G S W = g u n s h o t w o u n d ; B - bruit; P - pain; P H T N =
-B/GB
P/B P/B
--
Treatment 1 repair None 1 repair Bowel resection 1 repair Vein patch Vein patch Ligation bowel resection 1 repair 1 repair Mesocaval shunt 1 repair Arterial resection with vein graft 1 repair Ligation, excision embolization Interposition graft embolization Interposition vein bypass SMA ligation, SMA-PV embotization, AVF
Result Recovered Death Recovered Recovered Recovered Recovered Death Recovered Recovered Death Recovered Recovered Recovered Recovered Recovered Recovered Recovered
p o r t a l h y p e r t e n s i o n ; G B - GI b l e e d i n g ; A - ascites; D - d i a r r h e a
pair. In nine of 17 cases in the literature, the superior mesenteric artery was repaired primarily [1,3-15]. When the degree of arterial injury precludes primary repair, arterial bypass may be required; this is preferably done with autologous saphenous vein, as was done in three of 17 cases [1,3,141. Time-consuming, technically demanding primary repair may be inadvisable in the unstable patient. Ligation of the SMA proximal to the takeoff of the middle colic artery is well tolerated in terms of mesenteric ischemia because of gastro- and pancreaticoduodenal collaterals (see Fig. 2). SMA ligation more distally is fraught with a higher likelihood of circulatory embarrassment to the small bowel and usually will require arterial reconstruction at the initial setting if mesenteric infarction is to be avoided. Percutaneous transarterial catheter embolization has emerged as an additional nonoperative approach to this challenging problem. Prior experience was largely limited to the splenic, hepatic, pulmonary, and renal circulations. One of the earliest reports involving the superior mesenteric artery was that of Uflacker (1982) in which a postsurgical iatrogenic superior mesenteric artery AVF was embolized using Gianturco steel coils [22]. Gianturco steel coils are safe and effective embolizing "agents," come in a variety of sizes to choose from, are inexpensive, and are readily available in almost every arteriography lab. They are easy to deliver and ideal for the embolization of a large
vessel (or AVF), particularly in an urgent setting. A multitude of other materials have been used, including Gelfoam, detachable balloons, polyvinyl alcohol sponges, and isobutyl-cyanoacrylate [22-25]. Our review revealed two other cases where embolization was employed successfully in the posttraumatic setting [1,23]. Both cases involved residual AVFs after very complicated and difficult repeat laparotomies for traumatic complications. In the present case, after barely surviving initial laparotomy for massive hemorrhage and multiple visceral injuries (including major pancreatic injury), this patient underwent early postoperative arteriography. This was done because of suspicion of major mesenteric vascular injury thought to be incompletely explored and treated at initial laparotomy. Arteriography not only made the diagnosis of SMAportal venous fistula, but allowed nonoperative control by percutaneous embolization. Although percutaneous embolization can potentially alleviate an AVF with low morbidity and mortality, there are several theoretical dangers. Greatest among these would be acute thrombosis of the superior mesenteric artery or major venous structures (portal vein). Embolization intraparenchymally to the liver through the portal vein is also possible (as occurred in this case), this being of less immediate consequence than main vessel thrombosis. The optimal technique and materials used for embolization are in part a function of the size and location of the AVF, overall patient condition, and an experienced arteriography team. This technique
76
TRA UMATIC SMA--PORTAL VEIN FISTULA
deserves serious consideration in the postoperative management of the patient with a posttraumatic AVF, particularly in the setting of multiple injuries, multi-organ system failure, or previous laparotomies, and in the patient with established portal hypertension.
CONCLUSION
Traumatic superior mesenteric AVFs are unusual intraabdominal vascular injuries and present an extremely difficult management problem. Intraabdominal hemorrhage with shock, associated injuries, surgical inaccessibility, and in some instances established portal hypertension, all contribute to the complexity of treatment. If basic principles are adhered to, these injuries can be effectively diagnosed and treated either at initial laparotomy or in the early postoperative period. Alleviation of the A V F is warranted on the basis of future portal hypertension and potential bowel ischemia. Aggressive arteriography is useful both in the acute and chronic phase, not only for diagnosis, but also as a potential therapeutic option.
REFERENCES 1. R O S E N T H A L D, ELLISON RG Jr. L U K E JP, C L A R K MD, LAMIS PA. Traumatic superior mesenteric arteriovenous fistula: report of a case and review of the literature. J Vasc Surg 1987;5:486-491. 2. VAN WAY CW, CRANE JM, RIDDELL DH, POSTER JH. Arteriovenous fistula in the portal circulation. Surgery 1971 ;70:876-889. 3. STRODEL WE, E C K H A U S E R FE, LEMMER JH, W H I T E H O U S E WM, WILLIAMS DM. Presentation and perioperative management of arterioportal fistulas. Arch Surg 1987;I22:563-571. 4. N U S S E L T H. A case of successful repair of an arteriovenous a n e u r y s m of the superior mesenteric artery. Zentra/b Chirurg 1947;72:835-840. 5. R A B H A N NB, G U I L L E B E A U JG, BRACKNEY EL. Arteriovenous fistula of the superior mesenteric vessels after a gunshot wound. N Engl J Med 1962:266:603~505. 6. S U M N E R RG, K I S T L E R PC, BARRY WF Jr. MclNTOSH HD. Recognition and surgical repair of superior mesenteric arteriovenous fistula, Circulation 1963:27:943-950.
mmm
ANNALS OF VASCULARSURGERY
7. SPELLMAN MW, M A N D A L A, FREEMAN HP, MASSUMI RA. Successful repair of an arteriovenous fistula between the superior mesenteric vessels secondary to a gunshot wound. Ann Surg 1967;165:458-463. 8. H U N T T K , LEEDS PH, WANEBO HJ, BLA1SDELL FW. Arteriovenous fistulas of major vessels in the abdomen. J Trauma 1971:11:483--493. 9. F U L L E N WD, H U N T J, ALTEMEIER WA. The clinic spectrum of penetrating injury to the superior mesenteric arterial circulation. J Trauma 1972;12:656-663. 10. B R U N N E R JH, STANLEY RJ, Superior mesenteric arteriovenous fistula. JAMA 1973:223:316-318. I1. BOLE P, ANDRONACO JT. PURDY R. Superior mesenteric arteriovenous fistula secondary to a gunshot wound. J Cardiovasc Surg 1973:14:456-459. 12. NICHOLAS GG, LANE P. Traumatic superior mesenteric artery-superior mesenteric vein fistula. J Trauma 1974: /4:34,:1-347. 13. YAW PB, VAN BECK AL, GLOVER JL. Successful repair of a gunshot wound to the first part of the superior mesenteric artery. J Trauma 1974;14:885-887. I4. WOOD M, N y K A M P PW. Traumatic arteriovenous fistula of the superior mesenteric vessels. J Trauma 1980;20:378382, 15. 1MBERT P, CARDON J. MATH1EU J, TOUATI Y, Plaie de t'aorte et de ta veine cave inferieure compliquee secondairement d'une fistule arterio-veineuse mesenterique superieure, Chirurgie 1983:109:47-51. 16. MYLES RA, YELL1N AE. Traumatic injuries of the abdominal aorta. Am J Sttrg 1979:138:273-277. 17. K A S H U K JL, MOORE EE, MILLIKAN JS, MOORE JB. Major abdominal vascular t r a u m a - - a unified approach. J Trauma 1982:22:672--678. 18. MATTOX KL, McCOLLUM WB, BEALL AC, JORDON GL, DEBAKEY ME. Management of penetrating injuries of the suprarenal aorta, J Trauma 1975;15:808-813. 19. LIM RC, T R U N K E Y DD, BLAISDELL FW. Acute abdominal aortic injury. Arch Surg 1974:109:706-710. 20. R E Q U E N A R, C H E R U K U R I R, LERNER R. A logical approach in the management of intraabdominal vascular trauma. Cont Surg 1983:23:31-41. 21. MILLIKAN JS, MOORE EE. Critical factors in determining mortality from abdominal aortic trauma. Sttrg Gynecol Obstet 1985:160:313-316. 22. U F L A C K E R R, SAADI J. Transcatheter embolization of superior mesenteric arteriovenous fistula. A JR 1982;139: 12t2-t214. 23. HENNESSEY OF, GIBSON RN, ALLISON DJ, Use of giant steel coils in the therapeutic embolization of a superior mesenteric artery: portal vein fistula, Cardiovasc lntervent Radiof 1986:9:42--45, 24. AGHA PP, RA.I1 MR, Successful transcatheter embolic control of significant arterioportal fistula: a serious complication of liver biopsy. Brit J Radiol 1983;56:277-280. 25. KNOX M, C H U A N G VP, STEWART MT. Superior ruesenteric aneurysm and arteriovenous fistula: angiographic and CT features. A JR 1985;145:383-384.
An interesting and rare case of traumatic superior mesenteric artery-to-portal vein arteriovenous fistula is presented. Initial operative control of the bleeding superior mesenteric artery injury required ligation of the superior mesenteric artery at its origin to prevent exsanguination in an extremely unstable patient with multiple injuries. Early postoperative visceral arteriography documented ligation of the superior mesenteric artery with a proximal superior mesenteric artery-to-portal vein arteriovenous fistula. Percutaneous catheter embolization of the arteriovenous fistula was undertaken successfully at this time. Superior mesenteric artery ligation was surprisingly well tolerated. Major arterioportal fistulas require treatment to prevent long-term complications of intestinal ischemia, portal hypertension, and cirrhosis. Although traditional treatment involves ligation of the arteriovenous fistula and arterial bypass, percutaneous embolization is becoming a viable alternative. Arteriography remains the cornerstone of diagnosis and treatment planning. (Ann Vasc Surg 1990;4:72-76) KEY WORDS: trauma.
Arteries; superior mesenteric artery-to-portal vein fistula; fistula;
sion and bowel ischemia, in addition to formidable technical considerations involved in their surgical repair. Our case of a traumatic superior mesenteric artery (SMA) AVF not only demonstrates these points, but also illustrates a nonoperative method of management.
Arteriovenous fistulas (AVF) have long interested vascular surgeons because of their unique pathophysiology and clinical presentation. The physiologic consequences o f a hyperdynamic cardiovascular state and venous hypertension are well described. Etiology is varied and includes aneurysmal erosion, trauma, congenital, neoplastic, and iatrogenic injury [1-3]. Arteriovenous fistulas involving the superior mesenteric artery are particularly unique because of their rarity, inaccessibility and involvement of the central supply to the gut. These latter two features have import with regard to the grave and catastrophic consequences of portal hyperten-
CASE REPORT A 16-year-old black male presented to the emergency room in extremis following a gunshot wound to the mid-epigastrium, the bullet having first passed through his right arm. Blood pressure was 60 mmHg systolic, heart rate 150 beats per minute, and respirations labored. On examination his abdomen was distended, tense, and diffusely tender. A single entrance wound was present in the epigastrium to the right of the midline. Femoral pulses were barely palpable. The patient was resuscitated with four liters of crystalloid and four units of O-negative blood en route to the operating room. Several liters of free blood were found in
From the Divisions of Vascular and General Surgery, Department of Surgeo' and Department of Radiology, Medical College of Virginia, Richmond, Virginia. Reprint requests: Marc P. Posner, MD, Division of Vascular and Transplant Surge~, Box 57, MCV Station, Richmond, Virginia 23298-0057. 72
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Fig. 1. Abdominal aortogram performed after first operative procedure showing early filling of portal vein, suspicious for SMA-portal vein arteriovenous fistula.
Fig. 2. Late film of selective celiac injection demonstrating distal SMA filling through gastroduodenal and pancreaticoduodenal collateral vessels.
the peritoneal cavity. Proximal aortic control was obtained above the celiac axis. The bullet had lacerated the liver, gallbladder, root of the mesentery and head of pancreas, as well as causing multiple enterotomies. The patient's intraoperative course was marked by hemorrhage, hypotension, hypothermia, acidosis and dilutional coagulopathy. Hemostasis was achieved at the base of the mesentery with direct suture ligation of several bleeding vessels. The liver laceration was repaired, gallbladder removed, enterotomies repaired, and drains placed over the pancreas and in both upper quadrants. Although difficult to determine, a major SMA injury was suspected. Due to patient instability, further exploration was felt to be prohibitive. The small and large bowel were viable at the close of this procedure. On postoperative day 1 the patient required transfusion of four units of red blood cells but remained hemodynamically stable on low doses of dopamine. An aortogram was performed because of suspected major visceral vascular injury. It demonstrated SMA-portal vein arteriovenous fistula (Fig. 1). On selective injection of the celiac axis, the superior mesenteric artery filled through gastroduodenal collaterals, with good perfusion of the gut (Fig. 2). Selective SMA injection, however, opacified the SMA-portal venous fistula with no filling of the mesenteric vessels. This large A V F was successfully occluded arteriographically with a percutaneously placed 8 mm Gianturco steel coil (Fig. 3). An initial attempt using a 5 mm coil resulted in the coil embolizing into a distal portal venous branch. On postoperative day 2 the patient manifested acidosis and hemodynamic instability with continued massive
fluid requirements. Laparotomy was performed to assess bowel viability. The bowel was viable both grossly and on inspection with the Woods lamp following intravenous fluorescein injection. A third laparotomy was performed on hospital day 14 for suspected intraabdominal abscess. Liquefaction necrosis was found in the region of the head of the pancreas. There were abscesses in the pelvis and left subphrenic area. There were several small perforations of the cecum thought to be secondary to drain trauma and relative ischemia. Wide drainage of the peritoneal cavity with attention to the pancreas was accomplished along with end ileostomy and tube cecostomy. On hospital day 19 the patient had a fourth laparotomy to drain a pelvic abscess, cecal fistula, and duodenocutaneous fistula. Nutrition was maintained with parenteral hyperalimentation. Two months post-injury he was discharged from the hospital, tolerating a general diet with good iteostomy function. Repeat arteriogram at that time showed filling of the SMA through gastroduodenal and left gastric artery collaterals. No SMA-portal venous fistula could be demonstrated. At one year follow-up the patient has undergone successful ileostomy closure and is maintaining good nutrition without liver function abnormality.
DISCUSSION O u r r e v i e w o f the literature c o n f i r m s that traumatic superior m e s e n t e r i c a r t e r y (main trunk) A V F s are indeed rare injuries, with o n l y sixteen
74
TRAUMA TIC S M A - - P O R T A L VEIN FISTULA
Fig. 3. Late film of aortic injection (lateral view) following successful angiographic occlusion of SMAportal AVF showing position of bullet, occluding coil (upper arrow) and distal reconstitution of SMA by collaterals (lower arrow).
previously reported cases [1,3-15] (Table I). This type of AVF belongs to a larger group of AVFs involving major venous (hepatic vein, portal vein, splenic vein, superior mesenteric vein) and major arterial (aorta, hepatic artery, splenic artery) visceral vessels. The largest collective reviews of these various AVFs include those of Van Way [2], Strodel [3], and Rosenthal [1] involving 61, 36, and 16 cases, respectively. Only a fraction of these cases involve the main trunk of the superior mesenteric artery. Aneurysmal erosion and penetrating trauma account for the greatest number of visceral AVFs. Other etiologies include congenital lesions, neoplasia, and iatrogenic injury (liver biopsy, percutaneous transhepatic cholangiogram, umbilical artery catheters, postsurgical, etc.). Although portal hypertension is a sequelum shared by all of these types of fistulas, superior mesenteric artery involvement poses unique problems with respect to preserving gut viability. Additionally, the surgical approach to the superior mesenteric artery is quite difficult in the setting of portal
ANNALS OF VASCULAR SURGERY
hypertension, or the unstable trauma patient with multiple life-threatening injuries. Surgical inaccessibility compounds the technical difficulties of AVF closure and preservation of gut viability, making treatment of this injury particularly challenging. Presentation of traumatic SMA-portal arteriovenous fistula may be immediate or delayed. During the initial exploration for penetrating abdominal trauma, severe intraabdominal hemorrhage or retroperitoneal and mesenteric hematomas mandate direct exclusion of significant visceral vascular injury. AVFs may be missed if they are small or if the routine exploration of "central" posterior hematomas is not done. Presentation may then be delayed for months to years with subsequent sequelae of bowel ischemia, secondary cirrhosis, or portal hypertension. Operative intervention at this point is particularly hazardous because of dilated, "arterialized'" mesenteric collaterals and their propensity for massive hemorrhage if entered inadvertently. Presenting symptoms are varied and often nonspecific. The most common clinical findings in 17 reported cases of SMA-AVF include a history of penetrating trauma (17/17), and presence of a bruit or thrill (15/17). Abdominal pain is the next most frequent complaint (10/17), in addition to signs and symptoms of portal hypertension or liver failure (4/17), or diarrhea (4/17) [1,3-15,23] (Table I). Of interest is that immediate (early) diagnosis was made in only four of 17 cases and that there were three early deaths, due to uncontrollable hemorrhage or sepsis. Immediate treatment goals include arresting hemorrhage, eradication of the fistula, and preservation of gut viability. Specific treatment modalities will depend on the clinical situation, local anatomy, associated injuries, and whether the diagnosis is made intra- or postoperatively. Because of its anatomical location, control of hemorrhage from the SMA may require temporary supraceliac aortic clamping either directly through an anterior approach through the lesser sac just below the diaphragm or through a left retroperitoneal approach after performing a Maddox maneuver. In the presence of a massive supramesenteric central hematoma with ongoing hemorrhage, the safest option may well be thoracoabdominal extension of the incision to allow supradiaphragmatic thoracic aortic control. Once the injured vessel is identified, the clamp may then be moved to obtain more specific and direct control and thereby limit the period of total visceral ischemia induced by supraceliac aortic occlusion. Fistulas to non-critical venous structures (splenic vein, inferior mesenteric vein, middle colic vein) may be treated by venous ligation and primary repair of the artery with or without vein patch. More essential venous structures (portal vein, superior mesenteric vein) generally require direct re-
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TABLE I.mReview of reported cases of superior mesenteric arterynportal vein fistula Author Nusselt [4] Rabhan [5] Sumner [6]
Year 1947 1962 1963
Injury Shrapnel GSW GSW
Interval 24 months -3 months
Signs/Symptoms B B/D/P/A/GB/PHTN B/P
Spellman [7] Hunt [8] Hunt [8] Fullen [9]
1963 1971 1971 1971
GSW GSW GSW GSW
1 month Immediate -Immediate
B/P B/P/D
Brunner [10] Bole [11] Nicolas [12] Yaw [13] Wood [14]
1973 1973 1974 1974 1980
GSW GSW GSW GSW GSW
17 days 7 days 20 months Immediate 8 days
B/P B B/P/D/A/PHTN
Imbert [15] Hennessey [23]
1983 1986
GSW GSW
-17 months
P/B B/PHTN/GB/D/P/A
Rosenthal [1]
1987
GSW
3 weeks
B/P
Strodel [3]
1987
GSW
3 days
B
MCV
Present
GSW
Immediate
G S W = g u n s h o t w o u n d ; B - bruit; P - pain; P H T N =
-B/GB
P/B P/B
--
Treatment 1 repair None 1 repair Bowel resection 1 repair Vein patch Vein patch Ligation bowel resection 1 repair 1 repair Mesocaval shunt 1 repair Arterial resection with vein graft 1 repair Ligation, excision embolization Interposition graft embolization Interposition vein bypass SMA ligation, SMA-PV embotization, AVF
Result Recovered Death Recovered Recovered Recovered Recovered Death Recovered Recovered Death Recovered Recovered Recovered Recovered Recovered Recovered Recovered
p o r t a l h y p e r t e n s i o n ; G B - GI b l e e d i n g ; A - ascites; D - d i a r r h e a
pair. In nine of 17 cases in the literature, the superior mesenteric artery was repaired primarily [1,3-15]. When the degree of arterial injury precludes primary repair, arterial bypass may be required; this is preferably done with autologous saphenous vein, as was done in three of 17 cases [1,3,141. Time-consuming, technically demanding primary repair may be inadvisable in the unstable patient. Ligation of the SMA proximal to the takeoff of the middle colic artery is well tolerated in terms of mesenteric ischemia because of gastro- and pancreaticoduodenal collaterals (see Fig. 2). SMA ligation more distally is fraught with a higher likelihood of circulatory embarrassment to the small bowel and usually will require arterial reconstruction at the initial setting if mesenteric infarction is to be avoided. Percutaneous transarterial catheter embolization has emerged as an additional nonoperative approach to this challenging problem. Prior experience was largely limited to the splenic, hepatic, pulmonary, and renal circulations. One of the earliest reports involving the superior mesenteric artery was that of Uflacker (1982) in which a postsurgical iatrogenic superior mesenteric artery AVF was embolized using Gianturco steel coils [22]. Gianturco steel coils are safe and effective embolizing "agents," come in a variety of sizes to choose from, are inexpensive, and are readily available in almost every arteriography lab. They are easy to deliver and ideal for the embolization of a large
vessel (or AVF), particularly in an urgent setting. A multitude of other materials have been used, including Gelfoam, detachable balloons, polyvinyl alcohol sponges, and isobutyl-cyanoacrylate [22-25]. Our review revealed two other cases where embolization was employed successfully in the posttraumatic setting [1,23]. Both cases involved residual AVFs after very complicated and difficult repeat laparotomies for traumatic complications. In the present case, after barely surviving initial laparotomy for massive hemorrhage and multiple visceral injuries (including major pancreatic injury), this patient underwent early postoperative arteriography. This was done because of suspicion of major mesenteric vascular injury thought to be incompletely explored and treated at initial laparotomy. Arteriography not only made the diagnosis of SMAportal venous fistula, but allowed nonoperative control by percutaneous embolization. Although percutaneous embolization can potentially alleviate an AVF with low morbidity and mortality, there are several theoretical dangers. Greatest among these would be acute thrombosis of the superior mesenteric artery or major venous structures (portal vein). Embolization intraparenchymally to the liver through the portal vein is also possible (as occurred in this case), this being of less immediate consequence than main vessel thrombosis. The optimal technique and materials used for embolization are in part a function of the size and location of the AVF, overall patient condition, and an experienced arteriography team. This technique
76
TRA UMATIC SMA--PORTAL VEIN FISTULA
deserves serious consideration in the postoperative management of the patient with a posttraumatic AVF, particularly in the setting of multiple injuries, multi-organ system failure, or previous laparotomies, and in the patient with established portal hypertension.
CONCLUSION
Traumatic superior mesenteric AVFs are unusual intraabdominal vascular injuries and present an extremely difficult management problem. Intraabdominal hemorrhage with shock, associated injuries, surgical inaccessibility, and in some instances established portal hypertension, all contribute to the complexity of treatment. If basic principles are adhered to, these injuries can be effectively diagnosed and treated either at initial laparotomy or in the early postoperative period. Alleviation of the A V F is warranted on the basis of future portal hypertension and potential bowel ischemia. Aggressive arteriography is useful both in the acute and chronic phase, not only for diagnosis, but also as a potential therapeutic option.
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mmm
ANNALS OF VASCULARSURGERY
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