CITATION: Du Toit, D.F & Rademan, F. 1987. Traumatic superior mesenteric arteriovenous fistula - a case report. S Afr Med J, 71(9):587-588.The original publication is available at http://www.samj.org.zaENGLISH ABSTRACT: In a case of traumatic superior mesenteric arteriovenous fistula resulting from a stab wound in the abdomen clinical signs of high-output cardiac failure or portal hypertension were absent. Selective angiography was useful in confirming and locating the fistula. The patient made a good recovery after resection of the aneurysm and fistula and insertion of a prosthetic graft.AFRIKAANSE OPSOMMING: Geen opsomming beskikbaarPublisher’s versio

Du Toit, D. F.

Rademan, F.

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SAMJ VOLUME 71 2 MAY 1987 5873. Anderson KP, Atlas E, Ahem Ml, Weisbror IM. Cenrral nervous sysremroxoplasmosis in homosexual men. AmJ Med 1983; 75: 877-881.4. Wong B, Gold JMW, Brown AE ec of. CenrraJ nervous sysrem roxoplasmosisin homosexual men and parenreral drug abusers. Ann Inrem Med 1984; 100:36-42.5. Ruskin J, Remingron JS. Toxoplasmosis in rhe compromised hosr. AnnImern Med 1976; 84: 193-199.6. Frenkel JK, _'elson BM, Arias-Srella J. Toxoplasmic encephalitis. HumPocho11975; 6: 97-111.7. Vierke WN, Gelderman AH, Grimley PM, Valsamis MP. Toxoplasmosiscomplicating malignancy. Cancer 1968; 21: 816--827.Carey RM, Kimball AC, Armsrrong 0, Lieberman PH. Toxoplasmosis: clinicalexperience in a cancer hospiral. AmJ Med 1973; 54: 30-38.9. Krick JA, Remingron JS. Toxoplasmosis in rhe adulr: an overview. N EnglJMed 1978; 298: 550-553.10. Townsend JJ, Wolinsky JS, Boringer JR, Jobnson Pc. Acquired roxo-plasmosis: a neglecred cause of rrearable nervous disease. Arch Neuro11975;32: 335-343.11. Bach MC, Armsrrong RM. Acure roxoplasmic encepbalitis in a normaladulr. Arch NeuTo11983; 40: 596-597.12. Siverrsen B, Anderson JA. A case of acure polyradiculoneuritis and acquiredroxoplasmosis.J Neurol Neurosurg Psychiacry 1984; 47: 219-220.13. Jones TC, Kean BH, Kimball AC. Acquired roxoplasmosis. NY Scoce J Med1969; 69: 2237-2242.14. Donovan Posr MJ, Chan JC, Hensley GT, Hoffman TA, Moskowirz LB,Lippman S. Toxoplasmic encephaliris in Haitian adulrs wirh acquiredimmunodeficiency syndrome: a clinical-parhologic CT correlarion. AJR1983; 140: 861-868.15. Pirchenik AE, FiscW MA. Evaluarion of cerebral-mass lesions in acquiredimmunodeficiency syndrome. N EnglJ Med 1983; 308: 1099.16. Mazer S, Aruajo JC, Ribeiro RC, Kasting G. Unusual compured romographicpresenration of cerebral roxoplasmosis. AJNR 1983; 4: 458-460.17. Snider WO, Simpson DM, Aronyk KE, Nielson SL. Primary lymphoma ofrhe nervous sysrem associared wirh acquired immunodeficiency syndrome. NEngl J Med 1983; 308: 45.18. McLeod R, Berry PF, Marshall WH jun., Hum SA, Ryning FW,Remingron J5. Toxoplasmosis presenting as brain abscesses: diagnosis bycompurerised romography and cyrology of aspirared purulenr mareria!. AmJMed 1979; 67: 711-714.19. Enzmann OR, Branr-Zawadzki M, Brin RH. The CT appearance of cenrralnervous sysrem infection in immunocompromised parienrs. AJNR 1980; I:239-243.20. Conley FK, Jenkins KA, Remingron JS. Toxoplasma gondii infecrion of rhecemral nervous svsrem. Hum Pachol19 I; 12: 690-698.21. Emerson RG, jardine OS, Milvenan ES, D'Souza Bl, Elfembein Gl,Sanros G. Toxoplasmosis: a rrearable neurologic disease in rhe immuno-logically compromised patienr. Pediacrics 1981; 67: 653-655.22. McCabe RE, Remingron JS. The diagnosis and rrearmenr of roxoplasmosis.EurJ Clin Microbio11983; 2: 95-104.23. Anderson SF, Remingron JS. The diagnosis of roxoplasmosis. Soueh Med J1975; 68: 1433-1443.24. Hyde BE, Barnen EV, Remingron JS. Merhod for differenriation of non-specific from specific roxoplasma IgM fluorescenr amibodies in patienrswirh rheumaroid facror. PTOC Soc Exp Bioi Med 1975; 148: 1184-1188.25. Araujo FJ, Barnen EV, Genrry LO, Remingron JS. False-posirive anti-roxoplasma fluorescenr antibody resrs in patienrs wirh anrinuclear antibodies.Appl Microbiol1971; 22: 270-275.26. Nam Y, Remingron JS. An enzyme-linked immunosorbenr assay for derecrionof IgM antibodies ro Toxoplasma gondii: use for diagnosis of acure acquiredroxoplasmosis.J Infece Dis 1981; 142: 757-766.27. Naor Y, Barnen EV, Remingron JS. Merhod for avoiding false-posiriveresulrs occurring in immunoglobulin M enzyme-lUrked immunosorbenrassays due ro presence of bmh rheumaroid facror and anrinuclear antibodies.J CHn Microbiol1981; 98: 32-36.28. Murrhy SK, Smirh RP, Parikh N, Blarch AL, Bishop M. Faral roxoplasmosisof the central nervOUS system in a heroin user with acquired immuno-deficiency disease. NY Scoce J Med 1984; 84: 464-465.29. Chan JC, Moskowirz LB, Olivella l, Greenman RL, Hoffman TA. Toxo-plasma encephalitis in recenr Hairian enrranrs. Souch Med J 1983; 76:1211-1215.30. Perersdorf RG, ed. Hamson's Principles of Imernal Medicine. IOrh ed. NewYork: McGraw-Hill, 1983: 1205.•mesenterIcfistulaTraumatic superior•arterIovenousA case reportD. F. DU TOIT, F. RADEMANSummaryIn a case of traumatic superior mesenteric arterio-venous fistula res!Jlting from a stab wound in theabdomen clinical signs of high-output cardiac failureor portal hypertension were absent. Selective angio-graphy was useful in confirming and locating thefistula. The patient made a good recovery after resec-tion of the aneurysm and fistula and insertion of aprosthetic graft.S AIr Med J 1987; 71: 587-588.Department of Surgery, University of Stellenbosch andTygerberg Hospital, Parowvallei, CPD. F. DU TOIT, PH.D., FC.S (SA), F.R.C.S.F. RADEMAN, M.B. CH.B.A traumatic arteriovenous (AV) fistula in the mesenteric andportal systems is of special interest because of the effects onthe circulation and the challenge which its correction presentsto surgical ingenuity and skill.A patient with a superior mesenteric artery (SMA) AVfistula resulting from a knife stab in the abdomen is reported.Case reportA 30-year-old woman underwent an emergency laparoromy afterbeing stabbed in the epigastrium. At laparoromy two lacerations inthe sromach were sutured. Insignificant bleeding was observed atthe root of the small-bowel mesentery and bleeding vessels wereoversewn. The posroperative course was uneventful and the patientwas discharged from hospital on the 10th day.Readmission was necessary I month later because the patientcomplained of severe abdominal pain. Clinical examination wasessentially normal. Abdominal examination revealed a systolic-diasrolic bruit in the epigastrium associated with a palpable thrill.There were no signs of cardiac failure or portal hypertension:588 SAMT DEEL 71 2 MEI1987A selective mesenteric arteriogram (Fig. I) demonstrated a largeAV fistula between the proximal SMA and vein, communicatingthrough a false aneurysm. At a second laparotomy the fistula wasdivided and the aneurysm resected. The defect in the vein wasFig. 1. Pre-operative selective SMA arteriogram showing a sac-cular aneurysm related to the SMA and opacification of portalvein and its branches indicating the presence of a systemic-portal AV fistula.Fig. 2. Postoperative arteriogram showing good opacification ofthe SMA without filling of the portal vein confirming the surgicaland clinical impression of successful fistula repair.sutured and arterial continuity was restored by insertion of apolytetrafluoro-ethylene interposition graft. A postoperativearteriogram (Fig. 2) showed successful repair of the fistula. Thepatient made an uneventful recovery.DiscussionAV fistulas of the mesentericoportal circulation are relativelyrare. Acquired AV fistulas of the portal circulation are morecommon than congenital ones and may result from abdominaltrauma, either blunt or penetrating, as in our patient, or beiatrogenic in origin. I- 4 Mesenteric AV fistulas have beenreported after bowel resection, division of adhesions, massligation of the splenic vessels during splenectomy or aftergastrectomy. Most acquired fistulas involve the splenic vessels.The diagnosis of a traumatic mesenteric (AV) fistula isgenerally straightforward and is characterised by the fmding ofan abdominal bruit which is virtually diagnostic. Angiographyis essential for localisation and defmition.In all cases surgical correction is advisable because of thedangers of portal hypertension and cardiac failure developingif the fistula becomes haemodynamically significant,5 althoughportal-systemic fistulas characteristically do not cause symptomsof cardiac failure, presumably because of the buffer effect ofthe hepatic bed.6Treatment of these fistulas entails closure of the AV commu-nication which may be achieved by quadruple ligation of theartery and vein proximal and distal to the fistula and/orresection of the aneurysm with restoration of the arterialcirculation with autogenous or prosthetic engraftment to pre-serve the viability of the bowel. Although successful manage-ment of AV fistula by embolisation has been reported, emboli-sation was felt to be unsafe in our patient because of the largesize of the fistula and significant flow into the portal vein.We thank Professor L. C. J. van Rensburg for constructiveideas on contents and text, Dr N. Cirota for referring the patient,and the Medical Superintendent of Tygerberg Hospital for per-mission to publish.REFERENCESI. Brunner JH, Stanley RJ. Superior mesenteric aneriovenous fistula. JAMA1973; 223: 316-318.2. Diehl JT, Beven EG. Aneriovenous fisrulas of the mesenteric vessels. JCardiovasc Surg 1982; 23: 334-337.3. Rabhan NB, Guillebeau JG, Brackney EL. Aneriovenous fistula of thesuperior mesenteric vessels after a gunshot wound. N EnglJ Med 1962; 266:603-605.4. Smith RH, Stone HH. Traumatic aneriovenous fisrulas involving the portalvenous system. AmJ Surg 1970; 119: 570-573.5. Sumner DS. Hemodynamics and pathophysiology of aneriovenous fistulae.In: Rutherford BB, ed. VascuJar Surgery. 2nd ed. Philadelphia: WB Saunders,1984: 858-888.6. Baker WHo Aneriovenous fistulae of the aona and its major branches. In:Rutherford BB, ed. Vascular Surgery. 2nd ed. Philadelphia: WB Saunders,1984: 918-922. -

Traumatic superior mesenteric arteriovenous fistula

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Traumatic superior mesenteric arteriovenous fistula

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