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Traumatic Lower Extremity Arteriovenous Fistulae in Children
Abstract
Traumatic arteriovenous fistulae are rare injuries in the pediatric population. Most are caused by penetrating injuries or are post-surgical in nature. Fistulae resulting from non-penetrating injuries are often missed early in the course of physical examination. This occurs due to the absence of clinical signs of arterial or venous injury, despite the close proximity of the affected vessels to point of injury. Likewise, signs and symptoms of post-surgical vascular injury may be difficult to discern from normal postoperative discomfort. The astute clinician must be on alert for unusual presentations of vascular injury to intervene in an expeditious manner. This article presents a series of vascular complications following either blunt injury or surgical management of the lower extremity in children who presented to our facility between November 2004 and December 2005.
... En todos los casos, el flujo sanguíneo se caracteriza por estar separado de los estímulos extracelulares que inician la cascada de coagulación, ya sea por tejido fibroso o una capa arterial, por lo que se diferencian de los eventos trombóticos. 1,2,5 En los adultos, la prevalencia reportada es de entre el 0,2 % y el 3,8 %, mientras que no hay estudios estadísticamente significativos realizados en la población pediátrica. La etiología más frecuente es la iatrogénica, seguida por traumatismos no iatrogénicos y patologías inflamatorias que afectan el endotelio vascular. ...
... También puede ser asintomático o afectar la circulación distal. 3,5,7,8 El diagnóstico inicial suele realizarse con ecografía doppler color, que evidencia una imagen hipoecoica adyacente al vaso sanguíneo. 6,9,10 patognomónico la imagen característica similar al yin-yang formada por el flujo bidireccional; sin embargo, esta puede no estar presente en los casos en que existe trombosis dentro del saco pseudoaneurismático. 9 El tratamiento depende del tamaño, la localización y de la disponibilidad de especialistas para su abordaje. ...
... Debido a que, inicialmente, pueden ser asintomáticos, muchos pacientes consultan de manera tardía. 5,6,10 Debe sospecharse esta entidad ante cualquier masa pulsátil o con frémito, o ante el antecedente de traumatismo y masa dolorosa local. 5,7 Se destaca que, en caso de sospechar de inicio un pseudoaneurisma, no es aconsejable realizar una punción-aspiración de la zona dado el riesgo de ruptura y que, en el paciente presentado, la sospecha inicial que motivó el procedimiento fue la manifestación clínica compatible con causa infecciosa. ...
Pseudoaneurysm or 'false aneurysm' is defined asan abnormal arterial dilatation produced by an injury to its wall that does not affect the three parietal layers like in 'true' aneurysms. In general, false aneurysms are related to traumatisms and, less frequently, to inflammatory disease of vascular endothelium. Clinically, it shows a pulsatile, painful hematoma in the affected region. The initial diagnosis is usually achieved by Doppler ultrasound showing a hypoechoic image in relation to a blood vessel or its wall. Due to the low prevalence of false aneurysm, it is commonly confused with skin and soft tissue's infections or with thrombosis. There are different options of treatment, from extrinsic compression to open surgery. We describe the case of a 13-year-old patient with traumatic false aneurysm of a muscular branch of femoral artery, successfully managed with endovascular exclusion of the lesion with microcoils.
... It can be congenital, acquired or created surgically. Acquired AVFs in the pediatric population are rare and usually reported in the lower extremities secondary to multiple cannulation attempts for vascular access or traumatic injuries [1][2][3][4][5]. Very few cases of acquired pediatric upper extremity AVFs are reported to date [6][7][8]. ...
... Acquired AVF are well described in adults; however, this complication is rarely reported in the pediatric population and therefore may present a challenge for diagnosis and management. Data on acquired pediatric AVF mainly consists of case reports and small case series [1][2][3][4][6][7][8][9]. The presumed pathogenesis is due to the development of a hematoma following a vascular injury, such as multiple cannulation attempts, with associated healing and fibrosis leading to adhesions between the artery and the vein [7]. ...
Acquired arteriovenous fistula (AVF) are rare in the pediatric population. We report a 15-year-old boy who sustained a ballistic ball (BB) gun pellet injury to the left forearm leading to formation of a traumatic branchio-brachial AVF. He underwent successful open repair of his fistula using a vein patch graft. We share our management of this rare case and review management of pediatric arteriovenous fistulas.
... An Arteriovenous fistula (AVF) is a permanent communication between an artery and a vein. Depending of the size, it may cause hemodynamic alterations with cardiac effects [38,39]. It can be congenital or acquired (i.e., traumatic, iatrogenic) [40,41]. ...
Background
The aim of this study is to describe point-of-care ultrasound and Color flow Duplex Doppler characteristics of penetrating and blunt trauma-related vascular injuries of the limbs and neck. Methods
Penetrating and blunt trauma-related vascular injuries such as vein disruption, intimal flap, deep vein thrombosis, arterial dissection, pseudoaneurysm, and arteriovenous fistulae are discussed in this manuscript. Images of the most significant lesions of our personal clinical experience are presented to illustrate point-of-care ultrasound and Color flow Duplex Doppler ultrasound findings. ResultsPenetrating and blunt trauma-related vascular injuries represent a big challenge. While patients with hard signs of arterial damage must be sent immediately to surgical exploration, when there are soft signs or no clear signs of vascular injury at the physical examination, and the patient is stable, imaging investigation and observation can be useful in the diagnosis and management of these patients. Although angiography is the gold standard of the imaging methods, point-of-care ultrasound and Color flow Duplex Doppler ultrasound are widely available, cheaper, noninvasive, and faster to obtain. They can provide bedside valuable information for the identification of some vascular injuries allowing to an integrated management of the trauma patient, enriched by the use of ultrasound. Conclusions
Point-of-care ultrasound and Color flow Duplex Doppler examination are increasingly used in the decision making process of trauma-related vascular injuries.
Arteriovenous fistulae have not been extensively reported in pediatric patients and are rare for pediatric anesthesiologists to encounter in their routine practice. Awareness of these lesions enables clinicians to avoid giving medications through the anomalous vascular connections. We report a child scheduled for an excision of a sacrococcygeal mass in whom we incidentally diagnosed the presence of arteriovenous fistulae in both his upper limbs. The affected limbs should be avoided and the vessels of the lower limbs should be cannulated for administration of fluid and medications during surgery.
Résumé
Introduction
Les faux anévrysmes post-traumatiques sont des complications rares des traumatismes artériels des membres. Les modalités de leur prise en charge sont mal définies chez l’enfant. Nous rapportons le cas d’un enfant opéré pour un faux anévrysme post-traumatique de l’artère tibiale antérieure, survenu après un traumatisme minime pénétrant.
Observation
Il s’agissait d’un adolescent âgé de 14 ans qui avait été victime d’un traumatisme minime pénétrant de la jambe droite. Trois mois plus tard était apparue une douleur du mollet avec boiterie. À l’examen clinique il existait une masse douloureuse battante à la palpation et soufflante à l’auscultation au niveau du tiers moyen de la jambe droite, sans signe inflammatoire en regard. L’écho-doppler artériel a révélé la présence d’une structure kystique hypo-échogène adjacente à l’artère tibiale antérieure, siège d’un courant circulatoire, faisant suspecter un faux anévrysme post-traumatique qui a été confirmé par un angioscanner. Le traitement chirurgical a consisté en une mise à plat du faux anévrysme et interposition d’un greffon autologue.
Conclusion
Traditionnellement chirurgicale, la prise en charge des faux anévrysmes post-traumatiques des membres de l’enfant s’est ouverte à de nouvelles alternatives. Actuellement, les techniques endovasculaires, de compression manuelle écho-guidée, ou d’embolisation par injection de thrombine sont proposées.
Diagnosis of vascular injury in pediatric trauma is challenging as clinical signs may be masked by physiologic compensation. We aimed to (1) investigate the prevalence of noniatrogenic pediatric venous injuries, (2) discuss options in management of traumatic venous injury, and (3) investigate mortality from venous injury in pediatric trauma. Our objective was to provide the practicing clinician with a summary of the published literature and to develop an evidence-based guide to the diagnosis and management of traumatic venous injuries in children.
Blunt traumatic arteriovenous fistulae of the extremities are rare in children. We report the case of a 10-year-old boy with a traumatic infrapopliteal arteriovenous fistula and concomitant pseudoaneurysm diagnosed 2 months after he was struck by a car. It was definitively managed with coil embolization. Postprocedure, the vascular anatomy of the patient's right calf was well preserved. He had complete resolution of his symptoms immediately after the intervention and continues to do well 6 months later.
Arteriovenous fistula formation after a closed extremity fracture is rare. We present the case of an 11-year-old boy who developed an arteriovenous fistula between the anterior tibial artery and popliteal vein after closed fractures of the proximal tibia and fibula. The fractures were treated by closed reduction and casting. A fistula was diagnosed 12 weeks after the injury. It was treated by embolisation with coils. Subsequent angiography and ultrasonography confirmed patency of the popliteal vein and anterior and posterior tibial and peroneal arteries, with no residual shunting through the fistula. The fractures healed uneventfully and he returned to full unrestricted activities 21 weeks after his injury.
Surgical decompression remains the only effective treatment for the ischemia of the muscles and nerves of the leg that constitutes the principal defects in the compartment syndromes. Recently, partial fibulectomy has been proposed as a good way to decompress all four compartments instead of the older double incision. Both methods are effective in satisfactorily reducing intracompartmental pressures, as documented by our wick catheter measurements. However, the double-incision technique is easier, faster, safer, and is the treatment of choice when four-compartment decompressive fasciotomy is indicated.
During a recent 4-year period, 381 patients were admitted with injuries sustained from falls. Equal numbers of patients were less than and greater than 50 years of age and included 53 children (less than or equal to 16 years) and 214 elderly (greater than or equal to 55 years). Falls from heights occurred predominantly in young males (mean age 34.2 years), were most commonly job or recreation related and resulted in higher injury severity scores (ISS). Falls in the elderly occurred more commonly in women, typically on a flat surface, and were less severe. Despite lower mean ISS, fall victims over 55 years of age had longer hospitalizations (11.4 vs. 4.5 days) and incurred higher hospital charges compared to younger patients. There were 35 deaths (9.2%). In patients under 55 years, deaths resulted from fall-related central nervous system (CNS) injury and/or multisystem trauma. In patients over 55 years, fatalities were most commonly related to pre-existent medical conditions. Based on a review of this experience, we conclude that: (1) unlike other causes of blunt and penetrating trauma, both sexes are equally at risk from fall-related injuries but sex incidence is age related; (2) falls from heights are more common in men; (3) advanced age and pre-existing medical conditions account for the increased morbidity and mortality following falls and; (4) cost containment measures for fall-related trauma must consider not only injury severity, but the age and pre-existent medical conditions of the patient.
Currently, magnetic resonance (MR) is most useful as a means of providing distinct images of gross abnormalities in major blood vessels. While new advances and further refinements will continue, MR has proven its value as a convenient and effective diagnostic tool for the recognition and delineation of vascular abnormalities, such as acquired arteriovenous fistulae (AVFs). We report a case of a chronic, post-traumatic AVF, in which MR angiography provided excellent anatomic detail and angiographic correlation.
Traumatic arteriovenous (AV) fistulas produce several profound pathophysiologic and structural changes in the circulatory dynamics of the vessels associated with the fistula. Most of the changes are reversible with surgery. However, in longstanding AV fistulas, irreversible degenerative changes occur in the arterial wall and result in dilatation and thrombosis. This can make late closure technically difficult. This report presents a case of peroneal AV fistula of 18 years duration. The diagnosis, management, and complications of long-standing AV fistulas are discussed.
Between 1978 and 1982, 1,200 patients underwent angiography following acute traumatic injury, and arterial injuries were detected in 182 cases (15.2%). Two-thirds of the cases were associated with penetrating trauma; half the injuries occurred in the pelvis or lower extremities. The most common and reliable sign of arterial injury was the presence of extraluminal contrast media. Other signs included occlusion, laceration, transection, arteriovenous fistula, intimal flap, and intraluminal thrombus. Luminal narrowing was difficult to interpret and resulted from a variety of causes, some of which do not require surgical intervention. Embolotherapy to control arterial bleeding was attempted in 79 patients (43%), and hemostasis was achieved in 69 of them (87%). Transcatheter closure was attempted in 19 of 34 arteriovenous fistulas, resulting in complete success in 15 cases and partial success in two.
Traumatic arteriovenous fistula is rare in children. We describe one case resulting from a small glass-fragment stab wound in the left leg. There was an associated false aneurysm of the anterior tibial artery. The patient was cured after multiple ligation and excision of the aneurysm.
A 56-year-old man sustained blunt trauma to the right calf which, 15 months later, manifested as a painful soft tissue mass with aggressive destruction of the fibula. Contrast-enhanced computed tomography and popliteal arteriography disclosed a peroneal arteriovenous fistula and pseudoaneurysm. Five years after pseudoaneurysm repair and fistula ligation, the patient was free of symptoms and had no further bone destruction.
The natural history of untreated major injuries is not well known, although serious complications are seen. The follow-up of patients who have trauma is often incomplete, and this study was undertaken to evaluate the nature of these wounds.
Thirty-one patients with missed major arterial wounds were examined and treated according to the pathologic condition encountered. All had been seen at other hospitals, some on more than one occasion, and then sought assistance for continued problems.
There were 16 aneurysms in 31 patients: 4 arteriovenous fistulas, 4 dissections, 3 thromboemboli, and 1 stenosis. The arteries included the following: carotid 12, aorta 5, femoropopliteal 8, subclavian 2, axillary 1, innominate 1, iliac 1, and tibial 1. Three patients had a stroke, one had a transient ischemic attack, two had leg ischemia, and one had a gangrenous foot. Operation was required in 27 patients; there were no deaths.
Transmural traumatic arterial wounds of major vessels can result in serious delayed complications, months or even years after the injury. False aneurysms, dissections, occlusions, and fistulas in the extremities may not be lethal, but they cause significant disability. Such lesions in the neck or trunk are more dangerous. Despite the inconvenience and expense, patients with injuries of major arteries are best served by early repair of the wound.
We present a patient with an arteriovenous fistula of the peroneal artery acquired after a left dome tibial osteotomy with midshaft fibular osteotomy. He had subsequently had a total knee replacement on that side. The arteriovenous malformation was only diagnosed when he represented with symptoms and signs of venous hypertension with sterile recurrent haemarthroses in the left knee. Percutaneous obliteration of the fistula, by a combination of coil embolisation and balloon occlusion, cured the symptoms.
An arteriovenous fistula is an abnormal communication between the arterial and venous systems. It may be an incidental finding in an asymptomatic patient or it may manifest clinically with pain, edema, varicosities, and even heart failure. It is important for clinicians to be aware of this disorder because early diagnosis and treatment can prevent its long-term sequelae. This report presents a patient with a posttraumatic arteriovenous fistula.
The purpose of this report is to analyze the clinical presentation, diagnosis, and outcome of surgical treatment in patients with popliteal arteriovenous fistulas (AVFs) in order to make trauma surgeons aware of the various issues patients with popliteal AVFs might present.
From 1991 to 2000, 49 patients were treated for traumatic AVF. Among these patients, seven suffered from popliteal AVF of various durations. The patients were men and ranged in age from 17 to 27 years, with a mean age of 22.4 years. The time from injury to admission to our institutions varied from 5 days to 2 years. A diagnosis of popliteal AVF was made after clinical examinations revealed thrill and bruit over the injury sites. The diagnosis was confirmed in four of the patients after they underwent angiography. Patients with long-standing popliteal AVF underwent cardiology examinations to check for signs of heart failure. All patients with popliteal AVF received surgical treatment. Five patients had major blood vessels reconstructed, one patient had a minor blood vessel ligated, and another patient had a minor blood vessel reconstructed.
Five of the seven patients experienced no postoperative difficulties. No serious heart failure occurred; however, there were signs of cardiac overload in three of the five patients. The two remaining patients of the seven underwent leg amputations. However, one of the two patients had a gangrenous foot at admission to our institution, and vascular reconstruction on the other patient was unsuccessful. For all seven patients, the average hospital stay in the vascular surgery department was 16.2 days and the follow-up ranged from 2 to 44 months, with a mean of 21.5 months.
Trauma of the popliteal space requires special attention, since blood vessel injuries in that zone might result in serious complications. Popliteal traumatic AVFs result in a high rate of leg amputation and long-standing fistulas produce cardiac overload. The presence of thrill and bruit over the injury site should alert the examiner to consider the existence of AVF. Angiography is a reliable diagnostic tool, and should be used in all vitally stable patients. Surgical or nonsurgical closure of AVF will prevent local and systemic complications that might be irreversible in long-standing fistulas.
A case is reported of a 28-year-old patient with gradually developing massive swelling of the right thigh after sustaining a blunt trauma. 3 1/2 months after the injury, surgery was performed because of a persisting tumor at the thigh. Intraoperatively, massive bleeding occurred, the bleeding vessel was sutured. Postoperative angiography disclosed arteriovenous (av) fistulae from the internal iliacal artery to a gluteal vein as source for the bleeding. The feeding artery was closed by coiling, the patient recovered completely. To the authors' knowledge, development of an av-fistula following blunt trauma has not been described previously. Similarly, the differential diagnosis of a posttraumatic bleeding of a congenital av-malformation was not yet reported. The authors emphasize, that prior to the surgery of inadequately behaving hematomas, an angiography should be performed.
We describe an alternative presentation of 2 cases of femur fractures with pseudoaneurysms of the profunda femoris artery.
In both cases, there is a recurrent triad of: (1) thigh swelling, (2) bleeding from the fasciotomy wound, and (3) anaemia with a falling haemoglobin trend.
Surgical exploration is often not diagnostic or therapeutic. Angiography can accurately diagnose the presence of a pseudoaneurysm and intervention with coil embolisation is effective in arresting further bleeding.
Both cases show good outcome following coil embolisation.
Recognition of this triad is necessary to ensure early accurate diagnosis so that proper treatment is rendered to prevent further recurrent bleeds.
Acute compartment syndrome of the thigh is a rare condition, and the basic causes of high pressure within a muscle compartment have been considered to be intramuscular haematoma and soft-tissue oedema. However, the importance of arterial injury has not been well recognized.
Among 3658 blunt trauma patients admitted to our Level 1 Trauma Centre between 1994 and 2001, there were eight patients (nine thighs) who had undergone emergency fasciotomy and these were the subjects of the present study. Arteriography of the proximal lower limb had been performed after the fasciotomy in patients with prolonged hypotension and persistent bleeding from the fasciotomy wound.
All the patients had sustained high-energy trauma, systemic hypotension and local trauma to the proximal lower limb. Among them, four (five thighs) had undergone arteriography and four (four thighs) were confirmed as having sustained arterial injuries. In those patients with definitive arterial injuries, the time from injury to the onset of the compartment syndrome was less than 5 h.
Acute compartment syndrome of the thigh in blunt trauma patients may be the result of associated arterial injuries. It is suggested that patients with local trauma to the proximal lower limb who exhibit an acute compartment syndrome together with haemodynamic instability should undergo arteriography soon after fasciotomy.
An 18-year-old soldier had a gunshot wound to his left thigh during the Mexican Civil War (1910-1917). He presented with persistent bright red bleeding. His wound was treated by compression. A few years after the injury, he noticed a thrill, large varicose veins, limb swelling, and skin changes. A plain film showed an 8 x 10-cm midthigh mass. After a bullfighting incident, the pseudoaneurysm ruptured. Because of increased bulk and discomfort, the patient agreed 3 years later to be treated. Angiography showed a chronically obstructed femoral artery and vein. A 3000-mL hematoma was evacuated. This case illustrates the long-term sequelae of an arteriovenous fistula. This report describes a 51-year delay of treatment for causes unrelated to diagnosis. To our knowledge, this case is the longest delay in treatment of an arteriovenous fistula and its complications reported in the literature.
Popliteal trauma requires particular attention because blood vessel injuries in that zone might cause serious complications. Popliteal traumatic arteriovenous fistula (AVF) should be considered for serious leg amputation, and long-standing fistulae produce cardiac overload. The diagnosis is usually made after clinical examination, finding palpable thrill and audible bruit over the injury site, and is confirmed after duplex ultrasonography and/or angiography.
We present a case of popliteal traumatic arteriovenous fistula with false aneurysm (pseudoaneurysm) (PSA), in which duplex ultrasonography and angiography findings proved inconsistent with the findings at surgery, thus resulting in an unnecessary extensive dissection of a major artery and vein, whereas the fistula and the PSA were found in minor vessels (genicular artery and vein).