Arteriovenous Fistulas Resulting From Penetrating Trauma: A Collective Review
Stephanie S. Miljkovic, MS1, Parinaz J. Dabestani, MS1, Florian Wenzl, BS1, John J. Kessler, BS1, Tharun Kutaru, BS1, Carlos Fernandez, MD2, David Cornell, MD2, Viren Punja, MD2, Charles Voigt, MD2, Juan Asensio, MD2, Louay Kalamchi, BS1.
1Creighton University School of Medicine, Omaha, NE, USA, 2Creighton University Medical Center, Omaha, NE, USA.
Abstract
Introduction
Traumatic arteriovenous fistulas (AVF’s) are rare. The vast majority of these injuries occur secondary to penetrating injuries. Given their rarity, few surgeons have developed significant experience with their management. The objectives of this study are to review their clinical presentation, radiologic identification, management, complications, outcomes and to provide an extensive review of anatomic exposures and surgical techniques for their management.
Methods
A literature search on MEDLINE Complete-Pubmed for the period from 1829 to 2019 was conducted. PRISMA guidelines were utilized. Our literature search yielded a total of 305 potentially eligible studies, and 201 studies were included. Inclusion criteria: Patients age ≥ 18, titles and abstracts in the English language, AVF secondary to penetrating trauma, specified vessels involved in AVF formation, and those reporting reliable information on patient presentation, diagnosis, imaging, management, and outcomes of penetrating AVF’s. Exclusion criteria omitted studies reporting blunt or iatrogenic AVF’s, pediatric patients, studies lacking reliable patient outcomes, articles including cranial/spinal or cardiac AVF locations, and duplicate studies.
Results
There were a total of 291 patients with AVF following penetrating trauma identified from 201 studies. MOI: stab wounds (SW) - 126 (43.3%), gunshot wounds (GSW) - 94 (32.3%), miscellaneous - 35 (12%), penetrating unspecified 36 (12.4%). AVF location per anatomic area: neck - 69 (23.7%) patients, thorax - 46 (15.8%), abdomen - 87 (30%), upper and lower extremities - 89 (30.6%). The most commonly involved artery was the vertebral artery - 38 (13%) and the most commonly involved vein was the superficial femoral vein - 32 (10.7%). Angiography was used in the diagnosis - 265 patients (91.1%). Treatment data was available for 257 patients: Surgical intervention - 202 (59.6%), endovascular interventions - 118 (34.8%). Incidence of associated aneurysms/pseudoaneurysms - 129 (44.3%).
Conclusions
The majority of AVF’s present secondary to penetrating injuries. CT-angiography is the imaging modality for diagnosis of these injuries. SWs account for the majority of these injuries, most often injuring the vertebral artery and the superficial femoral artery. High-output heart failure is a known complication of these injuries. Surgical interventions are the most common mode of management followed by endovascular techniques. Surgeons must be able to identify and expose penetrating AVF’s and address associated injuries.
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