Acute Deep Vein Thrombosis in Venous Aneurysm following Closure of the Chronic Traumatic Arteriovenous Fistulae of the Lower Extremities

Abstract

Chronic traumatic arteriovenous fistula (AVF) commonly results from an unrecognized vascular injury. In this report, there were two cases of chronic traumatic AVF of the legs with a long history of stab (case 1) and shotgun wounds (case 2). Both cases presented with varicose veins together with hyperpigmentation around the ankle of the affected leg. Angiograms showed a single large AVF in case 1, whereas, in case 2, there was a single large AVF together with multiple small AVFs. In both cases large venous aneurysm was found next to a large AVF. An open surgical AVF closure for the large AVF was performed in case 1 successfully, but patient developed acute deep vein thrombosis (DVT) in a large venous aneurysm. In the second case, in order to prevent DVT, only closure of the large AVF was performed, which preserved arterial flow into the venous aneurysm. Case 2 did not have acute DVT. This report raised the concern about acute DVTs in venous aneurysms following the closure of chronic traumatic AVF in terms of prevention. Also chronic traumatic AVF is commonly due to misdiagnosis in the initial treatment, so complete and serial physical examinations in penetrating vascular injury patients are of paramount importance.

Management of dual traumatic arterial-venous fistula from a single shotgun injury: a case report and literature review

“…7. Concerning the sequence in dual fistulas, while some suggest repairing the larger fistulas first and leaving the smaller ones to reduce venous thrombosis [20], our situation was different since we caught the AVF rather early after the events; no venous aneurysms were present and only moderate venous dilatation. In any case, we elected to keep anticoagulation following the repair of the second, more proximal fistula for 3 months.…”

“…Correction of AVFs cause rapid resolution of symptoms, including the systemic ones [11,12,29,30]. There are three postoperative complications, however, that warrant special consideration; chronic TAVFs can cause venous dilatation and aneurysms, which in the setting of decreased blood velocity post repair, can precipitate the formation of venous thromboembolism (VTE) [20]. Therefore, close monitoring and DVT prophylaxis are necessary.…”

“…The second complication is the Branham effect, which is reflex bradycardia immediately after repairing an AVF due to the sudden increase in systemic vascular resistance [20]. In case of surgical correction, Orrapin et al recommend clamping the fistula prior to definitive excision to check for possible hemodynamic instability [20]. The third complication is aneurysmal arterial dilation proximal to AVF even post closure.…”

Repair of a high-flow superficial femoral arteriovenous fistula using a bell-bottom iliac limb endoprosthesis

“…[14][15][16] In the setting of decreased blood flow following repair of AVF, the massively dilated veins with stagnant flow may also fill with thrombus. 17 Endovascular treatment in traumatic AVF is promising but long-term follow-up is needed to determine durable patency. It will be intriguing to monitor the diameter of the arteries proximal to the fistula and assess whether the stent-graft seal will endure over time.…”

“… 14 , 15 , 16 In the setting of decreased blood flow after repair of an AVF, the massively dilated veins with stagnant flow can also fill with thrombus. 17 …”