Delayed High Output Heart Failure due to Arteriovenous Fistula Complicated with Herniated Disc Surgery

Abstract

A 36-year-old male presented with progressive exertional dyspnea over months. Physical examination showed jugular venous distension, lung crecipitations, femoral bruit and pitting pedal edema. Echocardiogram showed a dilated right ventricle with severe pulmonary hypertension and a non collapsing inferior vena cava (IVC). On right heart catheterization, IVC oxygen saturation was noted at 92% suggesting arterial mixing; a computed tomography of the abdomen showed a fistula between the right common iliac artery to the right common iliac vein at L4 level and a massive IVC; this was linked to trauma from a disectomy done 16 years ago at L4–L5 level. Endovascular sealing with a 16 × 60 mm bifurcated stent graft (S & G Biotech, Seoul, Korea) was performed which led to complete resolution of the patient’s dyspnea. Iatrogenic vascular injury during lumbar disc surgery, although rare, can lead to high output cardiac failure developing over months to years.

Pulmonary hypertension and severe right heart failure following lumbar spinal surgery

“…In another case, a 36-year-old man had presented with progressive dyspnoea. 3 Imaging had resulted in a provisional diagnosis of PAH. On right heart catheterisation, high oxygen saturations in the IVC (92.3%) had prompted further imaging of the aorta, which demonstrated a fistula between right common iliac artery and right common iliac vein.…”

High output heart failure: A review of clinical status - epidemiology, pathophysiology, diagnosis, prognosis and clinical management

“…Clinical evidence of HF include typical cardiac symptoms of HF, physical signs and imaging findings. The common cardiac symptoms included progressive exertional dyspnoea, lower extremities oedema, pulmonary oedema, fatigue and general weakness while the common sings in physical examination included elevated jugular venous pressure, hepatojugular reflux, third heart sound (gallop rhythm), laterally displaced apical impulse and pulmonary crepitation [48][49][50][51][53][54][55][56][57][58][59][60][61][62][65][66][67][68]. Others are tachycardia, cardiomegaly, and cardiac murmur [48,51,53,59,63,68].…”

“…In patients with high-output HF secondary to systemic AVF and cardiac symptoms refractory to maximal medical therapy, treatment focuses on either endovascular or surgical removal of AVF. Endovascular therapy was safe and efficacious in cardiac symptomatic resolution and normalization of cardiac output in high-output HF secondary to iatrogenic AVF [63,66] and scalp congenital haemangiomas [68]. In cases where fistulas were too large for endovascular closure, surgical removal was effective.…”

Morphometric analysis of the lumbar vertebrae and intervertebral discs in relation to abdominal aorta: CT-based study

“…In spine procedures, posterior lumbar disc surgery is the most performed. It is considered a safe and effective treatment of herniated discs; nevertheless, the possibility of vascular injury is still considered as a potential and serious complication of lumbar spine surgery [3,4,10,11,14,17,20,[22][23][24]. One of the most dangerous and usually fatal early complications is retroperitoneal haemorrhage resulting in haemorrhagic shock [10,22,24].…”

“…One of the most dangerous and usually fatal early complications is retroperitoneal haemorrhage resulting in haemorrhagic shock [ 10 , 22 , 24 ]. Furthermore, the diagnosis of late complications including arteriovenous fistula or pseudoaneurysm can be established even years after the operation when the patients may develop high-output heart failure or pulmonary hypertension [ 14 , 20 , 23 , 27 ]. The location of iatrogenic laceration is most commonly placed at the L4-L5 level [ 3 , 22 ].…”