Traumatic A-V A V Fistula

Transcription

1 Traumatic A-V A V Fistula

2 PRESENT HISTORY PAST HISTORY 30 year-old, male ( XX); Denied other systemic disease before. PRESENT HISTORY A deep stabbing wound (3*1 cm) noted on 07/01/2002 over Right anterior neck area due to traumatic knife cutting; Another sacral wound was also noted; Hypovolemic shock was noted then.

3 VITAL SIGNS & PE ER BP: 90/58 mmhg; T/P/R: 36.5/104/18; Conscious: Clear, Cooperative; GCS: E 3 V E M 6 Conjunctiva: Pale; Neck: Right neck stabbing wound with swelling and active bleeding; Trunk: Sacral area stabbing wound noted.

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5 ER RESUSCITATION 1. Intubation with Ventilator Usage; 2. Aggressive IVF Infusion & Blood Transfusion; 3. Vital Signs Maintenance; 4. Emergent OP Arrangement;

6 OP RECORDS Smooth OP Course on Date (07/01/2002) 1. Exploration, Right side neck; 2. Repair of thoracolumbar fascia and paraspinatous muscle; 3. Suture-ligation of the Vertebral artery; 4. Drainage insertion.

7 Post-OP COURSE (07/02-04/2002) Vital Signs: Acceptable, not Febrile Conscious: Clear but Sedated Neck Swelling with Serosanguineous Dsicharge Noted MV usage, FiO 2 : 0.35 (07/05/2002) Extubation Achieved

8 Post-OP COURSE (07/08/2002) Persistent Neck Swelling noted (CxR) Thrills noted over Right Neck Region Subjectively and Objectively Continuous Murmurs, Bruits noted by Auscultation and Pulsatile Palpation Noted over Right Neck Area No obvious Dizziness Noted (07/10-11/2002) Some pus discharge from back wound area with fever Post B/C (MRSA)

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10 CLINICAL IMPRESSION 1. r/o A-V Fistula Formation, post Trauma; 2. r/o Pseudo-aneurysm Formation; 3. Wound infection (MRSA)

11 ANGIOGRAPHY (07/10/2002)

12 ANGIOGRAPHY (07/10/2002)

13 ANGIOGRAPHY (07/10/2002)

14 ANGIOGRAPHY (07/10/2002)

15 ANGIOGRAM by Cath Venous return Vertebral artery

16 IMPRESSION 1. Traumatic A-V Fistula Formation (Right Vertebral Artery to Right Internal Jugular Vein); 2. Wound infection (MRSA).

17 TREATMENT CATHETERIZED EMBOLIZATION CATHETERIZED EMBOLIZATION 1. Right Subclavian Arteriography demonstrated a huge AV fistula from Right Vertebral Artery to Right Internal Jugular Vein with faint filling contrst due to tremendous shunt flow. 2. Via Right Radial Artery, we put a coil of 8 * 50 mm into vertebral artery through JR4 G.C. with a poor result. 3. Another second coil of the same size was inserted again, followed by Protamine 30 mg I.A. to reverse the effect of Heparin which was previously injected for radial sheath introduction.

18 TREATMENT CATHETERIZED EMBOLIZATION 4. A 3 rd coil of smaller size (6 * 100 mm) was introduced again due to poor secondary trial, and this time the result was quite satisfactory. There was no more existence of AV fistula, accompanied with disappearance of neck bruits. 5. Patient tolerated well during the whole procedure.

19 CATHETERIZED EMBOLIZATION

20 DISCUSSION AV communication in the neck result from trauma or from a medical intervention. Head injury Frequently Carotid Cavernous Fistula. Most frequently a central venous puncture for hemodynamic monitoring or for parenteral nutrition. Most AV communication in the neck after CVP puncture develop between the vertebral artery and jugular vein. Case demonstrate that AV communication can develop without any alarming sign of an arterial puncture. Diagnosis and management of trauma and iotragenic induced arteriovenous fistulas in the neck. Vasa. 1999;28:

21 DISCUSSION AV communications, even those with no or mild symptoms, should be treated either surgically or by endovascular therapy, avoiding further complications such as infection, thrombosis and arterio-arterial embolization. Endovascular therapy is safe and being less invasive is the treatment of choice using embolic coils or detachable balloons, if these tools and the expertise of selective catheterization are readily available. Arteriovenous fistula complicating central venous catheterization: value of endovascular treatment based on series of seven cases. Intensive Care Med. 1995:21;

22 LECTURE REVIEW A surgically treated arteriovenous fistula between the vertebral artery and internal jugular vein after insertion of a central venous catheter for mitral valve replacement Asolt Antal Varga, MD, PhD, et al AV communications created by CVP insertion First symptoms: A noise and mild dyspnea A Duplex Sonogram was used for noninvasive eximination tool Treatment: Suture Ligation by Surgery Follow up tools: Duplex Sonography The Journal of Thoracic and Cardiovascular Surgery 2002, Volume 123, Number 3, p