Pulmonary Hypertension Secondary to a Remote Gunshot Wound
CCCF ePoster library. Veldhoen R. Nov 9, 2018; 233403
Disclosure(s): No relevant disclosures.
Dr. Richard Veldhoen
Dr. Richard Veldhoen
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Abstract
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Introduction/Background



Arteriovenous fistula (AVF) is a known complication of penetrating trauma[1]. Here we present a patient with longstanding traumatic AVF eventually causing pulmonary hypertension (PH). Traumatic AVF is a rare etiology of PH, that may resolve with surgical ligation.



Summary



A 58-year-old man presented to hospital with a gunshot wound to the right buttock. Bowel/bladder repair and bullet extraction from the left thigh were performed emergently. Contrast enhanced CT showed stranding near the left common femoral artery and vein, with suspicion of pseudoaneurysm. Post surgical recovery was gradual and he was discharged home one month later.



Ultrasound imaging of his left leg was performed one-year post presentation due to subacute onset of leg swelling. Angiography confirmed a large, complex fistula between his left  profunda femoral artery and common femoral vein. Repair was deferred in the absence of severe symptoms due to his medical comorbidities. He was referred to cardiology approximately 6.5 years after his initial presentation due to transthoracic echocardiogram (TTE) evidence of PH with a pulmonary artery systolic pressure (PASP) of 68mmHg (see Table 1 for summary and Figure 1 for representative images). Subsequent workup for alternative causes of pulmonary hypertension was negative aside from moderate obstructive sleep apnea (OSA).



Despite OSA treatment his estimated PASP increased (Table 1) and his left leg swelling worsened. His functional status worsened to WHO class II. After consultation, vascular surgery decided to ligate his proximal left profunda fistula, leaving distal branches of the AVF patent due to massive venous dilation and concern for subsequent hemostasis and thrombosis. Pre-operative left heart catheterization revealed mild, non-obstructive coronary artery disease. Right heart catheterization (RHC) confirmed PH and showed a very high cardiac output (CO, Table 2). Ligation was performed successfully. His post surgery RHC showed a reduction in CO, and small decrease in the mean pulmonary artery pressure (mPAP, Table 2). He recovered uneventfully and was followed in both the vascular surgery and PH clinics.



His left leg swelling showed gradual improvement over six months followed by significant worsening and TTE showed that his PASP remained elevated. Angiography showed enlargement

of the distal fistula, so a complete closure was performed. Three months after final closure of the fistula his TTE showed decrease in PASP and decrease in the size of his right ventricular inflow tract. His six minute walk test improved from 363m (73% predicted) to 448m (87% predicted) and his functional class improved from WHO class II to WHO class I.



Discussion



PH is a rare complication of traumatic AVF, and AVFs may rarely present decades after the inciting injury[1]. A similar mechanism is attributed to cardiomyopathy associated with dialysis AVFs, which may also require surgical repair[2]. Given that high flow AVFs may lead to high output heart failure and PH, it is important for clinicians to recognize this potentially reversible

etiology[3]. Our patient showed severely elevated PASP, worsening RV dilation, and worsening left heart function that was found to be reversible with surgical ligation. In patients with traumatic AVF who develop exercise limitation, with or without signs of right heart failure, clinicians should have a high index of suspicion for the development of PH and consider correction of the AVF.


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