EJVES Extra
Volume 17, Issue 3 , Pages 21-23, March 2009

Endovascular Repair of Iatrogenic Superior Mesenteric Arteriovenous Fistula

  • J.P. Eiberg

      Affiliations

    • Department of Vascular Surgery, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Denmark
    • Corresponding Author InformationCorresponding author. J.P. Eiberg, Department of Vascular Surgery, Rigshospitalet 3111, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark Tel.: +45 35 45 2407; fax: +45 35 45 31 11.
    • ,
  • M. Bundgaard-Nielsen

      Affiliations

    • Department of Anaesthesiology, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Denmark
    • ,
  • M.A. Hansen

      Affiliations

    • Department of Radiology, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Denmark
    • ,
  • N.H. Secher

      Affiliations

    • Department of Anaesthesiology, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Denmark

Received 13 September 2008; accepted 7 November 2008. published online 29 December 2008.

Article Outline

Abstract 

Arteriovenous fistulas between the superior mesenteric artery and vein are extremely rare and often a late complication of bowel resection. We report a case of a 42-year-old male, who presented with abdominal pain and dyspnoea 9 years after ileo-caecal resection. A superior mesenteric arteriovenous fistula was detected and treated endovascularly with an Amplatzer Vascular Plug, thereby reducing the cardiac output and flow in the superficial mesenteric artery by 1.1lmin−1. The patient had an uneventful recovery.

Keywords: Iatrogenic arteriovenous fistula, Mesenteric artery, Cardiac output, heart failure, Bowel resection, Endovascular, Amplatzer vascular plug, Finometer

 

An arteriovenous fistula between the superior mesenteric artery and vein is extremely rare and is, in most cases, due to penetrating trauma (e.g., gunshot) or iatrogenic injury (e.g., appendectomy or bowel resection).1, 2, 3, 4 In iatrogenic cases, in particular, the causal relation is obscure due to vague clinical signs and the long time span between the injury and the development of the fistula. Estimation of the incidence is, therefore, difficult and probably underestimated. In 2005, only 40 cases of post-traumatic superior mesenteric arteriovenous fistulas (SMAVF) were cited in the English literature with a similar number of iatrogenic cases.3, 4, 5 Development of portal hypertension and, rarely, right heart failure is seen in patients with SMAVF. We report a case of SMAVF with symptoms of heart failure, successfully treated endovascularly under continuous cardiac-output monitoring and ultrasound-defined fistula-flow before and after closure.

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Case report 

A 42-year-old man with a history of Crohn's disease and a 9-year history of ileo-caecal resection was admitted with diarrhoea, abdominal pain and exercise-induced dyspnoea. At the time of admission, he appeared without jaundice or clinical ascites. Pulse rate and blood pressure were normal. An abdominal ultrasound examination demonstrated an SMAVF without any signs of ascites or hepato–spleno-megaly. The patient was admitted to the Department of Vascular Surgery. An additional ultrasound examination confirmed a fistula between the superior mesenteric artery and vein with a volume flow of 1.5lmin−1. Echocardiography and chest X-ray did not show any signs of heart failure. The following day, an arteriogram confirmed the diagnosis and an Amplatzer Vascular Plug II (AGA Medical, Plymouth, MN, USA) was deployed, percutaneously, occluding the fistula between the superior mesenteric artery and vein (Fig. 1). During this procedure the patient's cardiac output, estimated continuously and non-invasively using a Finometer® (FMS, Finapres Medical Systems BV, Amsterdam, The Netherlands), reduced by 1.1lmin−1 from 5.7 to 4.6lmin−1. Duplex ultrasound confirmed complete closure of the SMAVF and revealed a reduction in volume flow of 1.1lmin−1 in the superior mesenteric artery, from 1.5 to 0.4lmin−1 (Fig. 2). The patient had an uneventful recovery and was discharged in good condition. At the time of discharge and at follow-up after 3 months, the patient had no dyspnoea.

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  • Figure 1 

    (A) Arteriogram demonstrating the superior mesenteric arteriovenous fistula with enlarged artery and vein. (B) Arteriogram after placement of the Amplatzer Vascular Plug. (C) Ultrasound image demonstrating the Amplatzer Vascular Plug in place.

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Discussion 

The incidence of iatrogenic SMAVF following bowel resection is rare as compared to the frequency of bowel resections. However, the combination of no specific clinical signs and often the long delay between the injury and diagnosis could lead to an underestimation of the incidence. The clinical presentation of SMAVF is insidious – from asymptomatic to abdominal pain, anorexia, signs of portal hypertension (jaundice, acites, hepato– and spleno-megaly) and gastrointestinal bleeding.1, 4, 5 Right heart failure is rarely manifested in arterioportal fistulas (e.g., SMAVF) but has been described in other arteriovenous fistulas, for example, those following splenectomy6 and nephrectomy.7 In cases with increased arterioportal shunting, the hepatic sinusoids offer a resistance against increased flow to the right side of the heart. This explains why development of portal hypertension is more frequent in contrast to congestive heart failure.8 Donell et al. detected transient postoperative bradycardia following open closure of an SMAVF, probably as a compensatory measure to reduce the cardiac output.2 We have demonstrated a reduction in both cardiac output and superior mesenteric artery flow by 1.1lmin−1 after closure of the SMAVF. Although calculation of volume flow is an in-built function in most ultrasound devices, it still requires ultrasound experience. Continuous CO measurement with the Finometer® is non-invasive and easy although not previously described during closure of SMAVF.9

Several treatment options of SMAVF have been described, such as open resection,3, 4 covered stentgrafts8 and coil embolisation.1 Previous surgery and abdominal adhesions favour the endovascular approach, eventually using the Amplatzer Plug which is a Nitinol-based device primarily designed to close atrial-septal defects and patent arterial ducts. By using the Amplatzer Plug it was possible to close both the venous and the arterial component of the fistula.

In conclusion, in patients with equivocal symptoms and a history of bowel resection, SMAVF may be suspected irrespective of the time span between the resection and the onset of symptoms. Development of heart failure in arterioportal fistulas is rare. When treating SMAVF the endovascular approach is feasible. Because of the haemodynamic consequences of SMAVF, we suggest that fistula flow be estimated, either indirectly as a decrease in CO or directly as volume flow.

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References 

  1. de Gregorio MA, Gimeno MJ, Medrano J, Schonholz C, Rodriguez J, D'Agostino H. Ileocolic arteriovenous fistula with superior mesenteric vein aneurysm: endovascular treatment. Cardiovasc Intervent Radiol. 2004;27:556–559
  2. Donell ST, Hudson MJ. Iatrogenic superior mesenteric arteriovenous fistula. Report of a case and review of the literature. J Vasc Surg. 1988;8:335–338
  3. Francois F, Thevenet A. Superior mesenteric arteriovenous fistula after ileal resection. Ann Vasc Surg. 1992;6:370–372
  4. Kato S, Nakagawa T, Kobayashi H, Arai E. Superior mesenteric arteriovenous fistula: report of a case and review of the literature. Surg Today. 1993;23:73–77
  5. Chiriano J, Abou-Zamzam AM, Teruya TH, Ballard JL. Delayed development of a traumatic superior mesenteric arteriovenous fistula following multiple gunshot wounds to the abdomen. Ann Vasc Surg. 2005;19:470–473
  6. Madsen MA, Frevert S, Madsen PL, Eiberg JP. Splenic arteriovenous fistula treated with percutaneous transarterial embolization. Eur J Vasc Endovasc Surg. 2008;36:562–564
  7. Ozaki K, Kubo T, Hanayama N, Hatada K, Shinagawa H, Maeba S, et al. High-output heart failure caused by arteriovenous fistula long after nephrectomy. Heart Vessels. 2005;20:236–238
  8. Wu CG, Li YD, Li MH. Post-traumatic superior mesenteric arteriovenous fistula: endovascular treatment with a covered stent. J Vasc Surg. 2008;47:654–656
  9. Harms MP, Wesseling KH, Pott F, Jenstrup M, Van GJ, Secher NH, et al. Continuous stroke volume monitoring by modelling flow from non-invasive measurement of arterial pressure in humans under orthostatic stress. Clin Sci (Lond). 1999;97:291–301

PII: S1533-3167(08)00031-9

doi:10.1016/j.ejvsextra.2008.11.004

Refers to article:

  • Endovascular Repair of Iatrogenic Superior Mesenteric Arteriovenous Fistula , 29 December 2008

    J.P. Eiberg, M. Bundgaard-Nielsen, M.A. Hansen, N.H. Secher
    European Journal of Vascular & Endovascular Surgery March 2009 (Vol. 37, Issue 3, Page 369)

EJVES Extra
Volume 17, Issue 3 , Pages 21-23, March 2009

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