Traumatic Peri-Renal AV Fistula Presenting with Pulmonary Hypertension and Right-Side Heart Failure Chun-Cheng Wang, 1 Yu-Shien Ko, 1,3 Tsu-Shiu Hsu, 1 Kee-Min Yeow 2 and Chi-Tai Kuo 1 We describe a 47-year-old male patient who presented with symptomatic pulmonary hypertension in association with traumatic peri-renal arteriovenous (AV) fistulae. He developed symptoms and clinical evidence of pulmonary hypertension, and high-output right heart failure long after a left flank stabbing injury 16 years ago. Numerous AV fistulae were illustrated around the atrophic left kidney by spiral computed tomography. Although acquired systemic AVfistula has been implied in the substrates of pulmonary hypertension, association with traumatic AV fistula in the peri-renal region has not been reported previously. Key Words: Traumatic AV fistula · Pulmonary Hypertension · Right-side heart failure CASE REPORT A 47-year-old male was admitted to Chang-Gung Memorial Hospital for slowly progressive exertional dyspnea, orthopnea, bilateral leg edema, ascites and jaundice over 3 years. He had a history of laparotomy for a left flank stabbing injury 16 years before. Another operation for intestinal adhesion was performed 4 years later. At presentation, he sat with a pulsating internal jugular vein rising up to the mandible angle. Also, a pal- pable right ventricular heave, a loud P2 and a GrIII/VI pansystolic murmur at the left sternal border were heard. The abdomen was distended with shifting dullness indic- ative of ascites, and both legs were edematous. Further- more, a continuous bruit was heard over the left para- umbilical area. The electrocardiogram showed atrial fi- brillation with right ventricular hypertrophy. The trans- thoracic echocardiography revealed moderate tricuspid regurgitation (pressure gradient 52 mmHg) and pulmo- nary hypertension, and the left ventricular ejection frac- tion was 83%. The pulmonary function test and lung ventilation-perfusion scan results were both unremark- able. Initially the contrast-enhanced abdominal com- puted tomographic angiography and magnetic resonance angiography (MRA) revealed a high-flow arteriovenous shunting originated from the left renal area with marked engorgement of the left renal vein (36 mm wide) and in- ferior vena cava (IVC) (40 mm wide) (Figure 1). Subse- quently, dynamic abdominal spiral computed tomogra- phy (spiral CT) with 3D volume rendering confirmed numerous arteriovenous (AV) fistulae around the atro- phic left kidney. Feeding arteries with mild to moderate dilation came from the splenic artery, the left renal ar- tery, translumbar arteries and the renal capsular branch of the left inferior phrenic artery (Figure 2). Cardiac catheterization demonstrated a step-up of oxygen satura- tion from the low (77%) to high IVC (92%) level, a high cardiac output (8.62 L/min, index 5.7 L/min/m 2 ) and moderate pulmonary hypertension (pulmonary artery pressure, 69/26 mm Hg, mean 40 mm Hg). Due to com- plexity of the high-flow AV fistulae associated with 209 Acta Cardiol Sin 2008;24:209-11 Case Report Acta Cardiol Sin 2008;24:209-11 Received: January 8, 2008 Accepted: March 3, 2008 1 First Cardiovascular Division, Department of Internal Medicine; 2 Department of Imaging and Intervention; 3 College of Medicine, Chang Gung University, Chang-Gung Memorial Hospital, Taoyuan, Taiwan. Address correspondence and reprint requests to: Dr. Tsu-Shiu Hsu, First Cardiovascular Division, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, Taiwan. Tel: 886-3-328-1200 ext 2313; Fax: 886-3-327-1192; E-mail: tshsu@cgmh.org.tw