Traumatic aortorenal vein fistula: repair using total circulatory arrest.

Fistulas between the abdominal aorta and renal vein are exceedingly rare. Diagnostic delays are not unusual. Correction can be extremely difficult because of anatomical distortion and size of the arterialized veins. A young woman with such a fistula following a gunshot wound is presented. Four years following injury, the fistula was repaired successfully during intentional arrest of the circulation for 7 minutes. This was accomplished with deep hypothermia and cardiopulmonary bypass. No serious problems occurred during the operation. The patient tolerated the procedure well and has been relieved of her symptoms completely. Most patients with traumatic or spontaneous arteriovenous fistulas can be managed safely and effectively by conventional operative techniques. In selected situations, the risk of total circulatory arrest and deep hypothermia may be less than the risk of uncontrollable bleeding inherent in conventional techniques. Suggested indications for use of total circulatory arrest in vascular surgery are (1) inability to achieve vascular control by more conventional means, (2) massive distention of regional veins as occurrs in well established fistulas of the trunk, (3) one or more prior corrective attempts with use of conventional techniques, and (4) anticipated anatomical distortion and/or multiple abnormal vascular communications. This technique is a valuable approach to the correction of otherwise inoperable cardiovascular lesions.

Immediate assessment of vascular operations using segmental plethysmography.

Segmental plethysmography was used as a monitoring device during 156 direct vessel operations on the abdominal aorta and lower extremity vessels. Patency of distal vessels was assessed continuously and noninvasively before and during wound closure. A pulsatile response at wound closure was indicative of immediate and lasting patency in 94 per cent of extremities monitored. Plethysmographic detection of acute intraoperative occlusive phenomena allowed correction of such problems during the same procedure. The "chronic nonpulsatile" plethysmographic response, although not indicative of accidental occlusions in the majority of cases, portended a poor result, primarily on the basis of insufficient collateralization around pre-existing distal occlusive disease. Patients with such responses should be considered for additional efforts at revascularization. Segmental plethysmography is a reliable and objective method of immediate assessment of vascular patency and for prediction of long-term results.