Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 176-178

Long-standing traumatic femoro-femoral arteriovenous fistula presenting with congestive cardiac failure after 35 years


1 Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
2 Department of Medicine, College of Health Sciences, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
3 Department of Anaesthesia and Intensive Care, College of Health Sciences, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria

Date of Submission20-Jun-2020
Date of Decision06-Jul-2020
Date of Acceptance13-Jul-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
Olugbenga Olalekan Ojo
Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospital, Ile-Ife
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_84_20

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  Abstract 


Acquired arteriovenous fistulas (AVFs) could either be traumatic or iatrogenic, though a spontaneous etiology was described by Syme in 1831. Penetrating injuries from stab wounds account for a large proportion of civilian cases of traumatic AVFs. Chronic or long-standing AVFs are characterized by significant shunting of blood from the arterial to the venous system. We report a case of a large traumatic femoral AVF, presenting with features of congestive cardiac failure (CCF), in a 54-year-old male after a remote stab injury to the right groin. The patient had also developed signs of unilateral chronic venous insufficiency in the involved limb. Following clinical examination, duplex ultrasound, and computed tomography angiography, the diagnosis of chronic AVF was confirmed. He successfully underwent open surgical repair with a dramatic resolution of symptoms of CCF.

Keywords: Acquired, arteriovenous fistula, congestive cardiac failure, iatrogenic, open surgical repair, traumatic


How to cite this article:
Ojo OO, Onakpoya UU, Akintomide AO, Adenekan AT. Long-standing traumatic femoro-femoral arteriovenous fistula presenting with congestive cardiac failure after 35 years. Indian J Vasc Endovasc Surg 2021;8:176-8

How to cite this URL:
Ojo OO, Onakpoya UU, Akintomide AO, Adenekan AT. Long-standing traumatic femoro-femoral arteriovenous fistula presenting with congestive cardiac failure after 35 years. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jun 24];8:176-8. Available from: https://www.indjvascsurg.org/text.asp?2021/8/2/176/313571




  Introduction Top


An arteriovenous fistula (AVF) is an abnormal communication between an artery and a vein. Acquired AVFs are primarily due to vascular trauma, and they are further classified as traumatic or iatrogenic AVFs.[1] AVFs can cause significant complications including congestive cardiac failure (CCF), however there are few cases of remote trauma resulting in high-output cardiac failure.[2] We present a case of long-standing traumatic AVF which was initially managed as CCF before undergoing successful surgical correction.


  Case Report Top


A 54-year-old man presented to the cardiology outpatient clinic with complaints of progressively worsening dyspnea, cough, paroxysmal nocturnal dyspnea, orthopnea, palpitations, early satiety, and abdominal and pedal swelling of 2 years' duration. He was not a known hypertensive and had no previous history of ischemic heart disease. He was started on treatment for CCF with minimal improvement of symptoms. During the subsequent follow-ups, he was noted to have unilateral pitting edema over the right leg and foot as well as a spontaneous ulceration of the right gaiter's area. While probing the unilateral edema, he pointed to a “vibrating” sensation over the site of a stab injury he sustained 37 years previously. Considering the above, a Doppler ultrasound scan was requested, and he was referred to our unit.

Clinical examination revealed right pedal edema up to the knee with an irregularly irregular peripheral pulse, distended neck veins, and inferolaterally displaced heaving apex beat S1 and S2 which were irregular with a Grade IV pansystolic murmur loudest at the apex. In addition, there were a palpable thrill in the right iliac fossa and a nontender hepatomegaly.

The right lower limb was diffusely swollen and hyperpigmented with prominent veins. A pulsatile healed scar was present over the proximal thigh, with a palpable thrill and continuous bruit over it. There was an ulcer over the medial malleolus with dystrophic toenail changes. However, distal arterial pulsations were present.

Duplex ultrasound demonstrated an AVF between the superficial femoral artery (SFA) and the common femoral vein (CFV). Computed tomography (CT) angiography showed rapid early filling of the right CFV vein on the arterial phase imaging and lack of contrast opacification of the veins of the contralateral side [Figure 1]. Also seen were dilated tortuous iliac vessels and dilated inferior vena cava [Figure 2].
Figure 1: Computed tomography angiogram showing the site of fistulous connection (abnormal contrast flow) between the dilated proximal superficial femoral artery and common femoral vein

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Figure 2: Computed tomography angiogram showing dilated tortuous iliac vessels and dilated inferior vena cava

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Electrocardiogram confirmed atrial fibrillation, while transthoracic echocardiography revealed dilated cardiac chambers, good left ventricular systolic function, and moderate aortic stenosis.

Findings at surgery included tortuous and dilated right external iliac artery and vein, dilated common femoral artery (CFA) down to the area of fistulous connection, dilated CFV, and 2-cm wide AVF between the proximal SFA and adjacent CFV. After achieving proximal and distal arterial and venous controls, the AVF was dismantled. A lateral repair of the defect in the arterialized (thickened) CFV was done over a side-biting vascular clamp with 4.0 polypropylene suture [Figure 3]. An 8-mm polytetrafluoroethylene (PTFE) graft was used to establish continuity between the CFA and SFA. Due to the size discrepancy between the proximal CFA and the distal SFA, the PTFE graft was beveled, and the interposition was fashioned as a side-to-end (functional end-to-end) anastomosis.
Figure 3: Postresection of arteriovenous fistula and venorrhaphy, clamps on the common femoral artery and distal superficial femoral artery

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Postoperatively, right lower limb pulses were palpable, thrill was no longer felt, and postoperative Doppler ultrasound scan was satisfactory. At 4-week follow-up in clinic, the symptoms had resolved; he had no need for heart failure medications and the ipsilateral chronic leg ulcer had healed.


  Discussion Top


AVFs can be classified as either congenital or acquired. Congenital AVFs are rare and are usually the result of the persistence of embryonic vessels and their failure to differentiate into arteries and veins.[1] Acquired AVFs could either be traumatic or iatrogenic, though a spontaneous etiology where an aneurysm erodes into an adjacent vein has been described.[3],[4] Iatrogenic AVFs are mainly due to percutaneous vascular procedures, either diagnostic or therapeutic. Majority of the AVFs resulting from percutaneous interventional procedures are generally small and asymptomatic and close spontaneously over several months.[5]

Traumatic AVFs are the result of either blunt or penetrating injuries, and these injuries occur in both civilian and military populations. Penetrating injuries from stab wounds account for a large proportion of civilian cases resulting in traumatic AVFs.

AVFs may close spontaneously, decrease in size, or progressively enlarge as a result of degenerative changes within the arterial wall.[1] Chronic or long-standing AVFs are characterized by significant shunting of blood from the arterial to the venous system. The increased venous return can eventually lead to the development of a high-output cardiac failure state.[5] In Nigeria and sub-Saharan Africa, the common causes of heart failure include hypertension, dilated cardiomyopathy, rheumatic heart disease, cor pulmonale, and pericarditis.[6],[7]

Our patient was a middle-aged male who presented with features of CCF. Based on the history and prevalence of hypertension as the principal cause of CCF in our environment, he was treated as such. Considering the rarity of remote extremity AVFs presenting with CCF, no one would have thought of it as a possible etiology until the patient pointed to a healed stab wound he sustained in the right groin 37 years ago. The unilateral right leg edema and nonhealing ulcer suggest the presence of chronic venous hypertension, which is a known complication of chronic AVFs. The high venous pressure at the site of the fistula results in dilatation and valvular incompetence of the distal vein, producing chronic venous insufficiency.[1] Further diagnostic evaluation including a CT angiogram confirmed the presence of an AVF between the SFA and CFV immediately after the bifurcation of the CFA. Endovascular modalities of treatment such as coil embolization and stent graft placement were not considered in this patient due to the massive dilatation and tortuosity of the iliac vessels and the unavailability of endovascular stenting at our institution. The size and the proximity of the fistula to the bifurcation of the CFA were also not in favor of an endovascular approach. Open surgery which involves identification and resection of the fistula, followed by repair of the vein, and restoration of arterial continuity and blood flow was successfully performed in this case. Surgical repair was not easy due to massive hemorrhage from extensive collateral circulation and venous hypertension. We encountered significant bleeding from huge muscular collaterals and an unrecognized venous tributary, which were eventually identified and ligated. The patient had 4 units of blood transfused intraoperatively.

The prompt resolution of symptoms of CCF and the healing of the leg ulcer further confirm that both were because of the long-standing AVF.


  Conclusion Top


Long-standing AVF resulting in high-output CCF though rare must always be borne in mind when assessing patients with new-onset heart failure. Early recognition and prompt surgical treatment dramatically improves symptoms and prevents irreversible changes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to acknowledge Drs. Oghenevware Eyekpegha and Abayomi Oguns for their contributions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhou W. Acquired arteriovenous fistulae. In: Cronenwett JL, Johnston KW, editors. Rutherford: Vascular Surgery. 8th ed.., Vol. 2. Philadelphia: Elsevier; 2014. p. 1274.  Back to cited text no. 1
    
2.
Rymer JA, Anderson LL, Posenau JT, Jones WS. Remote stab wound resulting in AV fistula and high-output heart failure. Case Rep Cardiol 2013;2013:902719.  Back to cited text no. 2
    
3.
Syme J. Case of spontaneous varicose aneurysm. Edinb Med J 1831;36:104-5.  Back to cited text no. 3
    
4.
Mahajan A, Luther A. Acquired arteriovenous fistulae: A study of three cases and review of literature. Indian J Vasc Endovasc Surg 2016;3:125-7.  Back to cited text no. 4
  [Full text]  
5.
Porter J, Al-Jarrah Q, Richardson S. A case of femoral arteriovenous fistula causing high-output cardiac failure, originally misdiagnosed as chronic fatigue syndrome. Case Rep Vasc Med 2014;2014:510429.  Back to cited text no. 5
    
6.
Adebayo SO, Olunuga TO, Durodola A, Ogah OS. Heart failure: Definition, classification and pathophysiology – A mini review. Nig J Cardiol 2017;14:9-14.  Back to cited text no. 6
  [Full text]  
7.
Tantchou Tchoumi JC, Ambassa JC, Kingue S, Giamberti A, Cirri S, Frigiola A, et al. Occurrence, aetiology and challenges in the management of congestive heart failure in sub-Saharan Africa: Experience of the Cardiac Centre in Shisong, Cameroon. Pan Afr Med J 2011;8:11.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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