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Ann Thorac Surg 1999;67:849-850
© 1999 The Society of Thoracic Surgeons

Case Reports

Chest wall arteriovenous fistula: an unusual complication after chest tube placement

Terrence D. Coulter, MDa,b, Janet R. Maurer, MDa,b, Michael T. Miller, MDa,b, Atul C. Mehta, MDa,b

a Department of Pulmonary and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
b Department of Radiology, Soldier & Sailors Memorial Hospital, Penn Yan, New York, USA

Accepted for publication September 8, 1998.

Address reprint requests to Dr Maurer, Department of Pulmonary and Critical Care Medicine/A90, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Posttraumatic arteriovenous fistulas can form between vessels of the thorax that have sustained loss of integrity to the vessel wall. Although most are caused by injuries as a consequence of missile penetration or stab wounds, iatrogenic damage is a potential cause. Herein we present a case of a systemic arteriovenous fistula involving an intercostal artery and subcutaneous vein after chest tube placement.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Posttraumatic arteriovenous fistulas involving thoracic structures are classified into three different anatomic groups: systemic, pulmonary, and that between the systemic and pulmonary circulation. Systemic arteriovenous fistulas (SAVF) of the chest wall are a rare occurrence after a penetrating or blunt injury to the chest wall. Pulmonary arteriovenous fistulas (PAVF) are an infrequent complication of injury to the pulmonary vasculature, usually as a consequence of missile injury or stab wound [1]. An even rarer form is a systemic-to-pulmonary arteriovenous fistula (SPAVF), typically involving a systemic to pulmonary artery communication [2]. We report a documented case of an SAVF of the chest wall that developed after placement of a chest tube.

A 58-year-old woman with end-stage emphysema from {alpha}-1-antitrypsin deficiency experienced a spontaneous right-sided pneumothorax that resolved without complication after 48 hours of chest tube drainage. No difficulty was reported during insertion of the chest tube, nor was excessive bleeding noted after the procedure. The patient was seen on routine follow-up exam 2 months after the incident, at which time she reported no new symptoms. On physical examination, a harsh continuous bruit located over the right lower mid-axillary line, loudest overlying the chest tube scar, was noted. There was no tenderness, palpable thrill, or pulsatile mass. The findings raised the suspicion of an SAVF at the site of chest tube insertion. A chest magnetic resonance image with angiography confirmed a fistula involving an intercostal artery and subcutaneous vein of the chest wall (Fig 1). There was no rib erosion. The SAVF was thought to be inconsequential and no therapeutic intervention was planned.



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  		Fig 1. Magnetic resonance imaging angiography of chest wall revealing fistula formation between an intercostal artery (white arrow) and subcutaneous vein (black arrow).

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Vascular fistulas develop when injury is sustained to vessel walls, leading to loss of integrity and formation of a communication between two adjacent vessels [3]. Arteriovenous fistulas can occur between systemic, pulmonary, or systemic and pulmonary vessels. Traumatic SAVFs are a well-known consequence of penetrating injuries. In a recent review of military patients with this complication, the most common site of involvement was the extremities followed by the neck. The majority of these injuries were caused by bullets or shrapnel [4]. A civilian study of 202 patients reported cervicomediastinal and extremities as the most common sites of involvement with SAVF. In contrast to the military study, most of these injuries were caused by stab wounds [5]. Arteriovenous fistulas involving the pulmonary vessels are extremely rare because of the high mortality related to injury to the vessels and surrounding vital structures. Those who do survive may proceed to develop a fistula. Pulmonary arteriovenous fistulas occur when communicating pulmonary arterial vessels bypass the capillary bed, directing blood into the pulmonary vein, thus forming a right-to-left shunt. The first reported case of a traumatic PAVF was by Arom and Lyons in 1975 [1] involving a 47-year-old man who presented 10 years after a stab wound to the chest. Fistula formation between the systemic and pulmonary vessels is an extremely rare occurrence. Systemic-to-pulmonary arteriovenous fistula usually involves the internal thoracic artery draining into a lobar pulmonary artery. The first case of an SPAVF was reported by Cox and colleagues in 1967 [6] in a patient after insertion of an intercostal catheter.

We report this case of an SAVF developing as a consequence of chest tube insertion. Damage to the intercostal artery and subcutaneous veins of the chest wall during placement of the chest tube resulted in the fistula formation.

The clinical manifestations of a traumatic SAVF may be immediate or delayed, ranging from 1 week to 12 years. In one study, 85% of patients had clinical findings within 8 weeks of the initial insult [4]. The most common physical signs are a machinery murmur, pulsatile mass, and palpable thrill. Plain radiographs may or may not reveal an abnormal density on the basis of size and location, and bone erosion can occur if the fistula is large. Selective angiogram is the imaging modality of choice to establish the diagnosis. Contrast-enhanced magnetic resonance imaging is a comparable study if available.

Once diagnosed, the treatment decisions are based on clinical symptomology. Therapy is warranted in patients if there is an elevated shunt fraction, risk of hemorrhage, or local bone destruction. Traditionally these fistulas have been treated by surgical removal; however, recent success with transcatheter embolization offers a less invasive alternative [7, 8].

Our case demonstrates that acquired chest wall arteriovenous fistulas can develop as a consequence of chest tube placement. Even though not documented in our case, excessive bleeding from the chest wall during chest tube insertion should raise the possibility of injury to underlying vessels and the likelihood of arteriovenous formation. Because of the wide range of indications for chest tube insertion and the susceptible vascular supply of the thoracic structures, we suspect vascular fistulas develop more frequently than is reported and should be considered when suggestive clinical or radiographic signs are present.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Arom K.V., Lyons G.W. Traumatic pulmonary arteriovenous fistula. J Thorac Cardiovasc Surg 1975;70:918-920.[Abstract]
  2. Hirsch M., Maroko I., Gueron M., Goleman L. Systemic-pulmonary arteriovenous fistula of traumatic origin: a case report. Cardiovasc Intervent Radiol 1983;6:160-163.[Medline]
  3. Jeanfaivre T., Régnard O., L’Hoste P., Enon B. Chronic pain of vascular origin caused by a parietopulmonary fistula of the thoracic wall. Ann Thorac Surg 1997;63:839-841.[Abstract/Free Full Text]
  4. Yilmaz A.T., Arslan M., Demirkilic U., et al. Missed arterial injuries in military patients. Am J Surg 1997;173:110-114.[Medline]
  5. Robbs J.V., Carrim A.A., Kadwa A.M., Mars M. Traumatic arteriovenous fistula: experience with 202 patients. Br J Surg 1994;81:1296-1299.[Medline]
  6. Cox P.A., Keshishian J.M., Blades B.B. Traumatic arteriovenous fistula of the chest wall and lung secondary to insertion of an intercostal catheter. J Thorac Cardiovasc Surg 1967;54:109-112.[Medline]
  7. Kerr A., Sauter D. Acquired traumatic pulmonary arteriovenous fistula: case report. J Trauma 1993;35:484-486.[Medline]
  8. Lee D.W., White R.I., Egglin T.K., et al. Embolotherapy of large pulmonary arteriovenous malformations: long-term results. Ann Thorac Surg 1997;64:930-940.[Abstract/Free Full Text]



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