RENAL ARTERIOVENOUS FISTULA

FOLLOWING NEPHRECTOMY

MICHEL LACOMBE, M .D .

From the Consultation de Chirurgie, Hopital Beaujon,Paris, France

ABSTRACT-Three cases of postnephrectomy renal arteriovenous fistula are described . A reviewof the literature shows the rarity of this complication since only 62 cases (including the author'scases) are known . Reported cases have been recognized after intervals up to forty years . The majorcomplication is cardiac failure . Surgical treatment gives satisfactory results, but nonsurgical closurehas now become possible . Early diagnosis is easy by auscultation of the loin which constantly re-veals a continuous bruit .

Arteriovenous fistula of the renal vessels is anuncommon complication of nephrectomy .From the first report by Hollingsworth in1934,' to the present, 60 cases have been re-ported in the world literature. The increasingnumber of published cases during recent yearsprompted us to report our experience and to re-view the literature on this subject .

We analyzed previous clinical reports of arte-riovenous fistula of the renal vessels afternephrectomy and added our personal cases toform the basis of this report. The 60 previouslyreported cases include one of ours' (present Case1) which will be summarized briefly. Our 2 newcases increase the total number published in theworld literature to 62 .

Case ReportsCase 1

A fifty-four-year-old woman had undergoneright nephrectomy for tuberculosis at the age oftwenty-seven and was admitted because of as-thenia and intermittent lumbar pain . Clinicalexamination revealed a thrill and a continuousbruit in the right flank and lumbar fossa. Aor-tography showed the renal artery filling the re-nal vein through a multilocular aneurysm withimmediate filling of the inferior vena cava (Fig .1) . Cardiovascular repercussions were minimal :

UROLOGY / JANUARY 1985 / VOLUME XXV, NUMBER 1

blood pressure was 140/70 mm Hg, chest x-rayfilm and electrocardiogram (ECG) were nor-mal despite a cardiac output of 6 .45 L/min,

At operation, the fistula was totally excised .The blood flow through it, measured with anelectromagnetic flowmeter, reached 1,800 ml/min. After operation, the cardiac outputdropped to 4 .3 L/min . Her postoperative coursewas uneventful .

Case 2

A fifty-seven-year-old woman was admittedbecause of cardiac palpitations and a moderatehypertensive tendency. She had undergone leftnephrectomy for renal carcinoma two yearsearlier.

Clinical examination revealed a continuousleft lumbar bruit, a blood pressure of 170/100mm Hg, and a hyperdynamic apical impulse inthe fifth left intercostal space . The ECC dem-onstrated a sinus rhythm with some extrasys-toles . Aortography revealed a communicationbetween the left renal artery and vein (Fig . 2) ;there was no abnormal vascular network sug-gesting local recurrence of the tumor.

At operation, the fistula was totally excised .No recurrent malignancy was present. Herpostoperative course was uneventful, with dis-appearance of all symptoms .

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FIGURE 1 . Case 1 . Abdominal angiogram showingabnormal communication between right renal ar-tery and vein through multilocular aneurysm .

TABLE I . Causes of primary nephrectomy

Case 3

A forty-one-year-old man was admitted witha history of atypical epigastric and right flankpain . He had had a right nephrectomy forlithiasis twenty-one years earlier . Clinical ex-amination revealed a grade 3/6 midsystolicmurmur in the apical area ; the aorta wasstrongly pulsating in the epigastrium with acontinuous bruit at its level, irradiating in theright flank and loin . Blood pressure was 130/80mm Hg . ECG showed sinus rhythm . Aortog-raphy revealed a communication between theright renal artery and vein through a false an-eurysm 25 mm in diameter (Fig . 3) .

At operation, the fistula was excised with itsafferent and efferent vessels . All symptoms dis-appeared after operation .

Material and Methods

The number of published cases ofpostnephrectomy arteriovenous fistula has been

FIGURE 2 . Case 2. Abdominal angiogram showingleft renal arteriovenous fistula .

FICURE 3 . Case 3 . Abdominal angiogram showingarteriovenous fistula of right renal vessels throughlarge aneurysm .

increasing during recent years, with 31 of 62(50%) having been reported since 1970 .

Both sexes were affected with equal fre-quency : 32 women, 29 men, 1 unknown. Meanage of the patients was forty-nine years .

Table I shows the reasons for performingnephrectomy. Among these, infectious (tuber-culosis, pyonephrosis) or possibly infected le-sions (lithiasis, pyelonephritis) represent 50 percent of the cases .

The right side was involved in 44 cases(72%); 17 fistulas were on the left side, and 1was unknown . This localization can be ex-plained by the shortness of the renal vascularpedicle whose ligation may be difficult .

Technical difficulties during nephrectomywere often noted. Frequently, ligation of thepedicle and local hemostasis were difficult toachieve, requiring local tamponning in 1 case,leaving forceps in place in another, and reinter-vention in a third .

Cause Number

Renal tuberculosis 16Hydronephrosis 11Lithiasis 10Other causes of renal destruction 7

(pyonephrosis, pyelonephritis,cystinosis, diabetes)

Lesions of the ureter 5(stenosis, fistula, operative trauma)

Traumatic rupture of kidney 4Renal carcinoma 4Renal cyst IUnknown 4

To7AL 62

TABLE II . Clinical data in 62 patients

Mode of ligation of the pedicle was an impor-tant causative factor. In 14 cases where this de-tail was given, mass ligation was performedtwelve times, and of these, transfixing sutureswere used in 3 cases ; separate ligation of thevessels was reported only twice .

Infection is another factor strongly impli-cated in the genesis of these fistulas, infectiouslesions being a frequent indication for thenephrectomy (Table I) . Moreover, in 4 casespostoperative sepsis occurred . Infectious ulcera-tion of the vessels thus seems to play a role in alarge percentage of cases .

Clinical manifestations were slight but long-lasting, and the recognition of the fistula wasoften delayed. The interval between nephrec-tomy and discovery of the fistula extends fromfive months to forty years, with a mean of fif-teen years .

Clinical findings are listed in Table II . Thediagnostic value of the continuous abdominalor lumbar bruit appears paramount since it wasfound in all but 3 cases .

Cardiac symptoms were especially frequent,occurring in two thirds of the patients . Cardiacrepercussions have two characteristic features :(1) they appear after a long interval (mean : 18years) ; and (2) they are usually relieved by theclosure of the abdominal communication .

Bacterial endarteritis at the site of the fistulawas reported in 4 cases and cured in all casesafter excision of the arteriovenous communica-tion .

Arterial hypertension was present in 17 cases .Closure of the fistula resulted in cure in only 10cases, suggesting that the fistula is not alwaysresponsible for the elevated blood pressure .Moreover, Brandt's 3 patient became hyperten-sive after closure of the fistula .

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Plain abdominal x-ray films and/or intrave-nous pyelography revealed calcifications at thesite of the fistula in 9 cases (15%) . The remain-ing kidney was hypertrophic in most cases .

Aortography was performed in the majorityof patients; only 7 (11 %), mostly first reportedcases, had no aortography, for various reasons :fear of rupture of the aneurysm, emergency sur-gery, fortuitous operative discovery of the fis-tula .

Hemodynamic investigations were done in 14patients. In all cases, increased cardiac outputand cardiac index were noted ; the highest out-put was observed in Ekestrom's4 patient with 21L/min . Increase in right heart pressures wascommonly observed . Peripheral resistances de-creased . Oxymetric studies constantly showedincreased oxygen content at the inferior venacava . Closure of the fistula was remarkably ef-ficient in reducing all hemodynamic changes .

Treatment and ResultsFifty-six patients were operated on . Closure

of the fistula was achieved by ligation or sectionand suture of the afferent artery (ies) (8 cases),ligation of the artery and vein (8 cases), excisionof the fistula with afferent and efferent vessels(35 cases) ; the technique is unknown in 5 cases .One postoperative death occurred (1 .8%) :Muller's patients died of myocardial infarctsixty hours after the operation . In nearly allcases favorable results were observed : localsymptoms disappeared, and cardiac failure wasfavorably affected . Nevertheless, in Elkin'scase,0 cardiac failure and arterial hypertensionremained unchanged, in Brandt's case' arterialhypertension appeared after operation, as men-tioned before, and 6 other patients remainedhypertensive .

Two patients received no treatment . One pa-tient refused operation' and another' was notoperated on because of a malignant tumor ofthe contralateral kidney and good tolerance tothe fistula .

Four patients had closure of their fistulas bynonsurgical means. Thrombosis of the fistula bymeans of an inflatable balloon left in place forfour days was done in one ." Embolization withGianturco stainless steel coils was done in 2 .9 10

In all cases closure of the fistula was confirmedby angiography.

CommentArtcriovenous fistulas occurring after

nephrectomy appear to be rare, considering the

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Clinical DataNo. ofPatients

Local signsAbdominal or lumbar pain 15Pulsating mass 6Continuous bruit 59Thrill 19

Cardiovascular symptomsArrhythmias 4Cardiomegaly without failure 17Cardiac failure 23Arterial hypertension 17Bacterial endarteritis 4

Fortuitous discovery 10

number of nephrectomies performed . The in-frequency of symptoms over long periods oftime and the prolonged tolerance to the condi-tion in numerous cases may well indicate that itcould be more frequent than usually thoughtand that some cases are unrecognized . Earlydiagnosis can preclude an evolution toward car-diac failure . Since fortuitous discovery of thefistula was not rare (16% of cases), we suggestthat auscultation of the lumbar fossa should bea routine part of follow-up in every nephrec-tomized patient .

As early as 1923 Holman 11 observed that theabnormal communication produces a left-to-right shunt with selective perfusion of a vascu-lar bed with low resistances, Increased cardiacoutput is a compensatory mechanism for thesteal of arterial blood toward the venous systemand for the increased venous return to the rightheart . Cardiac output rises because of increasedheart rate and stroke volume . The increasedwork load affects both ventricles and leads tocardiomegaly both through hypertrophy of thewall and through dilatation of the cavities . Intime, this situation evolves toward cardiacfailure, but the tolerance of the heart to the fis-tula is extremely long in spite of its high outputand of its situation on vessels neighboring theheart .

The steal of arterial blood into a low-pressuresystem accounts for the frequency of blood pres-sure abnormalities : the diastolic pressure tendsto fall and the pulse pressure widens . But rela-tionships between the fistula and the presenceof arterial hypertension are not always clear.Arterial steal through the fistula may impairblood flow to the remaining kidney with ensu-ing renal ischemia, but this mechanism is notalways responsible for arterial hypertensionsince closure of the fistula does not constantlyrelieve it . In these latter cases, associated essen-tial hypertension or lesions of the remainingkidney are possible causative factors . There isno satisfactory explanation for hypertension ap-pearing after closure of the fistula .

The treatment must accomplish closure ofthe arteriovenous communication . Until recentyears, surgery was the only treatment availa-ble. For patients who were a satisfactory opera-tive risk, it gave satisfying results in most cases .

With the development of embolization tech-niques, nonsurgical closure of such fistulas hasbeen considered . As we have seen, 4 successfulcases have been reported so far . The major ob-jections to embolization techniques are : (1) the

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risk of cardiac and pulmonary migration of thematerial because of the large size of the com-munication ; this precludes the use of small par-ticulate matter (e .g ., Gelfoam, autologousclot) . In this respect, the technique using an in-flatable balloon which can be removed appearsless risky than embolization techniques ; (2) thechronic toxicity of tissue adhesives in an unre-solved question as noted by White et al . ; 12 (3)whether or not such closure will be completeand definitive,

For the present time, the safest treatment ap-pears to be surgical, and we still consider sur-gery as the treatment of choice . Because of theaforementioned risks, we would advise nonsur-gical techniques only for patients whose generalcondition and cardiac status are poor and rep-resent a high operative risk . But, should betterand more innocuous embolization materials be-come available in the future, nonsurgical clo-sure will gain a wide place in treatment of thesefistulas .

Whatever the treatment, prolonged delay inrecognition and treatment of the fistula can befollowed by incomplete hemodynamic im-provement and only moderate decrease in heartsize, This underlines the importance of earlydiagnosis which is possible by simple clinical ex-amination.

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References

1 . Hollingsworth EH : Arteriovenous fistula of the renal ves-sels, Am J Med Sci 188 : 399 (1934) .

2. Lacombe M, Nussaumc 0, Bronstein M, and Jungers P: Lesfistules arterio-veineuses do pedicule renal apres nephrectomie,Ann Chir Thorac Cardiovasc 12 : 91 (1973) .

3. Brandt JL: Hypertension following closure of a post-nephrectomy arteriovenous fistula : a case report and hypothesis,Can Med Assoc J 89: 405 (1963),

4. Ekestrom S, Karnell J Retamal E, and Rosenhamer G : Ar-teriovenous fistula post-nephrectomy : clinical aspects and surgicalrepair, Scand J Thorac Cardiovasc Surg 2 : 39 (1963) .

5. Muller WE, and Goodwin WE : Renal arteriovenous fistulafollowing nephrectomy, Ann Surg 144 : 240 (1956) .

6. Elkin DC : Aneurysms following surgical procedures . Reportof five cases, ibid 127 : 769 (1948) .

7. Chew QT. and Madavag MA : Post-nephreetomy arteriove-nous fistula, J Urol 109 : .546 (1973) .

8 . Plagued EG, Glickman MG, and Pais SO : Balloon-inducedthrombosis of renal arteriovenous fistula, AJR 134 : 605 (1980) .

9. Castaneda-Zuniga WR, et ad : Nonsurgical closure of largearteriovenous fistulas, JAMA 236 : 2649 (1976) .

10 . Keller FS, et al : Percutaneous angiographic embolization :a procedure of increasing usefulness, Am J Surg 142 : 5 (1981) .

11 . Holman EF: Physiology of an arteriovenous fistula, ArchSurg 7 : 64 (1923) .

12. White RI Jr, Strandherg JV, Gross CS, and Barth KH :Therapeutic embolization with long-term occluding agents andtheir effects an embolized tissues . Radiology 125 : 677 (1977) .

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