Systemic-Pulmonary Arteriovenous Fistula Following Closed-Tube Thoracotomy

Abstract

Systemic-pulmonary vascular anastomoses have been described associated with congenital heart and great vessel disease, congenital arteriovenous fistulae of the thoracic wall (4, 9), pulmonary arteriovenous fistulae with acquired thoracic wall attachments (1, 8), trauma and inflammation (2, 3, 5–7), and with neoplasia (3). Systemic-pulmonary arteriovenous fistula following insertion of a chest tube has not, however, been recorded in the literature. Our recently encountered case emphasizes the angiographic demonstration of such a lesion with an unusual etiology (post-tube thoracostomy). A review of the literature has revealed only 1 other traumatically induced systemic-pulmonary arteriovenous fistula, and 8 other related cases. Case Report Present Illness: H. A., a 39-year-old Caucasian male, was found on routine physical examination to have a Grade II systolic murmur in the right parasternal area. The patient's history disclosed a spontaneous pneumothorax on the right side one and one-half years previously with 50 per cent collapse of the lung. Treatment consisted of a closed-tube thoracotomy in the third right anterior intercostal space. The lung expanded well, and follow-up examinations showed the patient to be asymptomatic. Physical Examination: Positive physical findings included a soft, predominantly systolic bruit which carried over into diastole, heard over the right anterior chest wall, and a healed surgical scar 3 cm in length over the third right intercostal space. There was no evidence of cyanosis, clubbing of fingers and toes, or polycythemia. Laboratory Data: The patient's complete blood count, arterial oxygen studies, and blood volume were normal. X-ray Findings: The postero-anterior chest film demonstrated an ill-defined density in the right third anterior interspace (site of closed-tube thoracotomy). The lateral view revealed an ill-defined retrosternal density with linear radiating markings. Because of the above findings, right brachial arteriography was performed (Figs. 1 and 2), which demonstrated a fistula in the right anterior chest wall at the level of the third anterior intercostal space. This fistula was fed by large tortuous intercostal artery collaterals originating from the lateral thoracic and thoracoacromial branches of the right artery and anterior intercostal branches of the internal mammary artery. A second injection in the oblique position (Fig. 3) confirmed the presence of the fistula in the anterior chest wall with drainage into the right superior pulmonary vein. Substantiating evidence that the run-off was into the pulmonary vein was obtained later by pulmonary angiography (Fig. 4). This study demonstrated that the arteriovenous fistula was not draining via the pulmonary arterial system. Surgical Findings: At the time of surgical correction, a large adhesion of the right upper lobe was seen.