Ann Thorac Surg 1997;63:1792-1794
© 1997 The Society of Thoracic Surgeons
Case Report
Traumatic Arteriovenous Fistula
Samir M. Maher, FRACS,
Husein M. M. Rabee, FRCSI,
Mohammed S. Takrouri, FFRACSI,
Mussaad M. S. Al-Salman, FRCSC
King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
Accepted for publication February 3, 1997.
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Abstract
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Traumatic arteriovenous fistula in the head and neck may present a difficult problem in management. We present a surgical case of traumatic arteriovenous fistula between the right subclavian artery and internal jugular vein with false aneurysm formation. Traumatic injury of the subclavian artery causing arteriovenous fistula with false aneurysm is a serious surgical emergency with appreciable morbidity and mortality that requires early recognition and prompt surgical intervention.
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Introduction
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Traumatic arteriovenous fistulas in the head and neck are uncommon, accounting for 4% of all arterial injuries [1]. These lesions may present a problem of diagnosis and treatment. The associated morbidity and mortality signifies the importance of proper management.
We present an interesting case of penetrating injury to zone II of the neck resulting in fistula between the right subclavian artery and the internal jugular vein.
A 34-year-old man sustained an occupational injury by a nail (5 cm in length) that was fired from a special high-velocity gun in the building industry. The nail was reflected from the wall to penetrate the right side of root of the neck, and the patient was referred to King Khalid University Hospital, Riyadh.
On admission, he was hemodynamically stable with palpable peripheral pulses with a puncture wound and hematoma on the right side of the root of the neck. Chest roentgenography (Fig 1
) showed right hemopneumothorax, a nail in the lower chest field, and hematoma adjacent to the right sternoclavicular junction. A right intercostal drainage tube was inserted and drained 600 mL of blood. Gastrografin (E.R. Squibb & Sons, Princeton, NJ) swallow showed intact esophagus. Arteriography (Fig 2) revealed a false aneurysm arising from the first part of the right subclavian artery. A fistulous communication between the right subclavian artery and internal jugular vein was demonstrated. The patient was taken to the operating room.
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Fig 1. . Chest roentgenogram showing right hemopneumothorax, the nail, and hematoma adjacent to right sternoclavicular junction.
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Fig 2. . Arteriogram showing traumatic false aneurysm (long arrow), superior vena cava (short arrow), internal jugular vein (open arrow), brachiocephalic artery (large arrowhead), right subclavian artery (medium arrowhead), and right common carotid artery (small arrowhead).
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A double-lumen endotracheal tube was inserted. Fiberoptic bronchoscopy showed intact tracheobronchial tree. Through a median sternotomy with right supraclavicular extension, all great vessels were controlled. There was a palpable thrill over the jugular vein. A diffuse pulsating hematoma was obscuring the field; accordingly, the middle third of the clavicle was resected.
After administration of heparin (1 mg/kg body weight), extensive laceration of the right internal jugular vein was identified and deemed irreparable; accordingly, the vein was ligated. There was a tear in the first part of the right subclavian artery that was directly repaired by interrupted 4-0 Prolene (Ethicon, Somerville, NJ) sutures in the transverse direction. The right pleura was opened, and the nail protruding from the right lower lobe of the lung was retrieved. After reversal of heparin, the wound was closed with separate drains.
Postoperatively, the right hand was warm, with palpable pulse and equal blood pressure in both arms. The postoperative course was complicated by prolonged ventilatory support. The inflicting injury of the nail, which involved the brachial plexus and was manifested by parasthesia and mild muscular weakness in the distribution of C8 and T1 on the right side, improved with physiotherapy at the time of hospital discharge 21 days postoperatively.
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Comment
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Penetrating injury of the root of the neck involving the subclavian or innominate arteries is a serious condition with a mortality rate up to 30% [2].
In a series of 202 cases of traumatic arteriovenous fistula, Robbs and associates [3] showed that vessels of the neck and mediastinum constituted 54% of the cases and the most common vessels involved were the common carotid artery and internal jugular vein. Other sites of traumatic arteriovenous fistula include the vertebral artery, internal carotid artery, and internal jugular vein as well as subclavian artery and vein.
In our case the site of fistulous communication, between the right subclavian artery and the internal jugular vein, is rather unusual. This could be explained by the odd path of the nail reflected from the ceiling.
In civilian injuries, the agents inflicting the trauma vary. Stab wounds and gunshots predominate. Shotgun, accidental, iatrogenic, and industrial injuries are less common. The salient clinical features of acute traumatic arteriovenous fistula including hemorrhage, hematoma, thrill, and machinery murmur were found in our case; however, there was no pulse deficit with palpable radial pulse. In neglected cases, high output heart failure may develop due to left-to-right shunt. Late subclavian artery aneurysm formation has been reported [4].
Neurologic deficit due to involvement of the phrenic or vagus nerves and the brachial plexus are known sequelae. In our case, neurologic deficit was apparent as parasthesia and mild muscular weakness in the distribution of C-8 and T-1 in spite of the fact that all nervous structures were isolated and protected during the operation.
Management of cases with positive physical signs as well as positive arteriographic findings, similar to our case, requires early surgical intervention. The controversy is confined to a subgroup of patients with penetrating injuries of the neck violating the platysma without clinical evidence of structural injury. Mandatory exploration of the neck injuries penetrating the platysma has been advocated [5] to avoid the morbidity and mortality of delayed treatment.
The high negative yield of routine exploration (40% to 60%), with its consequent morbidity, urged other groups to advocate selective approach [6]. Median sternotomy with right supraclavicular extension is advised to gain proximal control of the right subclavian artery, and left thoracotomy is described to get proximal control on the left side. Balloon occlusion was reported to obtain proximal arterial control so that sternotomy or thoracotomy might not be required any more [7].
On contemplating arterial repair, if arteriorrhaphy or resection with end-to-end anastomosis is not feasible, a long saphenous vein or prosthetic interposition graft is inserted.
Due to extensive laceration of the internal jugular vein, we opted for its ligation, without ill effects. Other modalities of therapy for arteriovenous fistula include embolization [8]. This may be an appropriate alternative in long-standing conditions where there is a well-formed fistulous communication. In the setting of acute trauma with extensive damage of the vascular wall, especially with associated lesions, surgical intervention should be performed.
Traumatic injury of the right subclavian artery causing arteriovenous fistula with surrounding false aneurysm is a serious surgical emergency with appreciable morbidity and mortality that requires early recognition and prompt surgical intervention.
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Acknowledgments
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We thank Mrs Cora Rivera for her assistance in typing the manuscript.
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Footnotes
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Address reprint requests to Dr Maher, Division of Cardiac Surgery, King Saud University, College of Medicine, PO Box 7805, Riyadh 11472, Kingdom of Saudi Arabia.
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References
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- Hoff SJ, Reilly MK, Merrill WH, Stewart J, Frist WH, Morris JA Jr. Analysis of blunt and penetrating injury of the innominate and subclavian arteries. Am Surg 1994;60:151–4.[Medline]
- Robbs JV, Carrim AA, Kadwa AM, Mars M. Traumatic arterio-venous fistula: experience with 202 patients. Br J Surg 1994;81:1296–9.[Medline]
- Olinde AJ. Traumatic subclavian axillary artery aneurysm. J Vasc Surg 1989;11:848–9.
- Fogelman MJ, Stewart RD. Penetrating wounds of the neck. Am J Surg 1956;91:581–93.[Medline]
- Campbell FC, Robbs JV. Penetrating injuries of the neck: a prospective study of 108 patients. Br J Surg 1980;67:582–6.[Medline]
- Scalae TM, Sclafani SJ. Angiographically placed balloons for arterial control. A description of a technique. J Trauma 1991;31:1671–7.[Medline]
- Touho H, Furuoka N, Ohnishi H, Komatsu T, Karasawa J. Traumatic arteriovenous fistula treated by superselective embolisation with microcoils: case report. Neuroradiology 1995;37:65–7.[Medline]
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Abstract
Introduction
