TRAUMATIC ARTERIOVENOUS-FISTULA - EXPERIENCE WITH 202 PATIENTS

Experience with the management of 202 patients with 210 traumatic arte riovenous fistulas is reported. Penetrating trauma accounted for 98 pe r cent of injuries caused mainly by stabs (63 per cent) and missile wo unds (26 per cent). Seven of 15 patients with shotgun wounds had multi ple lesions. Over half of all fistulas occurred in the cervicomediasti nal vessels; abdominal and thoracic vessels were infrequently involved . The upper limbs were involved in 22 per cent and the lower limbs in 20 per cent. Some 133 patients were diagnosed and treated within 1 wee k of injury; 69 presented 1 week to 12 years later. Machinery murmur w as noted in 61 per cent of the early presenters, but was an almost uni versal finding in those presenting late. Only three patients had cardi ac failure and all had underlying cardiomyopathy. Active overt haemorr hage was not common. Arterial continuity was restored in 80 per cent o f cases, usually by autogenous reconstruction. Venous injury was usual ly treated by ligation or lateral suture. Patients treated within 1 we ek of injury had a lower rate of perioperative mortality and morbidity than those treated late, due mainly to technical difficulties in cont rolling the vessels caused by fibrosis and massive venous dilatation. If a policy of selective exploration of penetrating trauma is to be fo llowed, careful assessment for arteriovenous fistula must be made and the patient evaluated at regular intervals for several months. Shotgun injuries require routine angiography at the time of presentation. The earlier treatment is instituted, the better the results.