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COMMENTARY
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 65-66

Expert comments on “iatrogenic arteriovenous fistula after lumbar disc surgery: Case reports and review of literature”


Department of Peripheral Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication31-Jan-2018

Correspondence Address:
Dr. Ambarish Satwik
Department of Peripheral Vascular and Endovascular Surgery, Sir Ganga Ram Hospital
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.224456

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How to cite this article:
Satwik A. Expert comments on “iatrogenic arteriovenous fistula after lumbar disc surgery: Case reports and review of literature”. Indian J Vasc Endovasc Surg 2018;5:65-6

How to cite this URL:
Satwik A. Expert comments on “iatrogenic arteriovenous fistula after lumbar disc surgery: Case reports and review of literature”. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2020 May 29];5:65-6. Available from: http://www.indjvascsurg.org/text.asp?2018/5/1/65/224456



Pranay Pawar et al., with their two case reports on the management of traumatic (iatrogenic) arteriovenous communications as a consequence of intervertebral disc surgery have added to the small corpus of literature on this rare complication which is difficult to diagnose as it usually manifests with systemic features of an insidiously developing cardiac failure leading the patients to physicians rather than to vascular specialists.[1]

As is reinforced by the narrative in these two cases, there is, almost always, a considerable interlude between lumbar disc surgery and the time when a definitive diagnosis is made.[2],[3] The longer the interval, the greater the morphological changes incurred in the artery and vein. The artery gets progressively dilated and thin walled [4] on account of the lowered peripheral resistance and in very long-standing cases it might so transpire that an artery might get dilated to the extent that the usually available sizes of stent grafts might fall drastically insufficient to treat these arteries endovascularly, leading some practitioners to adopt innovative, off-the-shelf options to treat these arteriovenous fistulae [5]. It is therefore, always advisable to report the diameters of the affected artery and vein; the authors of this paper haven't done so.

With reference to the specifics mentioned in the first case, one would have to concur with the decision to surgically disconnect the fistula in a 28-year-old patient, if not deemed too hazardous (for open intervention). However, it needs to be mentioned that surgery in these cases can be a perilous exercise. Surgical planes in such patients are invariably affected by a considerable degree of fibrosis; dissection and repair, in unskilled hands can lead to significant bleeding and or nerve injury.[6],[7] It also needs to be stated that a landing zone of 9mm (as mentioned by the authors in the first case) isn't an immediate disqualification for an endovascular repair.[7],[8]

What's also interesting about the incidence of inadvertent vascular injuries in the course of lumbar discectomy is that arterio-venous fistulae seem to be more common than arterial lacerations and pseudoaneurysms. Papadoulas et al. have published a series of 98 vascular injuries in this surgical setting with the following incidence: 30% laceration, 67% arteriovenous fistula with or without pseudoaneurysm and 3% pseudoaneurysm alone.[3] Surely the mechanics of such an injury (rongeur caused or otherwise) that has the propensity for causing an arterio-venous communication rather than a pure arterial or venous injury needs to be theorized and studied in greater detail.

Overall, there seems to be an evolving consensus that traumatic arterio-venous fistulae should be treated endovascularly (as first line therapy) wherever possible. The evidence is clearly in favour of an endovascular approach with demonstrably lesser morbidity and mortality and the prospect of effecting a repair entirely by a percutaneous approach.[9],[10]



 
  References Top

1.
Pawar P, Sharma A, Raju R, Ayyappan MK. Iatrogenic Arteriovenous Fistula after Lumbar Disc Surgery: Case Reports and Review of Literature. Indian J Vasc Endovasc Surg 2018;5:63-5.  Back to cited text no. 1
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2.
Jarstfer BS, Rich NW. The challenge of anteriovenous fistula formation following disk surgery: A collective review. J Trauma 1976;16:726-33.  Back to cited text no. 2
    
3.
Papadoulas S, Konstantinou D, Kourea HP, Kritikos N, Haftouras N, Tsolakis JA. Vascular injury complicating lumbar disc surgery. A systematic review. Eur J Vasc Endovasc Surg 2002;24:189-95.  Back to cited text no. 3
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4.
Eugster T, Wigger P, Bölter S, Bock A, Hodel K, Stierli P. Brachial artery dilatation after arteriovenous fistulae in patients after renal transplantation: A 10-year follow-up with ultrasound scan. J Vasc Surg 2003;37:564-7.  Back to cited text no. 4
    
5.
Cronin B, Kane J, Lee W, Shriki J, Weaver FA. Repair of a high-flow iliac arteriovenous fistula using a thoracic endograft. J Vasc Surg 2009;49:767-70.  Back to cited text no. 5
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6.
Wang GJ, Foley PJ. Endovascular repair of iatrogenic iliac injuries. Endovasc Today. Available from: http://evtoday.com/2011/11/endovascular-repair-of-iatrogenic-iliac-injuries/. [Last accessed 2015 May 10].  Back to cited text no. 6
    
7.
Marino M, Kasemi H, Di Angelo CL, Fadda GF. Endovascular repair of a proximal ilio-iliac arterio-venous fistula and distal pseudoaneurysm of the hypogastric artery 23 years after penetrating trauma. Interact Cardiovasc Thorac Surg 2015;21:269-71.  Back to cited text no. 7
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8.
Liu X, Lu M, Shi H, Jiuang M. A Case of Iatrogenic Ilio-iliac Arteriovenous Fistula Initially Mistaken for Deep Venous Thrombosis; Eur J Vasc Endovasc Surg 2012;44:104.  Back to cited text no. 8
    
9.
Geraghty S, Durham JD, Levy JM, Wolf PS. Endovascular repair of an arteriovenous fistula after intervertebral disk surgery: Case report. J Vasc Interv Radiol 2009;20:1235-9.  Back to cited text no. 9
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10.
Ocal O, Peynircioglu B, Eldem G, Akpinar E, Onur MR, Kabakci G. Iliac arteriovenous fistulas after lumbar spinal surgery. Turk J Emerg Med 2017;17:109-11.  Back to cited text no. 10
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