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Conservative management of an arteriovenous fistula of the inferior epigastric artery

¹ Departments of General Surgery and ² Radiology, "Virgen de la Arrixaca" University Hospital, 30120 El Palmar, Murcia, Spain

Correspondence: A Piñero, Department of General Surgery, "Virgen de la Arrixaca" University Hospital, 30120 El Palmar, Murcia, Spain

	Abstract

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We present a case of pseudoaneurysm and arteriovenous fistula of the inferior epigastric artery secondary to the placement of a drain during a surgical intervention. We stress the utility of colour Doppler ultrasound and arteriography embolisation in diagnosis and treatment, respectively.

	Introduction

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Whilst the iatrogenic or accidental occurrence of pseudoaneurysms of the inferior epigastric artery has been reported in connection with retention sutures in the closure of laparotomies [1, 2], paracentesis [3] and removal of peritoneal dialysis catheters [4], the appearance of a traumatic epigastric arteriovenous fistula is an exceptional accident and, to the authors' knowledge, not so far reported. The inferior epigastric artery and vein run inside the rectus sheath, behind the rectus muscle. They are branches from the external iliac artery and vein that continue, in the retrosternal space, with the internal mammary artery and vein, respectively. They run side-to-side, so that simultaneous damage needed to produce an arteriovenous fistula is a feasible pathogenic mechanism.

We present a case of pseudoaneurysm and arteriovenous fistula of the inferior epigastric artery and address certain diagnostic and therapeutic considerations.

	Case report

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A 40-year-old woman was admitted to hospital having had a hysterectomy and right oophorectomy, for fibroids and an ovarian cyst, in the Gynaecology Unit of another hospital in our region. 24 h after surgery, the patient underwent re-operation for abdominal wall haematoma and haemoperitoneum, and in the bed of the cystectomy there was a diffuse haematoma, which was evacuated. A surgical drain was placed prior to closure, using a transparietal puncture, from inside the abdominal cavity, A significant jet of blood was observed coming from the puncture site and this ceased after application of several transfixion sutures. On the third day of the second post-operative period the patient presented with discomfort and swelling at the site of the puncture for the drain, where the haemostasis sutures were located. Examination revealed a painless compressible mass, some 2–3 cm in diameter, with a palpable thrill and audible systolic and diastolic bruits.

Ultrasound and CT were performed and were compatible with an image of a pseudoaneurysm contained in a haematoma of the right rectus muscle following puncture of the inferior epigastric artery. The patient was referred to our unit for further assessment of treatment.

Doppler ultrasound at our hospital demonstrated to-and-fro-like flow within the vascular structures and completed the diagnosis of a high-flow arteriovenous fistula inside the post-puncture pseudoaneurysm.

Arteriography was performed via the right femoral artery, revealing a hypertrophied inferior epigastric artery, with a 2 cm diameter pseudoaneurysm some 7 cm from the origin of the artery. Injection of contrast produced intense early filling of the epigastric vein from the pseudoaneurysm confirming the diagnosis of high-flow arteriovenous fistula (Figure 1). The epigastric artery was then selectively catheterized and then embolised, proximal and distal to the pseudoaneurysm, with coils of size 3 mm to 4 mm. A further arterial injection confirmed obliteration of the pseudoaneurysm with absence of any early venous filling (Figure 2), and Doppler ultrasound 24 h later confirmed the absence of any flow in the pseudoaneurysm.

View larger version (101K): [in this window] [in a new window]   Figure 1. Angiography shows the rapid filling of a pseudoaneurismal cavity (arrowhead) at the inferior epigastric artery and an arteriovenous fistula with blood flow to the iliac vein (arrow) through the inferior epigastric vein.

View larger version (75K): [in this window] [in a new window]   Figure 2. Coils (arrows) are shown occluding proximal and distal portions of inferior epigastric artery.

	Comments

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On reviewing the literature we found various causes for the occurrence of pseudoaneurysms of the inferior epigastric artery, all iatrogenic (abdominal retention sutures, paracentesis, peritoneal dialysis catheters), including a recent report of a fatality as a complication of inferior epigastric artery damage following percutaneous biopsy [5]. The case described here is also related to a surgical intervention, the placement of a drain, in which there also occurred a communication, via the pseudoaneurysm, between the inferior epigastric artery and vein, giving rise to an arteriovenous fistula.

Such a fistula may cause discomfort and the development of abdominal varices due to reflux of flow into tributaries of the epigastric vein and even more serious complications have been reported, such as cardiac overload [6].

Colour Doppler ultrasound can be diagnostic as it enables us to distinguish the different velocities and directions in the flows corresponding to arterial entrance and venous exit. This has led some authors to use ultrasound-guided compressive treatment to try to collapse and thrombose low-flow fistulas [6]. Also, percutaneous insertion of thrombin to obliterate the pseudoaneurysm has been reported [7]. We considered that the high flow associated with the arteriovenous fistula would have instigated successful thrombosis.

Arteriography allows confirmation of the diagnosis and treatment by embolisation of the pseudoaneurysm, distally and proximally, thus occluding the fistula even when the flow through the fistula is high. In conclusion, although successful surgical treatment of pseudoaneurysms with proximal and distal ligation of the inferior epigastric artery and evacuation of the pseudoaneurysm has been reported [1, 2, 4], we consider it more appropriate to attempt the radiological approach, as it is less invasive and also allows safe and efficient management of an associated arteriovenous fistula.

Received for publication June 17, 2002. Revision received August 21, 2002. Accepted for publication September 16, 2002.

	References

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1. Ello FV, Jun DB. False aneurysm of the inferior epigastric artery as a complication of abdominal retention sutures. Surgery 1973;74:460–1.[Medline]
2. Verbist J, Stillaert F, Dujardin P, Dewaele G. Pseudoaneurysm of the inferior epigastric artery. Acta Chir Belg 1997;97:196–8.[Medline]
3. Lam EY, McLafferty RB, Taylor Ll M Jr, Moneta GL, Edwards JM, Barton RE, et al. Inferior epigastric artery pseudoaneurysm: a complication of paracentesis. J Vasc Surg 1998;28:566–9.[CrossRef][Medline]
4. Werner M, Bernheim J, Witz M, Gritton Y, Savin H, Korzets Z. Pseudoaneurysm of the inferior epigastric artery: a rare complication of Tenckhoff catheter removal. Nephrol Dial Transplant 1999;14:1297–9.[Abstract/Free Full Text]
5. Todd AW. Inadvertent puncture of the inferior epigastric artery during needle biopsy with fatal outcome. Clin Radiol 2001;56:989–90.[CrossRef][Medline]
6. Hung M, Chang H, Cherng W. Diagnosis and ultrasond-guided compression of iatrogenic inferior epigastric arteriovenous fistula. J Med Ultrasound 1999;7:48–51.
7. Rothbarth LJ, Redmond PL, Kumpe DA. Percutaneous transhepatic treatment of a large intrahepatic aneurysm. AJR 1989;153:1077–8.[Free Full Text]

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