A Systematic Review And Individual Patient Data Meta-analysis Of Heart Failure As A Rare Complication Of Traumatic Arteriovenous Fistulas
Florian A. Wenzl, MD1, Stephanie S. Miljkovic, MS, BS, BA2, Parinaz J. Dabestani, MA, BS2, John J. Kessler, BS2, Tharun R. Kotaru, BS2, Louay D. Kalamchi, BS2, Sarah J. Aurit, MPH2, Juan A. Asensio, MD, FACS, FCCM, FRCS (England), FISS, KM2.
1Medical University of Graz, Graz, Austria, 2Creighton University School of Medicine, Omaha, NE, USA.
Objective: Traumatic arteriovenous fistulas (AVFs) are rare. The vast majority occur secondary to penetrating injuries. High-output cardiac failure is a well-recognized serious complication of arteriovenous fistulas, associated with high morbidity and mortality. The objective of this study is to identify predictors for heart failure (HF) in patients with traumatic AVF. Methods: Both PubMed/MEDLINE (Ovid) and CINAHL were searched (up to June 2019) for studies reporting individual patient data on clinical and demographic characteristics of patients with AVF secondary to penetrating trauma. Exclusion criteria were age < 18 years, no specification of symptoms, cranial, spinal or cardiac location of the AVF, and iatrogenic mechanism of injury. This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: A total of 274 AVF patients from 15 case series and 177 case reports were included. Median age at presentation was 32 years (interquartile range [IQR]: 24 years to 43 years), 90% were males. Most frequent mechanisms of injury were stab wounds (43%) and gunshot wounds (32%). Location of the AVF was abdomen (n=86, 31%), lower limb (n=79, 29%), neck (n=61, 22%), thorax (n=38, 14%), and upper limb (n=10, 4%). Thirty-five patients (13%) presented with HF and 239 (87%) presented with other symptoms. The risk for HF increased with feeding artery diameter (P<0.001). In univariate analysis, HF was significantly associated with longer median time from injury to presentation with AVF (11.2 years vs. 0.1 years; P<0.001), older median age at presentation (43 years vs. 31 years; P=0.002), involvement of a large feeding artery (aorta, pulmonary artery, subclavian artery, and external iliac artery) (40% vs. 13%; P<0.001), shrapnel injuries (11% vs. 2%; P=0.011) and injuries to the trunk or lower limb (94% vs. 71%; P=0.004). After adjusting for clinical and demographic patient characteristics, involvement of a large feeding artery (OR=3.25, 95% CI: 1.26 to 8.42; P=0.015) and every six
years of delay to presentation (OR=1.30, 95% CI: 1.03 to 1.63; P=0.026) remained independent predictors for HF. Conclusions: HF occurs in a small but important fraction of traumatic AVF patients and develops after highly variable latency periods. Large feeding arteries and delayed presentation independently predict HF in this cohort.
Back to 2021 ePosters