Large arteriovenous fistula between the common iliac artery and the vein after blunt trauma

Abstract

A 62-year-old man presented to the emergency department with dyspnea on exertion and bilateral leg edema 4 days after falling down stairs and sustaining injuries. The physical examination showed mild respiratory distress and blood pressure of 130/80 mm Hg. Lung examination revealed bilateral basilar rales. A chest radiograph showed mild pulmonary congestion and pleural effusion but no cardiomegaly (A). An axial computed tomography scan (B) showed fracture and spondylosis of the lower lumbar spine and sacrum (*) and a 50-mm thrombosed pseudoaneurysm of the right common iliac artery (CIA) that communicated with the right common iliac vein (CIV) near the distal inferior vena cava (C and D). Transthoracic echocardiography revealed normal mitral, aortic and tricuspid valves, mild dilatation of all cardiac chambers, and normal contraction of the ventricles. There was moderate pulmonary hypertension (right ventricular systolic pressure, 60 mm Hg). The patient’s arteriovenous fistula (AVF) was surgically repaired through a median laparotomy. After proximal and distal control of the aorta and the inferior vena cava was obtained, the pseudoaneurysm was excised, and the AVF defect was repaired with interrupted polypropylene sutures. The size of the AVF was 40 10 mm. After a proximal anastomosis at the distal abdominal aorta and obliteration of both common iliac arteries, distal anastomoses were constructed to the external iliac arteries with a Dacron graft. The patient had an uneventful recovery and was discharged 10 days after surgery. Postoperative computed tomography showed successful excision of the pseudoaneurysm and repair of the AVF.