Recovery of Cardiomegaly After Treatment of Traumatic Popliteal Arteriovenous Fistula

Abstract

Circ J 2009; 73: 776 -778 raumatic arteriovenous fistula (AVF) occurs infrequently after arterial injury. 1 Although the initial symptoms are frequently mild, the shunt flow increases with time and the patient becomes aware of a thrill or swelling over the affected area. Cardiac symptoms are eventually noted when compensation cannot cover the increased cardiac load. However, AVF in the extremity rarely leads to cardiac failure because the artery affected is relatively small. We describe a patient who was treated surgically for a long-standing popliteal AVF, in whom cardiomegaly promptly resolved after the operation. We also discuss the etiology and technical aspects of the treatment. Case ReportA 32-year-old man visited hospital complaining of swelling of the left leg, particularly below the knee. He had also noted redness, local heat and skin pigmentation. Nine years before, he had been involved in a traffic accident and had suffered a compound fracture of the left tibia with bone exposure. The fracture had been stabilized using a metal plate and nails, and since then he had been asymptomatic. However, several years later, he became aware of swelling of the left leg, which had gradually increased. The current presentation occurred after another traffic accident, which was not severe.Physical examination revealed marked swelling and skin pigmentation of the left leg below the knee and a thrill in the popliteal fossa. The patient complained of heaviness in the left leg, but was otherwise asymptomatic and had no shortness of breath. Chest roentgenography revealed cardiomegaly with a cardiothoracic ratio (CTR) of 61% (Figure 1A). Ultrasonic cardiography (UCG) revealed normal cardiac function with an ejection fraction (EF) of 77%, although the left atrium and ventricle were enlarged (Table). Enhanced computed tomography revealed distinct enlargement of the popliteal vein with early enhancement (Figure 2A) Recovery of Cardiomegaly After Treatment of Traumatic Popliteal Arteriovenous FistulaShunya Shindo, MD; Yoshihiro Honda, MD; Masatake Katsu, MD; Shigeaki Kaga, MD; Hidenori Inoue, MD; Masahiko Matsumoto, MD Circulatory distress can occur in the long term after the formation of a traumatic arteriovenous fistula (AVF), but cardiac failure rarely occurs in a patient with an AVF in the lower extremity. The present patient underwent surgery to treat a traumatic popliteal AVF 9 years after sustaining the injury. Although the patient was asymptomatic with regard to cardiac circulation, cardiomegaly was noted and it resolved promptly after the surgical treatment. Cardiac insufficiency should be borne in mind even when a patient is asymptomatic because young patients have a high tolerance for cardiac overload. CASE REPORT

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

“…For us, the surgical posterior approach was the obvious choice considering the location behind the knee joint, the very focal nature and the scarring medially from the previous exploration and tissue loss. 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].…”

“…While cases of repairing popliteal AVFs endovascularly have been reported, we elected to surgically repair this one due to the potential increased risk of stent fracture and thrombosis across the knee joint, especially in a young active individual [ 28 , 29 ]. This was the scenario in the popliteal case reported by Franz and Jump [ 28 ], especially that a stiffer stent was used originally for the repair.…”

“…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 ].…”