rapidly restore the blood-pressure there seems little doubt that immediate exploration of the great vessels is the only measure which gives the patient any hope of survival.Thirteen cases (including 2 described in this paper) of arteriovenous fistula following an operation for prolapsed intervertebral disk have now been described in the literature. In 3 cases the records do not give any account of the symptoms and signs which followed the disk operation. In 3 cases there seems to have been no indication of bleeding at the time of the operation, but in the other 7 there was either moderate external bleeding, severe surgical shock, or both.Early post-operative signs that an arteriovenous fistula has resulted include ileus and interference with micturition. Deep abdominal tenderness and the development of a murmur and thrill were noted early in nearly all cases.The time of onset of cardiac failure was variable and presumably depended on the size of the shunt and the amount of cardiac reserve. It may come on as early as a week after the operation or be delayed for some years. In a number of cases the onset of cardiac failure was the first sign that an arteriovenous fistula had resulted from the disk operation.
TREATMFiNTOperations directed to treatment of the fistula have been done at varying times, but the 2 cases described here are the earliest (7 days) and latest (7 years) after a disk operation that have been recorded.The onset of cardiac failure is a clear indication that closure of the fistula is an urgent necessity.One patient died during investigation and 4 were treated by ligature operations to exclude the fistula. There is no doubt that ligature of the common iliac artery above and below a fistula will result in little impairment of circulation to the corresponding foot as the collateral circulation is excellent, and in all the cases in which this was done a good result was recorded. Ligature or thrombosis of the iliac vein, however, is likely to be followed by Edema of the leg, which may be troublesome.In the 8 further cases reconstructive operations were performed, though in 3 of these it was necessary to introduce an arterial graft. Excellent results followed in all the recorded cases in which this was done.
SUMlMARYIt is possible to damage the great vessels during an operation for prolapsed intervertebral disk, and the ease with which the accident may happen is emphasized.The previously reported cases have been reviewed and z additional cases are described.I wish to express my thanks to Dr. D. H. Davies who diagnosed Case 2 and referred the patient to me.
