Case reports
Superior Mesenteric Arteriovenous Fistula After Ileal Resection F a b r i c e F r a n q o i s , MD, Andr~ T h ~ v e n e t , MD, Montpellier, France
Postoperative superior mesenteric arteriovenous fistula is very rare. We report the case of a 55-year-old woman in whom the discovery of an abdominal bruit led to the diagnosis of superior mesenteric arteriovenous fistula seven years after ileal resection. The clinical and pathophysiological aspects, as well as the therapeutic modalities, of this rare lesion are reviewed. (Ann Vasc Surg 1992;6:370-372). KEY WORDS: Superior mesenteric artery; arteriovenous fistula; ileal resection; iatrogenic trauma.
A r t e r i o v e n o u s fistula ( A V F ) o c c u r s rarely in the portal v a s c u l a r bed. M o s t o f these A V F s are splenoportal [1], due to r u p t u r e o f splenic artery aneur y s m , o r h e p a t o p o r t a l [2,3], s e c o n d a r y to percutan e o u s hepatic b i o p s y [4]. O c c u r r e n c e o f a superior m e s e n t e r i c A V F is the e x c e p t i o n . In 1983, only 38 cases had b e e n r e p o r t e d in the literature [5]. H a l f o f these w e r e iatrogenic, o c c u r r i n g mainly after operations on the small intestine [6]. T h e a d v e r s e arterial and v e n o u s c o n s e q u e n c e s on intestinal circulation c r e a t e d by these lesions c o n s t i t u t e a plea for routine surgical t r e a t m e n t .
CASE REPORT A 55-year-old woman was admitted to our unit in June 1987 for fatigue, anorexia, and right paraumbilical pain associated with intestinal disorders, including diarrhea alternating with constipation. This patient had undergone anterior transperitoneal hysterocystopexia in 1968. In 1980, intestinal obstruction due to incomplete volvulus
From the Service de Chirurgie Thoracique et CardioVasculaire, HOpital Aiguelongue, Montpellier, France. Reprint requests: A, Thevenet, MD, Service de Chirurgie, Thoracique et Cardio-Vasculah'e, HOpital Aiguelongue, 34059 Montpellier COdex, France.
led to resection of 120 cm of ileon followed by ileoileal anastomosis at 10 cm from the cecum. After this second operation, the patient experienced chronic diarrhea, believed to be due to a short bowel syndrome, which was poorly controlled by symptomatic treatment. Upon admission, she had moderate abdominal distention. Palpation of the abdomen revealed pain to the right of the umbilicus. A strong systolodiastolic bruit was heard over this same area. Blood chemistry was unremarkable. A follow-through examination of the small intestine showed it to be normal. Sonograms revealed that: (a) the spleen was homogeneous but enlarged (16 cm); (b) the diameter of the portal vein was increased near the hilum (15 cm in diameter); and (c) the superior mesenteric vein was dilated, measuring 20 mm in diameter. The liver was normal and there was no ascites. Digital subtraction arteriograms documented a large mesenteromesenteric arteriovenous fistula developed at the point of distal ligation of the superior mesenteric artery. In July, 1987, laparotomy was performed for cure of the AVF. Maximal thrill was palpated near the ileoileal anastomosis. The nearby superior mesenteric vein measured 20 mm in diameter. Initial venous pressure was 25 mmHg, but dropped to 15 mmHg once the afferent vessels were clamped. At the same time, the thrill disappeared. The fistula was opened and a 8 mm orifice was closed. The postoperative course was uneventful as intestinal transit returned to normal and all auscultatory
370
VOLUME 6 4 - 1992
SUPERIOR MESENTI~RIC ARTERIOVENOUS FISTULA
371
Fig. 1. Aortogram showing an arteriovenous fistula of mesenteric vessels and dilatation of superior mesenteric vein.
Fig. 2. Aortogram showing rapid visualization of portal vein originating from superior mesenteric vein.
signs disappeared. This patient was seen at one year without any signs of recurrence.
ischemia. Postprandial pain, intestinal transit disorders, occasionally associated with anorexia and weight-loss, frequently indicate the presence of fistula [8]. In our observation, such signs have been long believed to be due to the length of resected bowel. Arteriograms were obtained after an abdominal bruit was discovered. Asymptomatic bruit, ascites, or more often, bleeding from the anus, can also be the initial signs [6,7]. Cardiac failure, on the other hand, is rarely the initial symptom [8,9]. The pathophysiological mechanisms responsible for symptoms in mesenteric AVF are threefold:
DISCUSSION Superior mesenteric AVF is essentially posttraumatic or iatrogenic [5]. Posttraumatic AVF is mainly due to firearm wounds [7]. According to Meyer and associates [8], AVF can appear between three days and 15 years after the accident. Of 37 cases of superior mesenteric AVF collected by Imbert and colleagues [5], 17 were iatrogenic. One AVF, appearing 10 years later, was secondary to surgery of the small intestine, as in our patient. The interval between the accident and the onset of symptoms or the discovery of the fistula is variable, ranging from a few hours to 39 years, according to hemodynamic consequences [3]. Clinical signs of superior mesenteric AVF are not specific, but can be correlated with those of chronic mesenteric
I) Modifications in portal hemodynamics: Portal pressure varies according to portal venous flow and hepatic vascular resistance. In the case of superior mesenteric AVF, increased mesenteric flow results in portal hypertension, which in turn may be responsible for ascites or intestinal hemorrhage. The increase
372
SUPERIOR MESENTER1C ARTERIOVENOUS FISTULA
in mesenteric venous flow depends on the size of the anomalous communication and the arteriovenous pressure gradient [2]. Increased blood flow is compensated by the opening of hepatic sinusoids, which, by decreasing hepatic vascular resistances, delays the onset of portal hypertension. This hepatic sinusoid compensatory system, however, has its physiological limits [2]. Adverse consequences on liver parenchyma have not, however, been reported. 2) Modifications in arterial hemodynamics: As may be observed in systemic arteriovenous fistulas, the manifestations of chronic mesenteric ischemia are due to a steal syndrome [9]. 3) Modifications in general hemodynamics: The sinusoid network acts as a buffer by limiting the flow rate of the shunt [8]. While cardiac flow is increased in nearly all cases, heart failure occurs only as the exception. Hemodynamic modifications are reversible after cure of the fistula. The diagnosis of superior mesenteric AVF is dependent upon arteriograms. While aortography is occasionally adequate [5], selective mesenteric arteriograms are usually required to visualize the anatomical type of superior mesenteric AVF, its site, and the status of the arterial runoff. As well, the caliber of the portal and venous elements can be evaluated on arteriograms. Surgical treatment is advocated by the majority of authors in order to preclude or suppress portal hypertension and its consequences. The cure of superior mesenteric AVF provides excellent results and is technically simpler than the cure of hepatic or splenic AVF [2,4]. For Meyer and coworkers [8], mortality can be as high as 15% with death generally being due to hemorrhagic recurrence. Simple exclusion by ligature, or better, suture of the inflow and
mmm
ANNALS OF VASCULARSURGERY
outflow vessels, as performed in our case, are usually adequate measures. The vitality of the adjacent small intestine may occasionally warrant associated resection. Distal vascularity is ensured through vascular reconstruction [5]. Embolization could be an interesting alternative to surgery [10].
REFERENCES 1, VAN WAY CW, CRANE JM, RIDDELL DH, FOSTER JH. Arteriovenous fistula in the portal circulation, Surgery 1971:70:876-890. 2. PUGLIONIST A, DIGIOVANNI V, SN1DER F, CAMILL S, GINA G. A p r o p o s d'un cas de fistule art~rio-veineuse hepatico-portale: probl6mes de physiopathologie et revue de la litterature. J. Chir 1980;1/7:607~t9, 3. MAILLET P, GON1N A, BAUL1EUX J, BARBIER B, BOULEZ J, MONDESERT L, BARRAL X. Fistule art~rioveineuse m~sent6rique supdrieure. Lyon Chit 1976:72:343345. 4, BERT JM, THEVENET A, BALMES JL, MAR~ H, DUBOIS JB, FAVIER C, Fistule art6rio-veineuse h~paticoportale. Complication de la ponction-biopsie h6patique gu6tie par abord direct. Nouv Presse Med 1972;1:3187-3190. 5. IMBERT P. CARDON JM, MATHIEU JP, TOUATI Y. Plaie de l'aorte et de la veine cave infSrieure compliqu6e secondairement d'une fistule artdrio-veineuse m6senterique supdrieure. Chirurgie 1983:109:47-51, 6. DIEHL JT, BEVEN EG. Arteriovenous fistulas of the mesenteric: report of a case and review of the literature. J Cardiovasc Sur~,, 1982;23:334-337. 7. ROSENTHAL D, ELLISON RG, LUKE JP, CLARK MD, LAMIS PA. Traumatic superior mesenteric arteriovenous fistula: report of a case and review of the literature. J. Vase SurL, 1987;5:488-491, 8. MEYER C, KAUFFMANN JP, KOLLOR D, HOLLENDER LP. Les fistules artdrio-veineuses mdsent~riques sup~rieures post-opdratoires: fi propos d'un cas. J Chit 1980: l l 7: 579-,582. 9. DONELL ST, HUDSON MJK. latrogenic superior mesenteric arteriovenous fistula: report of a case and review of the literature. J Vase Sulg 1988:8:335-338. 10. REED JK, McGIIN RF, GORMAN JF, THOMFORD NR. Traumatic mesenteric arteriovenous fistula presenting as the superior mesenteric artery syndrome. Arch Stt/g 1986:121:1209,
Superior Mesenteric Arteriovenous Fistula After Ileal Resection F a b r i c e F r a n q o i s , MD, Andr~ T h ~ v e n e t , MD, Montpellier, France
Postoperative superior mesenteric arteriovenous fistula is very rare. We report the case of a 55-year-old woman in whom the discovery of an abdominal bruit led to the diagnosis of superior mesenteric arteriovenous fistula seven years after ileal resection. The clinical and pathophysiological aspects, as well as the therapeutic modalities, of this rare lesion are reviewed. (Ann Vasc Surg 1992;6:370-372). KEY WORDS: Superior mesenteric artery; arteriovenous fistula; ileal resection; iatrogenic trauma.
A r t e r i o v e n o u s fistula ( A V F ) o c c u r s rarely in the portal v a s c u l a r bed. M o s t o f these A V F s are splenoportal [1], due to r u p t u r e o f splenic artery aneur y s m , o r h e p a t o p o r t a l [2,3], s e c o n d a r y to percutan e o u s hepatic b i o p s y [4]. O c c u r r e n c e o f a superior m e s e n t e r i c A V F is the e x c e p t i o n . In 1983, only 38 cases had b e e n r e p o r t e d in the literature [5]. H a l f o f these w e r e iatrogenic, o c c u r r i n g mainly after operations on the small intestine [6]. T h e a d v e r s e arterial and v e n o u s c o n s e q u e n c e s on intestinal circulation c r e a t e d by these lesions c o n s t i t u t e a plea for routine surgical t r e a t m e n t .
CASE REPORT A 55-year-old woman was admitted to our unit in June 1987 for fatigue, anorexia, and right paraumbilical pain associated with intestinal disorders, including diarrhea alternating with constipation. This patient had undergone anterior transperitoneal hysterocystopexia in 1968. In 1980, intestinal obstruction due to incomplete volvulus
From the Service de Chirurgie Thoracique et CardioVasculaire, HOpital Aiguelongue, Montpellier, France. Reprint requests: A, Thevenet, MD, Service de Chirurgie, Thoracique et Cardio-Vasculah'e, HOpital Aiguelongue, 34059 Montpellier COdex, France.
led to resection of 120 cm of ileon followed by ileoileal anastomosis at 10 cm from the cecum. After this second operation, the patient experienced chronic diarrhea, believed to be due to a short bowel syndrome, which was poorly controlled by symptomatic treatment. Upon admission, she had moderate abdominal distention. Palpation of the abdomen revealed pain to the right of the umbilicus. A strong systolodiastolic bruit was heard over this same area. Blood chemistry was unremarkable. A follow-through examination of the small intestine showed it to be normal. Sonograms revealed that: (a) the spleen was homogeneous but enlarged (16 cm); (b) the diameter of the portal vein was increased near the hilum (15 cm in diameter); and (c) the superior mesenteric vein was dilated, measuring 20 mm in diameter. The liver was normal and there was no ascites. Digital subtraction arteriograms documented a large mesenteromesenteric arteriovenous fistula developed at the point of distal ligation of the superior mesenteric artery. In July, 1987, laparotomy was performed for cure of the AVF. Maximal thrill was palpated near the ileoileal anastomosis. The nearby superior mesenteric vein measured 20 mm in diameter. Initial venous pressure was 25 mmHg, but dropped to 15 mmHg once the afferent vessels were clamped. At the same time, the thrill disappeared. The fistula was opened and a 8 mm orifice was closed. The postoperative course was uneventful as intestinal transit returned to normal and all auscultatory
370
VOLUME 6 4 - 1992
SUPERIOR MESENTI~RIC ARTERIOVENOUS FISTULA
371
Fig. 1. Aortogram showing an arteriovenous fistula of mesenteric vessels and dilatation of superior mesenteric vein.
Fig. 2. Aortogram showing rapid visualization of portal vein originating from superior mesenteric vein.
signs disappeared. This patient was seen at one year without any signs of recurrence.
ischemia. Postprandial pain, intestinal transit disorders, occasionally associated with anorexia and weight-loss, frequently indicate the presence of fistula [8]. In our observation, such signs have been long believed to be due to the length of resected bowel. Arteriograms were obtained after an abdominal bruit was discovered. Asymptomatic bruit, ascites, or more often, bleeding from the anus, can also be the initial signs [6,7]. Cardiac failure, on the other hand, is rarely the initial symptom [8,9]. The pathophysiological mechanisms responsible for symptoms in mesenteric AVF are threefold:
DISCUSSION Superior mesenteric AVF is essentially posttraumatic or iatrogenic [5]. Posttraumatic AVF is mainly due to firearm wounds [7]. According to Meyer and associates [8], AVF can appear between three days and 15 years after the accident. Of 37 cases of superior mesenteric AVF collected by Imbert and colleagues [5], 17 were iatrogenic. One AVF, appearing 10 years later, was secondary to surgery of the small intestine, as in our patient. The interval between the accident and the onset of symptoms or the discovery of the fistula is variable, ranging from a few hours to 39 years, according to hemodynamic consequences [3]. Clinical signs of superior mesenteric AVF are not specific, but can be correlated with those of chronic mesenteric
I) Modifications in portal hemodynamics: Portal pressure varies according to portal venous flow and hepatic vascular resistance. In the case of superior mesenteric AVF, increased mesenteric flow results in portal hypertension, which in turn may be responsible for ascites or intestinal hemorrhage. The increase
372
SUPERIOR MESENTER1C ARTERIOVENOUS FISTULA
in mesenteric venous flow depends on the size of the anomalous communication and the arteriovenous pressure gradient [2]. Increased blood flow is compensated by the opening of hepatic sinusoids, which, by decreasing hepatic vascular resistances, delays the onset of portal hypertension. This hepatic sinusoid compensatory system, however, has its physiological limits [2]. Adverse consequences on liver parenchyma have not, however, been reported. 2) Modifications in arterial hemodynamics: As may be observed in systemic arteriovenous fistulas, the manifestations of chronic mesenteric ischemia are due to a steal syndrome [9]. 3) Modifications in general hemodynamics: The sinusoid network acts as a buffer by limiting the flow rate of the shunt [8]. While cardiac flow is increased in nearly all cases, heart failure occurs only as the exception. Hemodynamic modifications are reversible after cure of the fistula. The diagnosis of superior mesenteric AVF is dependent upon arteriograms. While aortography is occasionally adequate [5], selective mesenteric arteriograms are usually required to visualize the anatomical type of superior mesenteric AVF, its site, and the status of the arterial runoff. As well, the caliber of the portal and venous elements can be evaluated on arteriograms. Surgical treatment is advocated by the majority of authors in order to preclude or suppress portal hypertension and its consequences. The cure of superior mesenteric AVF provides excellent results and is technically simpler than the cure of hepatic or splenic AVF [2,4]. For Meyer and coworkers [8], mortality can be as high as 15% with death generally being due to hemorrhagic recurrence. Simple exclusion by ligature, or better, suture of the inflow and
mmm
ANNALS OF VASCULARSURGERY
outflow vessels, as performed in our case, are usually adequate measures. The vitality of the adjacent small intestine may occasionally warrant associated resection. Distal vascularity is ensured through vascular reconstruction [5]. Embolization could be an interesting alternative to surgery [10].
REFERENCES 1, VAN WAY CW, CRANE JM, RIDDELL DH, FOSTER JH. Arteriovenous fistula in the portal circulation, Surgery 1971:70:876-890. 2. PUGLIONIST A, DIGIOVANNI V, SN1DER F, CAMILL S, GINA G. A p r o p o s d'un cas de fistule art~rio-veineuse hepatico-portale: probl6mes de physiopathologie et revue de la litterature. J. Chir 1980;1/7:607~t9, 3. MAILLET P, GON1N A, BAUL1EUX J, BARBIER B, BOULEZ J, MONDESERT L, BARRAL X. Fistule art~rioveineuse m~sent6rique supdrieure. Lyon Chit 1976:72:343345. 4, BERT JM, THEVENET A, BALMES JL, MAR~ H, DUBOIS JB, FAVIER C, Fistule art6rio-veineuse h~paticoportale. Complication de la ponction-biopsie h6patique gu6tie par abord direct. Nouv Presse Med 1972;1:3187-3190. 5. IMBERT P. CARDON JM, MATHIEU JP, TOUATI Y. Plaie de l'aorte et de la veine cave infSrieure compliqu6e secondairement d'une fistule artdrio-veineuse m6senterique supdrieure. Chirurgie 1983:109:47-51, 6. DIEHL JT, BEVEN EG. Arteriovenous fistulas of the mesenteric: report of a case and review of the literature. J Cardiovasc Sur~,, 1982;23:334-337. 7. ROSENTHAL D, ELLISON RG, LUKE JP, CLARK MD, LAMIS PA. Traumatic superior mesenteric arteriovenous fistula: report of a case and review of the literature. J. Vase SurL, 1987;5:488-491, 8. MEYER C, KAUFFMANN JP, KOLLOR D, HOLLENDER LP. Les fistules artdrio-veineuses mdsent~riques sup~rieures post-opdratoires: fi propos d'un cas. J Chit 1980: l l 7: 579-,582. 9. DONELL ST, HUDSON MJK. latrogenic superior mesenteric arteriovenous fistula: report of a case and review of the literature. J Vase Sulg 1988:8:335-338. 10. REED JK, McGIIN RF, GORMAN JF, THOMFORD NR. Traumatic mesenteric arteriovenous fistula presenting as the superior mesenteric artery syndrome. Arch Stt/g 1986:121:1209,
