Present address: U. S. Army Hospital, Fort ... Stanford Mledical Center, Palo Alto, California. Aided by U. S. Public ..... Beattie, W., J. B. Oldham and J. A. Ross:.
Postnephrectomy Arteriovenous Fistula: * Case Report and Review of Literature CAPT. GEORGE F. GITLITZ, MC, USA, * STANLEY C. FELL, M.D., ROBERT H. SAGERMAN, M.D.,"*' ELLIOTT S. HURWITT, M.D. From the Divisions of Surgery and Diagnostic Radiology, Montefiore Hospital New York City, N. Y.
sign was positive at 60 degrees on the right and was negative on the left. There was tenderness over the lower dorsal spine and the lumbosacral regions. Routine laboratory data were within normal limits. Roentgenograms of the chest and spine, upper gastro-intestinal series, barium enema, and cervical and lumbar myelography were not remarkable. Intravenous pyelography demonstrated absence of the right kidney and a normal left kidney. Bone survey revealed osteoarthritic changes in the right hip and knee. The electrocardiogram showed regular sinus rhythm, occasional premature ventricular contractions, and nonspecific T-wave changes. The consulting resident in cardiology, Dr. Alfred Lowenstein, could find no pathology referable to the heart but noted a continuous murmur over the right abdomen, flank, and costovertebral region. He suggested the possibility of a renal arteriovenous fistula. A percutaneous retrograde femoral aortogram demonstrated a normal left renal artery and a large right renal artery terminating in a multilocular channel representing a dilated right renal vein. There was early opacification of the inferior vena cava, which was dilated (Fig. 1). Because of the possibility of future adverse cardiac effects resulting from the arteriovenous fistula, operation was performed on May 31, 1961. A long midline incision from xiphoid to pubis was utilized, and beneath the enlarged left renal vein the right renal artery was exposed. A thrill was palpable in the renal artery and the inferior vena cava. Compression of the renal artery eliminated the thrill. The artery was clamped as it presented to the right of the inferior vena cava; it was then divided and the ends oversewn. The postoperative course was uineventful, and the patient was discharged on June 28, 1961. Following her discharge, however, she was re-admitted to the neuirology service on Auiguist 28, 1961 with almost identical complaints, and again an exhaustive investigation has failed to disclose the cause of her pain,
RENAL arteriovenous fistulas may be congenital, traumatic, neoplastic, or surgically induced. Twenty-seven of these have been reported,5 14, 15 eight of which occurred subsequent to nephrectomy.2' 3 6, 8,10,16,18 The presently reported case is apparently the ninth, a very rare complication of a common
surgical procedure. Case Report
M. T. S., a 48-year-old Negro woman, was admitted to Montefiore Hospital for the first time on April 25, 1961 with the chief complaint of chest and back pain and weakness of the right lower extremity of one month's duration, following a fall. Investigation at another hospital, including myelography, had failed to demonstrate a cause for the pain and paresis, and the patient was transferred to Montefiore Hospital for further study. Her past history included a right nephrectomy for tuberculosis at the age of 20. On physical examination, the blood pressure was 120/70 mm. Hg, and the pulse rate 92. There was marked tenderness over the right fourth rib anteriorly. The heart was not enlarged to percussion. There was a Grade I high-pitched systolic murmur heard in the second left intercostal space at the sternal border. All peripheral pulses were palpable. Neurologic examination revealed weakness of the right leg, most marked on dorsi-flexion of the foot. There was hyperalgesia in the distribution of T5 and T6 and L4 and L5 on the right. Laseguie's
Submitted for publication Juine 14, 1962. Present address: U. S. Army Hospital, Fort Jay, Governors Island, New York. Present address: Department of Radiology, Stanford Mledical Center, Palo Alto, California. Aided by U. S. Public Health Service Grant #HP6645. **
511
512
GITLITZ, FELL, SAGERMAN AND HURWITT
FIG. 1. Retrograde femoral aortogram demonright renal artery, the sacciform renal vein, and opacification of the inferior vena cava. strates an enlarged stump of the right
Analysis of Cases Nine cases of arteriovenous fistulas following nephrectomy, including the presently reported case, have been reviewed (Table 1). Four of the patients were men, five women. The right kidney was involved in seven cases, the left in two. The ages of the patients at the time of nephrectomy ranged from 21 to 60 years, the average age being 35. Nephrectomy was performed for tuberculosis in three cases, for ureteral obstruction and hydronephrosis, or both, in four cases, and in one case for pyonephrosis complicating pregnancy. In one case the indication was not stated. In only one case was mass ligature of the renal vessels definitely known to have been performed, but in three others it was strongly suggested. In another case the vessels were ligated separately, but may have been traumatized by an aneurysm needle. The original op-
Annals of Surgery April 1963
eration was complicated in one case by severe bleeding necessitating packing of the wound, and in two other cases by prolonged drainage and postoperative infection. Symptoms or signs indicating an arteriovenous fistula developed from five months to 25 years following nephrectomy. The average latent period was seven years. The interval between nephrectomy and operation for cure of the fistula ranged from five months to 29 years and averaged 15 years. Cardiovascular effects of the fistula varied in severity. The patient presented here had no evidence of cardiac disease. In Elkin's case,2 enlargement of the heart and congestive failure were too far advanced for the patient to benefit from operation, and in Muller's case 10 cardiac damage was so advanced that cardiac arrest occurred during the induction of anesthesia. Though the patient was revived by open-chest cardiac compression, operation for closure of the fistula three weeks later was followed by fatal myocardial infarction. In four patients, closure of the fistula was followed by improvement. This included disappearance of pain, narrowing of pulse pressure, reversion of atrial fibrillation to regular sinus rhythm, and decrease in left ventricular size and in the severity of congestive heart failure. The diagnosis of arteriovenous fistula was proven in four cases by trans-lumbar aortography and in three others at operation. The method used in the presently reported case was percutaneous retrograde femoral aortography.17 The methods of operative management of the fistula varied. In one case two arteries and one vein were ligated, and the aneurysmal sac was resected. The procedure in four cases, including the presently reported one, was ligation or division of the artery or arteries supplying the fistula. Discussion Sauter,14 in 1960, collected 15 cases of renal arteriovenous fistulas occurring with
POSTNEPHRECTOMY ARTERIOVENOUS FISTULA
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Annals of Surgery GITLITZ, FELL, SAGERMAN AND HURWITT Another etiologic factor which has been the kidney in situ, and since then four more cases 5,15 have been reported. Nine suggested is infection, either existing prior cases were congenital, seven were trau- to surgery or as a postoperative complicamatic, and three were complications of tion.8' 10 This was known to have been renal carcinoma. These must be differenti- present in seven of the 25 postsurgical arated from those fistulas which follow ne- teriovenous fistulas cited, including five in phrectomy.15 Physiologically, a renal ar- the postnephrectomy group. It must be teriovenous fistula proximal to a kidney recognized, however, that just as there are presents not only the problems associated many vascular pedicles ligated en masse, so with any peripheral arteriovenous fistula, are many operations performed in the face but also the possibility of acquired sus- of infection without the development of tained hypertension.4 This is produced by arteriovenous fistulas. the decrease in blood pressure and blood Summary flow distal to the shunt, the effect being 1. A case of renal arteriovenous fistula identical to the narrowing of the renal arfollowing nephrectomy is reported, and the tery experimentally or by atherosclerosis. Postnephrectomy fistulas have physiologic literature is reviewed. 2. Mass ligature and transfixion suture effects resembling peripheral arteriovenous ligature of the vascular pedicle have been fistulas. cited as causes of arteriovenous fistula, but Since the report of two cases by William a more constant feature has been the presleast at in there have been 1757,9 Hunter, ence of infection. 58 recorded instances of arteriovenous fiseffects of the fistulas Cardiovascular 3. tulas following procedures ranging from from the complete ranged cases venopuncture to gastrectomy. Most of these in these intractable conto absence of symptoms were summarized in 1960 by Munnell,11 and at least 11 additional cases have been gestive heart failure. 4. Treatment of the fistula may consist reported.1' 7,12,13 In 33 of the cases penesimply of interruption of the blood flow in trating trauma was involved, with effects similar to the gunshot or stab wounds the renal artery or arteries supplying the which produce the more commonly en- abnormal communication. countered arteriovenous fistulas. These were Addendum the cases incidental to injections, thoracenof this manuscript to Subsequent tesis, disc operations, the insertion of ortho- for publication, an submission additional arteriovenous fistula pedic appliances, etc. In the other 25 cases, following nephrectomy was reported by Aravenis, including the nine which followed nephrec- Michaelides, Alivizatos, and Lazarides in Ann. tomy, the shunt developed in a ligated Surg. 156:749, 1962 (Nov.). 514
vascular pedicle. Mass ligature of a vascular pedicle has been thought to be a cause of induced arteriovenous fistula. Although this technic is frequently employed in a variety of surgical procedures, the occurrence of postoperative arteriovenous fistula is rare. Either many postoperative arteriovenous fistulas are unrecognized or unreported, or, as Schwartz 16 and Harbison6 have suggested, the danger of mass ligature has been exaggerated.
References 1. Beattie, W., J. B. Oldham and J. A. Ross: Superior Thyroid Arteriovenous Aneurysm. Brit. J. Surg., 48:456, 1961. 2. Elkin, D. C.: Aneurysms Following Surgical Procedures. Report of Five Cases. Ann. Surg., 127:769, 1948. 3. Elliott, J. A.: Post-nephrectomy Arteriovenous Fistulas. J. Urol., 85:426, 1961. 4. Goldblatt, H.: Hypertension: Experimental by Constriction of Main Renal Arteries. Method. Med. Physics, Chicago, The Year Book Publishers, 1944, p. 622.
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POSTNEPHRECTOMY ARTERIOVENOUS FISTULA
5. Grace, J. T., W. Staubitz, P. Lessmann and R. Egan: Intrarenal Arteriovenous Fistulas. Arch. Surg., 81:718, 1960. 6. Harbison, S. P., F. J. Gregg and J. Z. Gutierrez: Arteriovenous Fistula Following Nephrectomy, Report of a Case Complicated by Severe Azotemia and Congestive Failure. Ann. Surg., 152:281, 1960. 7. Hershey, F. B.: Secondary Repair of Arterial Injuries. Amer. Surg., 27:33, 1961. 8. Hollingsworth, E. H.: Arteriovenous Fistula of the Renal Vessels. Am. J. Med. Sci., 188: 399, 1934. 9. Hunter, W.: Cases cit. by Munnell. 10. Muller, W. H., Jr. and W. E. Goodwin: Renal Arteriovenous Fistula Following Nephrectomy. Ann. Surg., 144:240, 1956. 11. Munnell, E. R., C. R. Mota andW. B. Thompson: latrogenic Arteriovenous Fistulas: Report of a Case Involving the Superior Mesenteric Vessels. Am. Surgeon, 26:738, 1960. 12. Pridgen, W. R. and J. K. Jacobs: Postopera-
13. 14.
15.
16.
17.
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tive Arteriovenous Fistula. Surgery, 51:205, 1962. Reams, G. B.: A Middle Colic Arteriovenous Fistula Developing as a Post-gastrectomy Complication. Arch. Surg., 81:757, 1960. Sauter, K. E. and J. W. Sargent: Spontaneous Rupture of Intrarenal Arteriovenous Fistula: Report of a Case. J. Urol., 83:17, 1960. Scheifley, C. H., G. W. Daugherty, L. F. Greene and J. T. Priestley: Arteriovenous Fistula of the Kidney: New Observations and Report of 3 Cases. Circulation, 19:622, 1959. Schwartz, J. W., A. A. Borski and E. J. Jahnke: Renal Arteriovenous Fistula. Surgery, 37:951, 1955. Seldinger, S. I.: Catheter Replacement of a Needle in Percutaneous Arteriography. Acta
Radiologica, 39:368, 1953. 18. Shirey, E. K.: Cardiac Disease Secondary to Post-Nephrectomy Arteriovenous Fistula. Cleveland Clin. Quart., 26:188, 1959.
