Department of Surgery, Creighton University School of Medicine, Omaha, Neb; Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.
Department of Surgery, Creighton University School of Medicine, Omaha, Neb.
J Vasc Surg. 2021 Mar;73(3):1087-1094.e8. doi: 10.1016/j.jvs.2020.08.138. Epub 2020 Sep 28.
Traumatic arteriovenous fistulas (AVFs) are rare. The vast majority occur secondary to penetrating injuries. High-output cardiac failure is a well-recognized serious complication of AVFs, associated with high morbidity and mortality. The objective of the present study was to identify predictors of heart failure (HF) in patients with traumatic AVF.
Both PubMed/MEDLINE (Ovid) and CINAHL were searched (up to June 2019) for studies reporting individual patient data on the clinical and demographic characteristics of patients with AVF secondary to penetrating trauma. Exclusion criteria were age <18 years, no specification of symptoms, a cranial, spinal, or cardiac AVF location, and an iatrogenic mechanism of injury. The present study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.
A total of 274 AVF patients from 15 case series and 177 case reports were included. The median age at presentation was 32 years (interquartile range, 24-43 years), 90% were men. The most frequent mechanisms of injury were stab wounds (43%) and gunshot wounds (32%). The AVF location was the abdomen (n = 86; 31%), lower limb (n = 79; 29%), neck (n = 61; 22%), thorax (n = 38; 14%), and upper limb (n = 10; 4%). Of the 274 patients, 35 (13%) had presented with HF and 239 (87%) with other symptoms. The risk of HF increased with an increased feeding artery diameter (P < .001). On univariate analysis, HF was significantly associated with a longer median time from injury to presentation with AVF (11.2 years vs 0.1 years; P < .001), older median age at presentation (43 years vs 31 years; P = .002), involvement of a large feeding artery (ie, aorta, pulmonary artery, subclavian artery, external iliac artery; 40% vs 13%; P < .001), shrapnel injuries (11% vs 2%; P = .011), and injuries to the trunk or lower limb (94% vs 71%; P = .004). After adjusting for clinical and demographic patient characteristics, involvement of a large feeding artery (odds ratio, 3.25; 95% confidence interval, 1.26-8.42; P = .015) and every 6 years of delay to presentation (odds ratio, 1.30; 95% confidence interval, 1.03-1.63; P = .026) remained independent predictors for HF.
HF occurs in a small but important fraction of traumatic AVF patients and develops after highly variable latency periods. Large feeding arteries and delayed presentation independently predicted HF in this cohort.
创伤性动静脉瘘（AVF）很少见。绝大多数继发于穿透性损伤。心输出量增加导致的心力衰竭是 AVF 的一种公认的严重并发症，与高发病率和死亡率相关。本研究旨在确定与创伤性 AVF 相关的心衰（HF）的预测因素。
检索了 PubMed/MEDLINE（Ovid）和 CINAHL（截至 2019 年 6 月）中有关穿透性创伤引起的 AVF 患者的临床和人口统计学特征的个体患者数据的研究。排除标准为年龄＜18 岁、无症状描述、颅、脊或心 AVF 位置和医源性损伤机制。本研究符合 PRISMA（系统评价和荟萃分析的首选报告项目）指南。
共纳入了来自 15 个病例系列和 177 个病例报告的 274 例 AVF 患者。发病时的中位年龄为 32 岁（四分位距，24-43 岁），90%为男性。最常见的损伤机制为刺伤（43%）和枪击伤（32%）。AVF 的位置为腹部（n=86；31%）、下肢（n=79；29%）、颈部（n=61；22%）、胸部（n=38；14%）和上肢（n=10；4%）。在 274 例患者中，35 例（13%）出现 HF，239 例（87%）出现其他症状。随着供血动脉直径的增加，HF 的风险增加（P＜.001）。单因素分析显示，HF 与从损伤到出现 AVF 的中位时间较长（11.2 年比 0.1 年；P＜.001）、发病时中位年龄较大（43 岁比 31 岁；P=0.002）、较大的供血动脉受累（即主动脉、肺动脉、锁骨下动脉、髂外动脉；40%比 13%；P＜.001）、弹片伤（11%比 2%；P=0.011）和躯干或下肢损伤（94%比 71%；P=0.004）显著相关。在调整了临床和人口统计学特征后，大供血动脉受累（比值比，3.25；95%置信区间，1.26-8.42；P=0.015）和每延迟 6 年就诊（比值比，1.30；95%置信区间，1.03-1.63；P=0.026）仍然是 HF 的独立预测因素。
HF 发生在一小部分但非常重要的创伤性 AVF 患者中，并且在高度可变的潜伏期后发展。大的供血动脉和延迟就诊独立预测了本队列中的 HF。
