Travma sonrasý geliþen arteriyovenöz fistüllerin tedavisi: Üçüncü basamak akademik merkez deneyimi

AMAÇ: Bu çalýþmada, kardiyoloji ünitemizde gerçekleþtirilen endovasküler tedavide baþarýsýz olan, travmatik arteriovenöz fistüllü (AVF) hastalarda cerrahi deneyimimizi sunmayý amaçladýk.
GEREÇ VE YÖNTEM: Eylül 2014–Mayýs 2016 tarihleri arasýnda travmatik AVF’si olan toplam 27 hasta ameliyat edildi. Yaralanma yeri, cerrahi zamanlamasý ve kullanýlan cerrahi yöntemler geriye dönük olarak incelendi.
BULGULAR: Arteriyovenöz fistüller alt ekstremitede 26 hastada (%96.29), üst ekstremitede tek bir olguda (%3.7) bulundu. Etiyolojik faktörler 23 hastada (%85.18) ateþli silah yaralanmasý ve dört hastada (%14.81) penetran yaralanma idi. Alt ekstremitedeki AVF’ler, 21 hastada popliteal arter ve ven arasýnda, beþ hastada femoral arter ile ven arasýnda idi. Üst ekstremite AVF’li tek olguda brakiyal arter ve sefalik ven arasýnda iletiþim vardý. Cerrahi onarým için ligasyondan sonra arter ve venin primer onarýmý, arteriyel greft interpozisyon artý primer ven tamiri ve arteryal ve venöz greft interpozisyonu iki, beþ ve 20 hastada gerçekleþtirildi. Tüm olgularda safen ven greft olarak kullanýldý.
TARTIÞMA: Majör vasküler yapýlarýn yakýnýnda penetran travmalara maruz kalan hastalarda oskültasyon ile birlikte ayrýntýlý öykü alma ve fizik muayene yapýlmalýdýr. Arteriyovenöz fistüller cerrahi olarak veya endovasküler giriþimle (kaplý stent greft veya embolizasyon) tedavi edilebilir. Son yaklaþým, daha düþük komplikasyon oranlarý, prosedürün invaziv olmayan doðasý ve hastane içi maliyetlerin azalmasý ve iþ verimliliðinde azalma temel alýnarak ilk tercih yönetimini temsil edebilir. Bununla birlikte hemodinamik olarak kararsýz, endovasküler tedavi için uygulanabilir olmayan veya endovasküler tedavinin baþarýsýz olduðu hastalarýn önemli bir bölümünde ameliyat kaçýnýlmazdýr.

Management of traumatic arteriovenous fistulas: A tertiary academic center experience

BACKGROUND: To present the surgical experience at a tertiary academic center of treating patients with traumatic arteriovenous fistulas (AVFs) who in whom endovascular treatment was contraindicated or in whom unsuccessful endovascular treatment had been performed.
METHODS: A total of 27 patients with traumatic AVFs who underwent surgery between September 2014 and May 2016 were included. The site of injury, timing of surgery, and the surgical methods utilized were analyzed retrospectively.
RESULTS: Arteriovenous fistulas were located in the lower extremity in 26 patients (96.29%) and in the upper extremity in one patient (3.7%). Etiological factors included gunshot injuries in 23 patients (85.18%) and penetrating injury in four patients (14.81%). AVFs in the lower extremity were between the popliteal artery and vein in 21 patients and between the femoral artery and vein in five patients. The one patient with upper-extremity AVF had a communication between the brachial artery and cephalic vein. Primary repair of the artery and vein after ligation, arterial graft interposition plus primary vein repair, and arterial and venous graft interposition were performed for surgical repair in two, five, and 20 patients, respectively. The saphenous vein was used for grafting in all cases needing grafts.
CONCLUSION: In patients enduring penetrating trauma in the close vicinity of major vascular structures, a detailed history-taking and physical examination should be performed along with auscultation. The endovascular approach may represent the initial choice of management because of its lower rate of complications, noninvasive nature, decreased in-hospital costs, and decreased loss of work productivity. However, surgery is still unavoidable option in a significant proportion of patients who are either hemodynamically unstable, contraindicated for endovascular treatment, or in whom endovascular treatment was unsuccessful.