Rare cases surgical treatment of posttraumatic arteriovenous fistulas renal vessels

Khanchi Mead; Kospanov N.A.; Demeuov T.N.; Akanov E.K.; Matkerimov A.Zh.

III. СЛУЧАЙ ИЗ ПРАКТИКИ

УДК616.13/14-001-089.12

RARE CASES SURGICAL TREATMENT OF POSTTRAUMATIC ARTERIOVENOUS FISTULAS RENAL VESSELS

ABOUT THE AUTHORS

Khanchi Mead -surgeonof the department of angiosurgery, can.med., a high level certificate physician. e-mail: [email protected]

Khanchi Mead, Kospanov N.A., Demeuov T.N., Akanov E.K., Matkerimov A.Zh.

National Scientific Center of Surgery named after A.N. Syzganov

Keywords

Arteriovenous fistula (AVF) of the renal vessels. Aortovenoznye traumatic fistula, acquired diseases

Abstract

The article analyzes examined and operated on 7patients with arteriovenous fistulas of different localization in the vascular surgery department them. AN Syzganov Scientific Centre of Surgery with 1990-2003. Of these, 4 cases were observed aorto-caval fistula after penetrating stab wounds - two of them between the abdominal aorta in its infrarenal segment and the inferior vena cava, one - between the right renal artery and the inferior vena cava, and in another between the aorta above the mouth of the left renal artery and left renal vein. The first diagnostic test of choice is the Doppler ultrasound, in which 90% of patients may be suspected A VM. The highest value in the diagnosis attached study contrast CT, computed 3D reconstruction can form the basis for surgical interventions.

Computed tomography and KT angiography primary diagnostic test for suspected traumatic fistula aortovenoznye. MSKT with bolus contrast enhancement allows you to accurately assess the size and its location.

KT angiography to diagnose damage to abdominal organs, damage to the aortic branches. All this makes it possible to take timely decision on the choice of surgical treatment.

Surgery Arteriovenous fistula (AVF) renal vessels are the only effective method of treatment of this severe pathology.

Буйрек кан-тамырлардьщ жаракаттан кешнп артерия-веналык жыланкезд1 хирургиялык емдеушщ сирек кезесетш окигалары

АВТОРЛАР ТУРАЛЫ

ХанчиМиад -А.Н. Сызганов атындагы YfXO кан-тамырлар бел1м1н1н хирургы, м.г.к., жоеары санатты хирург-дэргер. А.Н.Сызганов атындагы YfXO, ангиохирургия бел1м1 e-mail: [email protected]

Туйш сездер

буйрек кан-тамырларынын артериовенозды фистулалары (АВФ), журе пайда болган ауруларга жаракаттан кей1нп аортовенозды фистулалары.

Ханчи Миад, Коспанов Н.А., Демеуов Т.Н., Аканов Е.К., Маткер1мов А.Ж.

КР ДСМ А.Н.Сызганов атындаш хирургия улттык, шлыми орталыш. Алматы к,.

Ацдатпа

Макалада А.Н.Сьжанов атындаеы YfXO кантамыр хирургиясыньщ бел!мшес!нде 1990-2003жж аралышнда турлi окшалануымен артериявенозды жыланкез ауруына шалдыккан 7 ауру тексершп, олареа ота жасалеандыы бойынша талдау журпзлген. Сонын iшiнен 4 окта бойынша теш еткен пышак жаракаттарынан кейн: ею жащайда онын инфрареналды сегментнде 0перде аортасынын арасында жэне теменп iшперде к±ыс тамырында, сонымен таеы б'р жащайда аорта мен сол жаеындаеы буйрек саеасынын жэне сол жаеынын тамыры арасындаеы аорто-кавалды жыланкез ауруынын аеымы байкалеан. Б1р1нш1 диагностикалык тестт тандау ультрадыбыс доп-плерография болып табылады, ондай жайтта аурулардын 90% АВМ шыкты деген кудШ орын алуда. Диагности-калау кезiнде айтарлыктай маеынасы айырмашылык KT, компьютерлiк 3D реконструкциялау бойынша зерттеулер хирургиялык араласып ота жасаудын непзi болады.

Жаракаттан кейiнгi аортовеналык фистулалар шы№у кудin кезнде бастапкы диагностылау тестн журпзуде компьютерлк томография мен KT-ангиография болып табылады. Болюсты контрасты кушейту 'шен МСКТ онын орналаскан орнынын келемiн накты аныктауеа болады.

KT-ангиография аркылы iшперде к±ысы органдарынын, аорта б±тактарынын закымдануын диагностикалауга болады. Осы тэсiлдердiн барлыы хирургиялык емдеу тактикасын тандау туралы шешiмiндер кезiнде кабылдауына ыкпалын тигiзедi.

Буйрек кан-тамырларынын артерия-веналык фистулалары (АВФ) осындай ауыр патологиясына катысты емдеуд 'щ жалшз тшмдi эдiсi болып табылады.

Редкие случаи хирургического лечения посттравматических артериовенозных свищей почечных сосудов

Ханчи Миад, Коспанов H.A., Демеуов Т.Н., Аканов, Е.К., Маткеримов А.Ж.

ННЦХ им. А.Н. Сызганова, отдел ангиохирургии

Аннотация

В статье проведен анализ обследованы и оперированы 7 больных с артериовенозными свищами различной локализации в отделении хирургии сосудов НЦХ им. А.Н. Сызганова с 1990-2003гг. Из них в 4 случаях наблюдались аорто-кавальные свищи после проникающих ножевых ранений - в двух из них между брюшной аортой в ее инфраренальном сегменте и нижней полой веной, в одном - между правой почечной артерией и нижней полой веной и еще в одном между аортой над устьем левой почечной артерии и левой почечной веной. Первым диагностическим тестом выбора является Ультразвуковая допплерография, при которой у 90% больных может быть заподозрен АВМ. Наибольшее значение при диагностике придают исследование контрастной KT, компьютерная 3D реконструкция может служить основой для хирургических вмешательств.

Компьютерная томография и KT-ангиография первичным диагностическим тестом при подозрении на посттравматические аортовенозные фистулы. МСКТ с болюсным контрастным усилением позволяет точно оценить размеры и ее локализацию.

KT-ангиография позволяет диагностировать повреждения органов брюшной полостей, повреждения ветвей аорты. Все это дает возможность своевременно принять решение о выборе тактики хирургического лечения.

ОБ АВТОРАХ

Ханчи Миад -врач-хирург отделения ангиохирургии АО ННЦХ им.А.Н. Сызганова, к.м.н., врач высшей категорий.

e-mail: [email protected]

Ключевые слова

Артериовенозные фистулы (АВФ) почечных сосудов. Посттравматические аортовенозные фистулы, приобретенным заболеваниям

Arteriovenous fistula (AVF) renal vessels are one of the rare forms of renovascular hypertension (RVH).

When an AVF renal vessels observed hypertensive syndrome associated with impaired blood flow in the kidney as arterial reset reduces blood flow to the kidney, and at the same time leads to venous stasis, which in turn makes its contribution to the formation of hypertensive nature nephrogenic syndrome. Furthermore, arteriovenous discharge leads to a sharp increase in pressure in the inferior vena cava, which greatly increases the functional load on the right heart. Thus, abrupt changes in central hemodynamics with systemic hypertension leads to rapidly progressive heart failure. Most AVF are acquired pathology that emerged on the basis of penetrating trauma with injury of renal vessels and the formation of arteriovenous fistula [1, 2, 3].

During the last decade due to the worsening crime situation has sharply increased the number of patients with gunshot and stab wounds to blood vessels. The first surgical assistance is usually provided by a general surgeon, and is mainly in stopping bleeding and suturing wounds injured abdominal organs. In penetrating wounds of the abdomen, in rare cases is the formation of fistulas aortocaval. Aortovenous traumatic fistula are severe acquired diseases leading to emergency mortality without surgery [4,5,6,7,8].

In vascular surgery department them. (National Scientific Center of Surgery). with 1990-2012gg. examined and operated on 10 patients with arteriovenous fistulas of different localization. Of these, 7 cases were observed aorto-caval fistula after pen-

etrating stab wounds - 3 of them between the abdominal aorta in its infrarenal segment and the inferior vena cava, one - between the right renal artery and the inferior vena cava, and in another between the aorta above the mouth of the left renal artery and left renal vein.

Here are his own clinical observation:

Patient T., 36 years old admitted to the hospital them. A. N. Syzganov routinely 19.12.02. complaining of shortness of breath, heaviness and pain in the heart and the right upper quadrant.

The history: a penetrating wound to the abdomen in 1990. Produced laparotomy, revision. Since 1996, there was dyspnea on exertion, and swelling in the lower extremities. In February 2002, he underwent surgery for bleeding from veins gemor-raidalnyh. During this time the patient was under the supervision of a cardiologist on a residence and periodically held courses of inpatient treatment with the diagnosis of dilated cardiomyopathy. In the dynamics of the phenomena of heart failure progressed, due to which the patient was sent to Kaz. N II cardiology and internal medicine for diagnosis and to determine further treatment strategy. In this clinic, the patient was examined by a vascular surgeon and diagnosed with post-traumatic arteriovenous fistula was recommended translated into AN Syzganov Scientific Centre of Surgery. When a serious condition. Skin and visible mucous net, normal color. In the lungs vesicular breathing, no wheezing. Heart sounds are muffled, the rhythm is broken. A / H 150-160 / 110-120 mmHg Pulse is 120 beats per 1 minute. Abdominal palpation is soft, moderately painful in the right upper quadrant. Liver 4 cm. In favor of the costal arch.

Figure 1.

With the introduction of contrast medium into the abdominal aorta was visualized enhanced left kidney and inferior vena cava.

Locally: The epigastric artery at the level of the renal auscultated systolic-diastolic murmur. Ripple main artery at all levels distinct.

In the clinic, the patient made a full clinical examination:

KLA, OAM in the normal range. The urine biochemical analysis revealed increased bilirubin level up to 25 mmol / l, which decreased over time.

The results of instrumental research methods:

X-ray examination of the chest: Conclusion mitral and tricuspid fault with predominance of stenosis in the mitral and tricuspid valve insufficiency.

ECG: atrial fibrillation. The vertical position. Atrial fibrillation, normosistolicheskaya form. Left ventricular hypertrophy.

Echocardiography: fibrous ring 2.2, 3.5 ascending aorta, arch 27, 19. cardiac ejection fraction 62%. Regurgitation of II degree on the tricuspid valve, I st. on the mitral valve. Left ventricular hypertrophy.

Doppler ultrasound: The infrarenal abdominal aorta is determined by the message with the extended left renal vein (33 mm). The left renal vein lumen of turbulent blood flow. The left kidney is increased (138h51 mm), the left ureter expanded to 10mm. The right kidney was normal. Conclusion: Aneurysm of the left renal vein. Fistula with the abdominal aorta. Hydronephrosis transformation of

the left kidney. Magnetic resonance angiography: in the series of tomograms is determined by the expansion of the inferior vena cava above the renal arteries, lower notes aortovenons fistula. Conclusion: arteriovenous fistula at the level of the renal arteries. Aneurysmal expansion of the inferior vena cava. Expansion of the left renal vein.Using angiography localization of the fistula was confirmed (Figure 1) and is formulated preoperative diagnosis: condition after surgery for penetrating abdominal injuries with damage to the aorta and the left renal vein. Posttraumatic arteriovenous fistul between the aorta and the left renal vein. Dilated cardiomyopathy. Atrial fibrillation. NC I-IIa stage.

In the preoperative period, the patient experienced an episode of bleeding from acute ulcers 5 antrum and right-sided lobar pneumonia. In this connection, the corresponding complex therapy was performed. On stabilization 01/07/03 performed surgery - torakofrenolyumbotomiy 9 intercostal space on the left.

Obtained aorta and left renal artery. In the area of the alleged dumping is determined arteriove-nous tissue calcification. On aorta imposed clamps above the celiac trunk and below the renal arteries, and then shake disappeared. Produced separation fistula.

The defect of the aorta and left renal vein eliminated. Phased forced off the clips. Bulk circulation. Operation completed drainage of the left pleural cavity and retroperitoneal space (Figure 2).

Postoperatively conducted antibacterial, car-diometabolic, symptomatic therapy. Momentary made puncture the left pleural cavity. Wound healing by first intention. In satisfactory condition at 10 days after surgery the patient was discharged from the hospital.

The patient is examined in six months. No complaints.

This unique example of a long history of the disease (over 12 years), the patient during this time was under the supervision of cardiologists in the

Figure. 2

shows the localization of the fistula and its separation scheme

community diagnosed with dilated kardimiopatiya.

In patients with stable hemodynamics is possible to use different diagnostic methods. The first diagnostic test of choice is the Doppler ultrasound, in which 90% of patients may be suspected AVM. The highest value in the diagnosis attached study contrast KT, computed 3D reconstruction can form the basis for surgical interventions.

Computed tomography and KT angiography primary diagnostic test for suspected traumatic

^MTepaiypa

1. Spiridonov AA Rare forms of renal vessels. -VNIIMI, Scientific Review, edited by AV Intercession, 1975, pp 61-64.

2. Pokrovsky AV Clinical angiologiya. M: Medicine, 1979-C. 368.

3. Shalimov AA, Dryukov NF Aortic Surgery and main arteriy. Kiev: Health, 1979.-S.383.

4. Vasiliev AI, Zakharov PI, Fedoseyev AK Surgical treatment of traumatic fistula aortovenoznogo // Clinical hirurgiya№4, -C. 111-112.

5. Hafez H.M., Woolgar J., Robbs J.V. Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss // J. Vasc. Surg.-2001.-Vol.33, N6.-P.1212-1219.

6. Megalopoulos A., Siminas S., Trelopoulos G. Traumatic pseudoaneurysm of the popliteal artery after blunt trauma: Case report and a review of the literature // Vasc. Endovasc. Surg.-2007.-Vol.40.-P.499-504.

7. Franz R. W., Jump M. A. Endovascular repair of post-traumatic, concomitant popliteal artery pseudoan-eurysm and arteriovenous fistula // Int. J. Angiol.-2009.-Vol.18, N1.-P.41-44.

8. Ilijevski N., Radak D., Radevi B. et al. Popliteal traumatic arteriovenous fistulas // Trauma.-2002.-Vol.52, N4.-P.739-744.

9. 1MycaranneB fl.T, 2A63anneB K.5., 1OHnacbHOB A.K., 1Eepfln6eKOB A.E., 1Ann6eKOB A.H., 1Tow6ae-Ba A.K. 3$$eKTHBHOCTb SHAOBacKynnpHoro neHeHHn BpoxfleHHbix aHrMOAMcnna3MM. XypHan «neAnaTpHn h AeTCKan xnpyp™n» №3 2015r - c.32-37

fistula arteriovenous. MSKT with bolus contrast enhancement allows you to accurately assess the size and its location.

KT angiography to diagnose damage to abdominal organs, damage to the aortic branches. All this makes it possible to take timely decision on the choice of surgical treatment.

Thus: Surgery arteriovenous fistul (AVF) renal vessels are the only effective method of treatment of this severe pathology.

References