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A 30 year old man with a stab wound to the right flank initially presented to another hospital. Haemodynamically unstable on admission he was taken directly to the operating room for laparotomy at which timehe was found to have a liaceration to the liver and the inferior vena cava (IVC). The liver injury was not bleeding and the anterior wall of the IVC was repaired. The haaemorrhage was controlled and the abdomen left open to avoid abdominal compartment syndrome. The patient was transferred to a tertiary centre for on-going care. On arrival a CT scan was performed:
An aortocaval fistula was apparent - the IVC is disrupted and there are areas of enhancement with a similar density to that of the aorta. There was a large left sided retroperitoneal haematoma with active haemorrhage within its substance. An angiogram was performed which demonstrated the aortocaval fistula and active haemorrhage.
The patient was taken back for a laparotomy. While the anterior wall of the IVC had been repaired there was also a large injury to the posterior IVC with laceration of the lumbar veins. The Posterior wall of the aorta was also disrupted with avulsion of two lumbar arteries. The aorta was controlled below the renals and the iliacs controlled distally. The IVC was exposed by completing a medial visceral rotation and controlled with direct pressure. There was significant bleeding from the lumbar veins. As a damage control procedure the IVC was ligated and the lumbar veins clipped. The posterior wall of the aorta was repaired and the lumbars transfixed. The abdomen was left open.
Left sided retroperitoneal haematoma
Ligated IVC (between tapes)
Post-traumatic arterio-venous fistula is somewhat of a misnomer. There is an injury to both artery and vein, surrounded by a haematoma. Blood leaking from the arterial injury follows the path of least resistance and flows into the vein. There is no defined track as in chronic conditions. The clinical course of this patient highlights the importance of following the injury track along its entire length and carefully examining the posterior wall of injured structures to identify through-and-through injuries.
Krishnasastry KV, Friedman SG, Deckoff SL, Doscher W 'Traumatic juxtarenal aortocaval fistula and pseudoaneurysm.' Ann Vasc Surg 1990;4:378-80
Linker RW, Crawford FA Jr, Rittenbury MS, Barton M 'Traumatic aortocaval fistula: case report.' J Trauma 1989;29:255-7
Rosenthal D, Atkins CP, Jerrius HS, Clark MD, Matsuura JH 'Diagnosis of aortocaval fistula by computed tomography.' Ann Vasc Surg 1998;12:86-7
trauma.org (7:8) August 2002