Posttraumatic pulmonary arteriovenous fistula: is resection the procedure of choice? A case report and review of literature

Traumatic Pulmonary Arteriovenous Malformation Presenting as Spontaneous Hemothorax

Pulmonary arteriovenous malformations (PAVM), also known as pulmonary arteriovenous fistulas, are abnormal connections between the pulmonary arterial and venous systems. The majority occur secondary to the congenital syndrome hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease. Trauma is an extremely rare etiology of PAVM, comprising less than 1% of all reported cases. Trauma can be associated with both immediate and delayed development of PAVM, and present similarly to PAVM associated with HHT. We report a case of a traumatic PAVM that developed in a patient one year following blunt thoracic trauma with a rib fracture. The patient subsequently developed a rupture of the PAVM, resulting in spontaneous hemothorax. She required multi-unit blood transfusion and multiple thoracostomy tube placements. The patient subsequently underwent a failed attempt at angioembolization of the PAVM. She eventually required a thoracotomy for surgical excision of the PAVM. We discuss the traumatic etiologies, clinical presentation, diagnostic assessments, and therapeutic modalities for the management of PAVM.

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.