An Unusual Case of Lung Collapse in a patient with Arteriovenous Fistula - Dr. Sanjiv Jasuja

1. AN UNUSUAL CASE OF LUNG COLLAPSE IN A PATIENT WITH ARTERIOVENOUS FISTULA
Jasuja S1, Sagar G1, Mahajan R 2, Gupta AK1
1Department of Nephrology, 2 Department of Vascular Surgery Indraprastha Apollo Hospitals, New Delhi, India.
Background: Arteriovenous fistula (AVF) for hemodialysis
can become hyperdynamic and have local or systemic
complications. We present a very unusual complication of
such an AVF.
Case Report: A 40-year-old male with End Stage Renal
Disease on maintenance hemodialysis for three years
presented with epistaxis, hemoptysis, accelerated
hypertension (HTN) and breathlessness.
Examination showed a well functioning radio-cephalic
arteriovenous fistula with swelling and palpable thrill in the
entire right arm. There were distended veins over chest
wall (Fig1& 2). He was managed with anterior nasal packing
and anti-hypertensive treatment. His condition deteriorated
and oxygen saturation dropped. Chest radiograph (CXR)
showed complete collapse of right lung (Fig 3). He was
intubated and ventilated. Bronchoscopy revealed bilateral
clots; right main bronchus was occluded. (Fig 4) Contrast
enhanced CT scan revealed an enhancing mass lesion
partially occluding the right main bronchus (Fig 5&6).
Angiogram was suggestive of a highly vascular lesion in
the right main bronchus fed by bronchial artery, with
bronchial artery to pulmonary vein fistula (Fig 7).
Vascular Doppler showed hugely increased flows in the AVF
& enormously dilated veins. There was no thrombosis or
stenosis. A possible link between hyper-dynamic AVF and
pulmonary arterio-venous fistulous communication was
considered.
The AVF was surgically ligated with resultant dramatic
decrease in swelling of the right arm. (Fig8) Repeat
bronchoscopy two days later showed no vascular tumor or
fresh bleed. Clot clearance and full expansion of the right
lung was achieved. CT pulmonary angiogram five days after
AVF ligature also showed fully expanded lung with no
evidence of any vascular communication (Fig9).
Conclusion: It appears that in addition to the aspiration of
epistaxis, the right lung collapsed due to a vascular pseudo-
tumor, the result of a bronchial artery to pulmonary vein fistulous
communication, latent fistulas, which are known to open in hyper
dynamic circulatory flows.
Fig 1
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Fig 2
Fig 3 Fig 4
Fig 5 Fig 6
Fig 7 Fig 8
Fig 9