Advances in diagnostics and successful repair of proximal posttraumatic superior mesenteric arteriovenous fistula

Multidetector Computed Tomography Angiography Role in Diagnosing Superior Mesenteric Arteriovenous Fistula with Superior Mesenteric Vein Thrombosis: A Case Report

Introduction

Arteriovenous fistulas (AVF) of the superior mesenteric vasculature are rare vascular abnormalities. It often occurs due to iatrogenic injuries during bowel resection or abdominal traumas. As the patient exhibits a variety of signs and symptoms and can present late, diagnosis may be difficult.Multidetector computed tomography (MDCT) is the most common modality for imaging the small bowel, vessels, and mesentery in patients with mesenteric ischemia.

Case presentation

We present the case of a 25-year-old man who presented with features of acute intestinal obstruction and was operated on in an emergency. Resection of gangrenous small bowel and bowel adhesiolysis with double barrel ileostomy was performed. During exploratory laparotomy, gangrenous bowels were found, but no cause of mesenteric ischemia could be delineated. Finally, on computed tomography angiography (CTA) superior mesenteric arteriovenous fistula (SMAVF) with superior mesenteric vein (SMV) thrombosis was diagnosed. The patient was advised of aggressive anticoagulant therapy.

Conclusion

Computed tomography angiography has become the most reliable diagnostic modality to confirm the diagnosis and guide the best treatment strategy.

How to cite this article

Satyam S, Kose S, Singh S, et al. Multidetector Computed Tomography Angiography Role in Diagnosing Superior Mesenteric Arteriovenous Fistula with Superior Mesenteric Vein Thrombosis: A Case Report. Euroasian J Hepato-Gastroenterol 2022;12(2):98-101.

Endovascular Occlusion of Giant Posttraumatic Pseudo-Aneurysm of Superior Mesenteric Artery Connected to Mesenteric Arteriovenous Fistula

The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and life-threatening esophageal variceal bleeding.

Traumatic penetrating arteriovenous fistulas: a collective review

INTRODUCTION

Traumatic penetrating arteriovenous fistulas (AVFs) are very rare. The majority of these injuries occur secondary to penetrating trauma. Objectives of this study: review their incidence, clinical presentation, radiologic identification, management, complications and outcomes.

METHODS

A literature search was performed on MEDLINE Complete-Pubmed from 1829-2019. PRISMA guidelines were utilized. Of 305 potentially eligible articles, 201 articles were selected.

INCLUSION CRITERIA

patients age ≥ 18, articles with title and abstract in English, AVFs secondary to penetrating trauma, articles which specified vessels involved in AVFs, and those reporting complete information on patient presentation, diagnosis, imaging, surgical and/or endovascular surgical management, and outcomes of penetrating AVF's.

EXCLUSION CRITERIA

articles reporting blunt or iatrogenic AVFs, pediatric patients, fistulas used for dialysis and their complications, articles lacking complete information, cranial/spinal AVFs or cardiac AVFs, and duplicate articles. Mechanism of injury (MOI), diagnosis, involved vessels, management and outcomes of patients with AVFs secondary to penetrating trauma were recorded.

RESULTS

There were a total of 291 patients with AVFs secondary to penetrating injuries. Mechanism of injury (MOI): stab wounds (SW)-126 (43.3%), Gunshot wounds (GSW)-94 (32.3%), miscellaneous-35 (12%), mechanism unspecified-36 (12.4%). Anatomic area: neck-69 (23.7%) patients, thorax-46 (15.8%), abdomen-87 (30%), upper and lower extremities-89 (30.6%). Most commonly involved vessels-vertebral artery-38 (13%), popliteal vein-32 (11.7%). Angiography was diagnostic-265 patients (91.1%).

INTERVENTIONS

Surgical- 202 (59.6%), Endovascular-118 (34.8%). Associated: aneurysms/pseudoaneurysms-129 (44.3%).

CONCLUSION

Most AVFs occur secondary to penetrating injuries. Stab wounds account for the majority of these injuries. Most frequently injured vessels are vertebral artery and superficial femoral vein. Surgical interventions are the most common mode of management followed by endovascular surgical techniques.

Superior mesenteric arteriovenous fistula embolisation complicated by bowel ischaemia

Superior mesenteric arteriovenous fistulas are rare, especially when iatrogenic in origin. Management of these fistulas can be surgical or endovascular. Endovascular embolisation is the preferred modality with a low rate of complications. Among the reported complications, bowel ischaemia is considered an unlikely occurrence. We report a case of a complex iatrogenic arterioportal fistula that was managed by endovascular embolisation and controlled through both its inflow and outflow, and was later complicated by bowel ischaemia.

Successful coil embolization of an unusual aorto-superior mesenteric vein fistula

The aortovenous fistulas are rare, most of them are aortocaval fistula. The non-caval communication of the fistula is sparse. Herein we report a 47-year-old female diagnosed as traumatic aorto-superior mesenteric vein (Ao-SMV) fistula. The abdominal pain, fullness, and frank bruit on abdominal auscultation suggested the diagnosis of an intra-abdominal arteriovenous fistula. The diagnosis of Ao-SMV was further confirmed by the computed tomography (CT) and aortography. The fistula was successfully treated with transcatheter coil embolization. This is the first case of Ao-SMV fistula. It provides an alternative option of treatment other than conventional surgery.

Delayed Development of a Traumatic Superior Mesenteric Arteriovenous Fistula Following Multiple Gunshot Wounds to the Abdomen

Traumatic visceral arteriovenous fistulae are rare and pose a diagnostic and therapeutic challenge. We present the case of a 20-year-old male who sustained multiple gunshot wounds to the abdomen, injuring the inferior vena cava, duodenum, stomach, and small bowel. The patient was taken emergently to the operating room for repair of his injuries, which required primary small bowel repair, duodenal repair, and inferior vena cava ligation due to exigent hemorrhage. At the initial operation there was a normal pulse in the superior mesenteric artery at the base of the small bowel mesentery, with no evidence of hematoma or thrill in the small bowel mesentery. The patient was subsequently returned to the operating room several times for bowel exploration and abdominal wall closure with mesh. Ten days after his initial injury, the patient was noted to have an abdominal bruit on physical exam. Arteriography demonstrated a fistula between the proximal superior mesenteric artery and vein with significant portal hypertension. The patient underwent surgical repair of the superior mesenteric artery and vein with closure of the fistula. The patient had no further complications and was discharged from the hospital 1 month later, after abdominal wall skin grafting, in good condition. The patient remains in good health 12 months later. Continued vigilance and careful physical examination are important in the identification of delayed vascular injuries and allow timely treatment and avoidance of untoward long-term sequelae.