Annals of Vascular Surgery
Volume 24, Issue 7 , Pages 952.e17-952.e21, October 2010

Popliteal Arteriovenous Fistula Due to a Gunshot Injury

  • Guillaume Lebreton

      Affiliations

    • Service de Chirurgie Thoracique et Cardio-Vasculaire, CHU, Fort de France, France
    • Corresponding Author InformationCorrespondence to: Guillaume Lebreton, Service de Chirurgie Thoracique et CardioVasculaire, CHU Fort de France, Route de la Meynard, 97261 Fort de France Cedex, France
    • ,
  • André-Pierre Uzel

      Affiliations

    • Service d'Orthopédie et Traumatologie, CHU, Pointe-à-Pitre, France
    • ,
  • Jocelyn Celerien

      Affiliations

    • Service de Chirurgie Vasculaire, CHU, Pointe-à-Pitre, France
    • ,
  • Francois Roques

      Affiliations

    • Service de Chirurgie Thoracique et Cardio-Vasculaire, CHU, Fort de France, France
    • ,
  • Michel Deneuville

      Affiliations

    • Service de Chirurgie Vasculaire, CHU, Pointe-à-Pitre, France

published online 05 July 2010.

Article Outline

We report the case of a 22-year-old man who presented with a popliteal arteriovenous fistula after a gunshot injury to his right knee. The diagnosis, made in the Emergency Department, was confirmed by arteriography, allowing quick therapeutic intervention. The lesions to the popliteal artery and vein were repaired with a double venous bypass, followed by relieving fasciotomy. Satisfactory clinical results were achieved after 2 months and magnetic resonance imaging revealed normal permeability of the vascular axes. Three years after his operation, our patient has normal function of his knee. The physiopathology, diagnostic difficulties, and management of this type of lesion are discussed with a review of the literature.

 

An arteriovenous fistula (AVF) is a direct communication between an artery and a vein, without passage of blood through the distal capillary network.1 AVFs were first described in 1757 by Hunter,2 and can be congenital or acquired; in the latter case, AVFs are always pathological and may go unrecognized. Their diagnosis is difficult but should be considered after any penetrating trauma. AVFs are commonly seen during military conflicts, where they are usually ballistic in origin. The basis of management of AVFs has been proposed mainly since the Second World War and the wars in Korea and Vietnam. These lesions are rare in times of peace but are sometimes seen after attacks. Their diagnosis has become more difficult as clinicians have less experience with this type of injury.

We report our experience of a case that occurred after a gunshot injury to the popliteal fossa, with only minor symptomatology. Although rare, orthopedic traumatologists should be familiar with these types of lesions.

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Case Reports 

A male patient aged 22-years without any previous history, presented at the Emergency Department of the CHU on the evening of August 9, 2005, a victim of a firearm attack while he sat on his scooter. On admission, he had stable hemodynamics (pulse 90/min and arterial pressure = 130/90). Clinical examination revealed two wounds on his right knee, a posterointernal wound on the proximal third of the right knee (entry wound), and an anterolateral wound to the distal third of the homolateral thigh (exit wound). The right popliteal fossa appeared swollen but popliteal, pedal, and posterior tibial pulses were detected. An asymmetry in perception of the pedal pulse was noted, with the pulse being clearly less strong on the right side. The patient did not have any sensory-motor deficit or compartment syndrome.

Initial radiological examination of the front and the side of his right knee revealed a projectile approximately 7 mm in diameter, situated in the soft tissue two finger-widths above and outside the patella (Fig. 1). Radio-opaque debris was also noted along the probable trajectory of the bullet, without any bone lesion except for a discrete bone defect in the superointernal third of the tibia. An emergency arteriography was carried out, revealing evidence of leakage of contrast medium around the subarticular segment of the popliteal artery and a popliteal AVF (Fig. 2).

The area around the wounds was cleaned carefully in the Emergency Department, and the upper popliteal artery was then accessed under spinal anesthesia in ventral decubitus through an elongated S approach to control the bleeding. Arterial and venous bleeding was controlled with an Esmarch band, allowing examination of the lesion. Hemic infiltration of the muscular and cutaneous structures of the popliteal fossa was observed. Approximately 4 cm of the lower portion of the popliteal artery was dilacerated and ruptured, whereas the popliteal vein was broken into two segments separated by a healthy segment (Fig. 3).

The homolateral greater saphenous vein was removed from the leg muscle, and two bypasses of the popliteal artery and vein were created. The arterial anastomosis was prepared first: short, inverted, popliteal venous retroarticular- lower popliteal termino-terminal bypass. An ellipsoid termino-terminal anastomosis was then created using a 7/0 Prolene (Ethicon, Inc., Auneau, France) running suture and loupe magnification. A relieving fasciotomy of the superficial posterior compartment of the leg completed the reconstruction, and arteriography on the operating table demonstrated repermeabilization of the axes of the right leg (Fig. 4).

Postsurgical management was straightforward; the patient received antibiotherapy with amoxicillin and clavulanic acid for 6 days and anticoagulant treatment with low molecular weight heparin for 1 month.

The patient was seen at 2 months, and magnetic resonance imaging (MRI) confirmed good permeability of the anastomosis. After 3 years, the results are excellent, with a strong symmetrical pulse and normal function of the knee.

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Discussion 

Penetrating trauma is the second most common cause of vascular traumatic injury and is complicated by AVFs in 5% of the cases.3 In our patient, the cause of the penetrating trauma was a small caliber bullet. This type of wound, associated with white weapons, often results in AVFs because less tissue is lost as compared with lesions caused by high velocity shrapnel or bullets, which are more often complicated by hemorrhaging.4

The effects of a fistula and how it is tolerated depend on two factors: the size and the duration of the shunt.5 Some fistulas can remain unnoticed and do not become apparent for several years.6 Two clinical entities can be distinguished: an acute form and a chronic form resulting from an unrecognized or neglected fistula. In the majority of cases (80-85%), the fistulas affect the limbs.3 The extremities are more exposed to trauma and the vascular pedicles are extremely vulnerable because they are more superficial. The femoral artery is most often involved (40%), followed by the popliteal artery (20%).7

When multiple fistulas are present (7% of cases), they are often better tolerated than a single fistula because the presence of one fistula close to another causes a loss of flow in both.5, 8 In the present case, we observed a cessation of retrograde flow at the first valves met distally, and an injection of the vein as far as the femoral vein. With all shunts, arterial pressure below the fistula is slightly or greatly reduced, resulting in ischemia of the distal territory.9

The classic signs of AVF (pulsatile swelling and a continuous thrill) are occasionally found in the acute phase, particularly in low-flow fistulas, but are often not looked for. Signs of arterial (pallor, coldness) or venous (edema, warmth, cyanosis, etc.) insufficiency, as well as pulsatile varicose veins, may also be present. The pulse may be absent, but is more often present but decreased. In the case described here, the diagnosis was made first from the path of the bullet, then from the swelling around the popliteal cavity, and finally from the decrease in the right pedal pulse.

Outside emergency situations, clinical suspicion should be followed up immediately by investigations enabling confirmation or rejection of an arterial trauma. In the emergency department, arterial Doppler can aid diagnosis, and is risk-free. This technique reveals evidence of increased flow in the upstream region of the artery and of the arteriovenous communication, with pulsatile flow in this area.9, 10 The exact topography, form, and effects of the lesion should be determined by arteriography or angio-scanner, the reference techniques, whenever possible.3, 7, 11, 12, 13, 14 This technique can reveal the anatomy of the fistula. Arteriography has the advantage over other techniques in that it can, in some cases, assist in therapeutic intervention. However, it does not show the relationship with neighboring structures or with thrombosed false aneurysm. Sometimes, it may be possible to use tomodensitometry or even better, MRI, which offers the possibility of obtaining sections through several different planes. This is helpful for estimating the difference in flow,11, 15, 16 and is currently the reference technique for congenital fistulas. However, MRI is often contraindicated in traumas caused by firearms because of the potential presence of metal fragments.

Three approaches have been described: surveillance, reconstructive surgery, and endovascular treatment. The first approach is rare and should be reserved for parenchymatous fistulas (hepatic, renal, etc.) and for cases where the benefit of an intervention is outweighed by a major risk.3 Surveillance is not recommended for an AVF.3, 4, 7, 17

The aim of surgical treatment is to repair the arterial and venous structures and to ligate the fistula. This has become the most popular approach since the Korean war.18 Reconstructive surgery helps to re-establish the anatomic continuity of the vessels by lateral suture or « patch » of the walls, using a termino-terminal anastomosis or bypass.5, 19 Repair of the vein is essential and should not be neglected, at the risk of the development of distal venous insufficiency.20 After controlling the feeding vessels, the fistula could be controlled.19 Thus, at the time of dissection, arterial flow is under good control.

Conversely, hemostasis of venous structures, which is often the origin of bleeding, is more difficult, and it may be necessary to abandon this before starting vascular repair. In the case that we report, use of an Esmarch band enabled us to carry out vascular repair with perfect venous hemostasis. We recommend this technique because it eliminates one of the main technical difficulties of this intervention. It enables a perfect venous inspection, and has a garrote effect. The band should be placed after the dissection of the fistula and remain in place during construction of the anastomosis. Care should be taken not to cause nerve lesions. Relieving fasciotomy has been recommended by several authors13, 19, 21 and, in our opinion, has many indications. A review of the published data has revealed a number of postoperative compartment syndromes.12, 13, 19, 21 Finally, arteriographic monitoring on the operating table is essential to detect any technical problems.19

Endovascular treatment depends on the insertion of covered endoprostheses and on percutaneous embolization. This technique is attractive because it is selective, but it remains reserved for fistulas that are inaccessible to surgical treatment, most often chronic and distal. It requires a highly experienced surgeon because it is associated with several major risks (e.g., ischemia, emboli). This technique is a therapeutic alternative to surgery in a hemodynamically stable patient. The indications for this technique have expanded progressively with the constant development of this discipline.5, 22, 23

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Conclusion 

Trauma, particularly ballistic, is a common cause of vascular lesions, notably AVFs. Diagnosis of these lesions often goes unrecognized and is made only after a long delay and progression. Clinical features can be atypical; the presence of a distal pulse does not exclude the diagnosis. In addition, any trauma to a vascular region should raise the question of a vascular lesion, and the cause of the lesion and the path of the vulnerant agent should be investigated. Therapeutic management should be initiated immediately after a diagnosis has been made. In our view, reconstructive surgery remains the method of choice for most of these lesions, particularly in the emergency setting. Endovascular treatment will, without doubt, play a more important role in the future.

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References 

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PII: S0890-5096(10)00149-4

doi:10.1016/j.avsg.2010.02.051

Annals of Vascular Surgery
Volume 24, Issue 7 , Pages 952.e17-952.e21, October 2010

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