J o s é C a rlo s C o s ta B a p tis ta -S ilv a , L u iz F ra n c is c o P o li d e F ig u e ire d o , M a rc o s J o a q u im C a s tro , M a rc o s J o s é M a rtin s V e rís s im o , A n d ré L u iz G u im a rã e s C a m a ra
Postnephrectomy arteriovenous fistula
Hospital: Beneficência
Portuguesa,
Universidade Federal de São Paulo - São Paulo, Brazil
T h e d e ve lo p m e n t o f th e p o stn e p h re cto m y a rte rio ve n o u s fistu la (P N A V F ) b e tw e e n th e re n a l ve sse ls stu m p s is ra re . H e re w e p re se n t a ca se re p o rt o f P N A V F , a n d re vie w th e d ia g n a sis, tre a tm e n t a n d p re ve n tia n . T h e m a st ca m m a n clin ica i fe a tu re s in clu d e a la u d m u rm u r a ve r th e p re via u s n e p h re cta m y sca r, a n d h e a rt fa ilu re re sista n t ta ca m m a n m e d ica i tre a tm e n t. A 5 8 -ye a r-a ld w h ite w a m a n w a s a d m itte d ta th e h a sp ita l fa r a ca m p le te e va lu a tia n a f a n u n e xp la in e d ca n g e stive h e a rt fa ilu re w ith n a re sp a n se ta ca m m a n m e d ica i tre a tm e n t. S h e h a d h a d a rig h t n e p h re cta m y fa r p ya n e p h ra sis 1 3 ye a rs b e fa re . T h e d ia g n a sis a f P N A V F w a s sL !sp e cte d b e ca u se a ve r th e rig h t lu m b a r re g ia n a d e fin ite trill w a s p a lp a te d , a n d a n a u scu lta tia n a h a rsh , m a ch in e ry-like m u rm u r w a s h e a rd . T h e d ia g n a sis w a s ca n firm e d b y a a rta g ra m a n d se le ctive re n a l a rte ria g ra p h y. In M a y 1 9 8 9 , th e rig h t a rte ria ve n a u s w a s e xcise d th ra u g h a rig h t su b ca sta l tra n sp e rita n e a l a p p ra a ch . T h e re n a l ve sse l stu m p s w e re in d ivid u a lly Iig a te d a n d su tu re d se p a ra te ly cla se ta a a rta a n d ve n a ca va . T h e p a tie n t's p a sta p e ra tive ca u rse w a s e n tire ly u n e ve n tfu l in th e fa lla w in g se ve n ye a rs. W e ca n clu d e th a t d u rin g n e p h re cta m y, th e re n a l ve sse ls sh a u ld b e Iig a te d se p a ra te ly, a n d th e tra n sfixa tia n in m a ss a f th e stu m p s a va id e d ta p re ve n t a rte ria ve n a u s fistu la .
U N IT E R M S : A rte ria ve n a u s fistu la . R e n a l ve sse ls. N e p h re cta m y. H e a rt fa ilu re .
IN T R O D U C T IO N
T
he developm ent of the postnephrectom y arteriovenous fistula (PN A V F) is arare com plication of a com m on surgical procedure.I-3 M ass ligation and transfixation of the renal vessels in nephrectom y, although com m only practiced, is condem ned by m any surgeons as favoring the developm ent of arteriovenous fistula.I,4,5 W e present a case of thepostnephrectom y arteriovenous fistula, review the literature and discuss the diagnosis, treatm ent and prevention.
A d d re s s fo r c o rre s p o n d e n c e :
J o s é C a rlo s C o s ta B a p tis ta -S ilv a R u a P ro f. A rtu r R a m o s , 1 7 8 , 1 2 3 -V e g a S ã o P a u lo /S P - B ra s il- C E P 0 1 4 5 4 -9 0 4
C A S E R E P O R T
R.S., a 58-year-old w hite w om an, w as adm itted to the Beneficência Portuguesa H ospital w ith an unexplained congestive heart failure nonresponsive to com m on m edicaI treatm ent. The patient had undergone a right nephrectom y 13 years earlier for pyelonephrosis, and had been presenting sym ptom s of gallbladder lithiasis w ith surgical indication.
U pon physical exam ination, blood pressure w as 150/ 80. m m H g and the cardiac rate w as 96 bpm . A trill w as palpated over the right lum bar region and a loud, continuous m achinery-like m urm ur w as heard upon auscultation over the right flank. Eletrocardiography revealed left ventricular hypertrophy and arrhythm ia, and chest roentgenogram s show ed a m inim al cardiom egaly and slight vascular congestiono A lllaboratory tests w ere w ithin norm allim its.
W ith a suspicion of a system ic arteriovenous fistula, a percutaneous transfem oral abdom inal aortogram and a
1 4 4 5
s e le c tiv e r e n a l a r te r io g r a p h y w e r e p e if o r m e d .
A r te r io g r a p h ic s tu d ie s r e v e a le d a d ila te d r ig h t r e n a l a r te r y
w ith a d ia m e te r o f 1 0 m m . A t a p o in t 3 e m f r o m its a o r tic
o r ig in , th e c o n tr a s t m e d iu m c o u r s e d th r o ú g h a w in d in g
c h a n n e l a n d e n te r e d th e in f e r io r v e n a c a v a , a n d a la r g e
a r te r io v e n o u s f is tu la b e tw e e n th e r e n a l a r te r y a n d v e n a c a v a
a tth e s ite o f p r e v io u s r ig h t n e p h r e c to m y w a s r e v e a le d . T h e ilf e r io r v e n a c a v a p r o x im a l to th e r e n a l v e s s e ls s tu m p s w a s d ila te d a n d h a d a m a x im u m d ia m e te r a b o u t 4 0 m m ( F ig . 1 ) .
O n M a y 3 ,1 9 8 9 , c o r r e c tio n o f th e f is tu la w a s c a r r ie d
o u t th r o u g h a r ig h t s u b c o s ta l tr a n s p e r ito n e a l in c is io n . A
p u ls a tin g m a s s a b o u t 2 e m in d ia m e te r w a s f o u n d n e a r th e
r ig h t r e n a l v e s s e l s tu m p s . T h e r e n a l v e s s e l s tu m p s w e r e
is o la te d , lig a te d a n d d iv id e d . T h e s a c ( f is tu la ) w a s
in d iv id u a liz e d a n d r e m o v e d . T h e r e n a l a r te r y a n d v e in
s tu m p s w e r e in d iv id u a lly lig a te d w ith 2 - 0 s ilk , a n d ~ u tu r e d
s e p a r a te ly w ith m o n o f ila m e n ta r p o ly p r o p y le n e c lo s e to
a o r ta a n d v e n a c a v a r e s p e c tiv e ly . T h e r e tr o p e r ito n e u m
w a s c lo s e d , a n d th e c h o le c y s te c to m y w a s c a r r ie d o u t.
T h e p a tie n t's p o s to p e r a tiv e c o u r s e w a s e n tir e ly
u n e v e n tf u l. T h e m u r m u r a n d tr ill d is a p p e a r e d a f te r th e
p r o c e d u r e . T h e p a tie n t w a s d is c h a r g e d f r o m th e h o s p ita l
f iv e d a y s la te r o n M a y 8 w ith o u t a n y c o m p lic a tio n s . I n
M a r c h 1 9 9 6 , th e p a tie n t w a s a s y m p to m a tic a n d c lin ic a I
e x a m in a tio n s r e v e a le d n o s ig n o f h e a r t f a ilu r e . B lo o d
p r e s s u r e s , a n a ly tic te s ts a n d p u ls e w e r e w ith in n o r m a l
lim its , a n d th e c a r d io m e g a ly w a s r e d u c e d . A n a b d o m in a l
u ltr a s o n o g r a p h y w a s w ith in n o r m a llim its , e x c e p t f o r th e
a b s e n c e o f th e g a llb la d d e r , r ig h t k i~ n e y a n d a r te r io v e n o u s
f is tu la ( p o s to p e r a tiv e s ta tu s ) .
D IS C U S S IO N
R e n a l a r te r io v e n o u s f is tu la c a n b e id io p a th ic ,
c o n g e n ita l o r a c q u ir e dA
,6 P o s tn e p h r e c to m y r e n a l
a r te r io v e n o u s f is tu la s a r e r a r e c o m p lic a tio n s th a t m a y
d e v e lo p o v e r a p e r io d o f tim e r a n g in g f r o m d a y s to 3 5
y e a r s .2
,7 ,8 I n 8 0 0 r e n a l tr a n s p la n ts p e r f o r m e d a t th e
U n iv e r s ity o f M in n e s o ta , th is c o m p lic a tio n h a s o c c u r r e d
o n ly tw ic e , a n d m a y w e ll h a v e b e e n c a u s e d b y
s im u lta n e o u s lig a tio n o f r e n a l a r te r y a n d r e n a l v e in .7
F a c to r s c o n s id e r e d to b e o f e tio lo g ic s ig n if ic a n c e in
th e d e v e lo p m e n t o f p o s tn e p h r e c to m y a r te r io v e n o u s f is tu la
in c lu d e : m a s s lig a tio n o f th e r e n a l p e d ic le , e s p e c ia lly w h e n
tr a n s f ix a tio n s u tu r e s a r e u s e d ; n e p h r e c to m y f o r
tu b e r c u lo s is o f th e k id n e y ; p o s to p e r a tiv e in f e c tio n in th e
n e p h r e c to m y b e d , a n d ; r e n a l c a r c in o m a .2 -5,8-1O T h e
m e c h a n is m o f f is tu la f o r m a tio n w a s c le a r in s o m e o f th e
c a s e s . T h o s e w h ic h d e v e lo p e d f o llo w in g n e p h r e c to m y
w e r e lik e ly d u e to lig a tio n in m a s s o f v e s s e ls , w ith
s u b s e q u e n t n e c r o s is o f th e w a ll a n d p e r f o r a tio n . S im ila r
c h a n g e s o c c u r r e d a f te r d ir e c t tr a u m a . I n c o n g e n ita lle s io n s ,
th e la r g e v e s s e ls m a d e u p ' th e f is tu la .
A m o n g th e c a s e s o f h y p e m e p h r o m a , th e r e f r e q u e n tly
e x is te d b o th a c o n n e c tio n o f la r g e a r te r y to th e v e in d u e to
tu m o r in v a s io n , a n d la r g e c o m m u n ic a tin g v a s c u la r s p a c e s
w ith in th e p a r tia lly n e c r o tic tu m o r .4 I n th e r e m a in in g c a s e s ,
th e in itia lle s io n p r o b a b ly w a s a n a r te r ia l a n e u r y s m w h ic h
e v e n tu a lly e r o d e d th e w a ll o f th e v e in to f o r m th e
c o n n e c tio n , b u t th is c o n d itio n is r a r e .4,ll
F ig u re 1 - P e rc u ta n e o u s re tro g ra d e ,a b d o m in a l a o rto g ra m d e m o n s tra te s d ila te d rig h t re n a l a rte ry , w in d in g s tu m p o f th e re n a l v e in , a n d o p a c ific a tio n o f in fe rio r v e n a c a v a .
F ig u re 2 - P e rc u ta n e o u s re tro g ra d e re n a l a rte rio g ra m
d e m o n s tra te s d ila te d rig h f re n a l a rte ry , to rtu o u s s tu m p o f th e re n a l v e in , a n d o p a c ific a tio n o f in fe rio r v e n a c a v a .
B A P T IS T A -S IL V A , J .C .C .; F IG U E IR E D O , L .F .P .; C A S T R O , M .J .; V E R íS S IM O , M .J .M .; C Â M A R A , A .L .G . - P o s tn e p h e p h re c to m y a rte rio v e n o u s fis tu la
1446
T he literature has recorded m ore frequent
involvem ent of the right postnephrectom y renal
arteriovenous fistula because of the anatom ic disposition of the right kidney and a short renal vein pedicle. T w o-thirds of the cases are found on the right side; rem oval of
the kidney is technically m ore difficult on this side.2,7,12,13
L ike all peripheral arteriovenous fistula, they create a high venous return, an increase in cardiac output, and som etim es, a rise in systolic blood pressure. T his leads to
a reduction in peripheral resistance and a decrease in
diastolic blood pressure. If the heart cannot com pensate
for this shunt w hile trying to m eet increased tissue
dem ands, high output cardiac failure w ill naturally result.4
Postnephrectom y renal arteriovenous fistula m ust be
suspected in alI patients w ith a history of previous
nephrectom y w hen congestive heart failure and a high
cardiac output state are present, especially if resistant to
com m on m edicaI treatm ent.2,14 T he clinicaI presentation
of this syndrom e is very im pressive because m any patients have sym ptom atic congestive heart failure, high cardiac
output, hypertension and continuous abdom inal m urm ur.4
W ith the clinicaI m anifestations of an increased
cardiac output, hyperthyroidism , anem ia, beriberi heart
disease, Paget' s disease and an intracardiac shunt as
m entioned should be considered in the differential
diagnosis. T he pertinent clinicaI features of these various conditions w ill not be discussed at this tim e but a com plete physical exam inations, fluoroscopy ofthe chest, and a few laboratory studies w ill usually suffice to distinguish the various disorders.
T he duplex scan ultrasound, helical. 3-D (spiral)
com puter tom ography and m agnetic resonance
angiographic im ages are alternative im aging m odalities for the aorta and its branches, but definitive diagnosis is
m ade by abdom inal aortogram and selective renal
arteriogram in case of the PN A V F.1,2,4,14-16
T reatm ent can be accom plished through em bolization or occlusion of the fistula through angiographic techniques,
but the possibility of pulm onary em boli exists. M ost
surgeons prefer surgical excision and ligation of the
fistula.17-19 In our patient, w e preferred surgical procedure
to treat the arteriovenous fistula and the gallbladder lithiasis at the sam e tim e. W e concluded that during nephrectom y,. the renal vessels should be ligated separately, and the
transfixation in m ass avoided in order to prevent the
arteriovenous fistula.
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O
d~senvolvirrento de fístúl~. ~rteri9ye~osa.e~t.r~'q~gotosdR~ya~os rerlai~.~ôs:n~f~~G!PTia (FAVPN)é r~ro~<?
objetivo ére:latar um caso de FAVPN,sua~.óaus~~, diagnóstiçoe tratamento. Era umél' mulher.de.?8anos submetida a nefrectomia
direita há 13 anos, que ..se apr~sentoucom'insu:fi~iênGia ..ç~~pía~a congestiva.de diHcil:c~ntrol.e~ O diagnóstico clínico da
FAVPN foi feito devido o sopr9 ..9?ntínyoçorn referç(> ~istól:ipOngJI:anco direito
e
confirrr1:ad() pela art~riogr~fia. O tratamento foia ressecção dessa Hstulae su~ur~ dos c:otos vascylare~ sep~radamen.te junt~ às sua~~rigens ...Hpuve b().élevolução e cura da
FAVPN nq a~ompanham7nt~:ne~tes9Itim()s s~t~:~Q?s ...C9QGluí~.8~que durante a •..n7fr~G~orpiél: ...osY9s0S renais' deve ser
ligados ~usu:turados s~p~r~d~rn~nte,~xit~nd? atu:n~fixaç~gemF'Tlpnobloce dos ~()t9s8()~'{'.lsçulares Pélra prevenir Hstula
arteriovenosa . . '. : . . . .
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B A P T IS T A - S IL V A , J .C .C .; F IG U E IR E D O , L .F .P .; C A S T R O , M .J .; V E R íS S IM O , M .J .M .; C Â M A R A , A .L .G . - P o s tn e p h e p h r e c to m y a r te r io v e n o u s fis tu la
