| An iatrogenic brachial arteriovenous fistula in an infant: A case report | |
| DOI: 10.5606/e-cvsi.2017.633 | |
| Engin Karakuş1, Soysal Turhan2, Onur Işık3 | |
|
1Department of Cardiovascular Surgery, Batman Regional State Hospital, Batman, Turkey 2Department of Cardiovascular Surgery, Tepecik Training and Research Hospital, İzmir, Turkey 3Department of Cardiovascular Surgery, Division of Pediatric Cardiology, Tepecik Training and Research Hospital, İzmir, Turkey |
|
| Keywords: Arteriovenous fistula; premature; surgery | |
Acquired arteriovenous fistulas, which are caused by arterial or venous puncture, are common in patients with a history of hospitalization
in the intensive care unit for a long time. A four-month-old girl, who was born at 25 weeks and treated in the neonatal intensive care unit
for one month due to respiratory distress, was admitted to our clinic with complaints of swelling and bruising on the right arm. Doppler
ultrasound revealed an arteriovenous fistula located between the basilic vein and brachial artery, which was surgically treated. Unlike
adults, fistulas during infancy may lead to a variety of morbidity, including heart failure, if left untreated. Herein, we report a rare pediatric
case of an arteriovenous fistula and discuss our clinical approach. |
|
Arteriovenous fistulas (AVFs) are characterized by
an abnormal connection between the arterial and
venous systems, which can be congenital or acquired.
The main causes of AVFs during infancy include
arterial or venous punctures. In the majority of
patients, medical history reveals premature birth and
prolonged intensive care unit stay due to additional
lung problems.[1] Herein, we report a rare pediatric
case of an arteriovenous fistula who was successfully
treated with surgery. |
|
|
CASE PRESANTATION
|
|
The four-month-old girl was admitted to our clinic with
complaints of swelling and bruising on the right arm.
She was born 25 weeks old and was treated in intensive
care unit for about one month due to respiratory distress.
She underwent venous and arterial puncture frequently
during this treatment period. The swelling started from
the antecubital fossa and spread to the forearm. A strong
thrill was obtained with palpation. The peripheral pulses
of both upper extremities were palpable and equal. There
was a difference in the diameter between the upper
extremities, and the antecubital region measurements
without difference in length. A hyperdynamic heart
peak was present; however, the cardiac-to-thoracic
ratio on the cardiac telemetry was within normal
limits. Doppler ultrasound revealed a large-base fistula between the brachial artery and the basilic vein in the
right antecubital fossa. In addition, brachial venous and
arterial diameters increased about two times, compared
to the contralateral measurements, and the arterial flow
was within the brachial vein, increasing the brachial
artery flow. Velocity measurement at the level of the
fistula was recorded at 350 cm/sec and calculated blood
flow at 250 mL/min. The patient was scheduled for surgery, and a written informed consent was taken from her parents. Surgical dissection showed a broad base fistula between the median antecubital vein and the brachial artery. The median antecubital vein was seen to be aneurysmatic (Figure 1). Vein was ligated and the aneurysmatic area was excised. Brachial artery was primarily repaired with a 7/0 monofilament suture material. No complications developed after surgery. She was discharged in the second postoperative day following a rapid recovery period. |
|
Arteriovenous fistulas during childhood are rare
pathologies.[2] These fistulas are typically caused
by multiple punctures in the arterial and/or venous
system.[3] Recognition can be difficult due to their
rarity in childhood. However, the thrill on the lesion
may be accompanied by hyperdynamic precordium,
and cardiac murmur, and enlarged veins on the
related extremity. The definite diagnosis can be
usually made using Doppler ultrasound. In our case,
the suspected AVF was supported with the presence
of swelling which caused the diameter difference in
the antecubital region, a strong thrill on palpation,
and prolonged intensive care hospitalization. The
diagnosis was confirmed through ultrasonographic
examination. Sonography is the first choice, as it is non-invasive, does not need sedation or ionizing radiation, is easily accessible, and can make definite diagnosis. Diagnostic criteria with sonographic examination include a low-resistance flow in the artery, highvelocity arterial flow within the vein, and turbulence in the fistula.[4] Clinical management of childhood AVFs is based on adult studies, due to its infrequency and limited data. Therefore, treatment options include surgical excision, transcatheter embolization, ultrasound-guided compression or placement of a covered stent to exclude the lesion.[5] However, we consider that treatment with invasive techniques is not appropriate for infants. Even if the coated stents can be deployed successfully, complications may continue to grow, depending on the need for anticoagulation. Compression on ultrasound guidance may be an appropriate technique for narrow neck lesions; however, it may not be feasible in large and organized fistulas. On the other hand, we suggest that the complication rate of transcatheter embolization for distal vessels in infants would be high. Therefore, we believe that the most appropriate treatment is surgical repair of the artery and vein. In conclusion, arteriovenous fistulas are infrequent in infants, and the main cause is multiple attempts in the arterial and/or venous system. These fistulas may cause morbidity in infants, leading to various conditions from aesthetic disorders on the limb to high-burdened heart failure. Thus, repair with surgical intervention is an appropriate approach.
Declaration of conflicting interests
Funding |
|
1) Dzepina I, Unusic J, Mijatovic D, Bulic K. Pseudoaneurysm
of the brachial artery following venipuncture in infants.
Pediatr Surg Int 2004;20:594-7.
2) Tran HS, Burrows BJ, Zang WA, Han DC. Brachial
arteriovenous fistula as a complication of placement of a
peripherally inserted central venous catheter: a case report
and review of the literature. Am Surg 2006;72:833-6.
3) Kotagal M, Reiss A, Vo N, Feldman K, Drugas G, Avansino
JR. Iatrogenic arteriovenous fistula in the arm in an
infant: diagnostic and therapeutic considerations. J Clin
Ultrasound 2012;40:381-4.
|
|
){kind=link}