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Diagnosis of Clinically Unsuspected Posttraumatic Arteriovenous Fistulas of the Pelvis Using CT Angiography

Jennifer K. Chen1, Pamela T. Johnson2 and Elliot K. Fishman2

1 Johns Hopkins University School of Medicine, Baltimore, MD 21287-0801.
2 Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline St., Rm. 3251, Baltimore, MD 21287.


Figure 1
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  		Fig. 1A —35-year-old man presented with swelling of left leg. CT angiography was ordered for evaluation of pelvic mass. Patient had history of gunshot wound to buttocks 14 years earlier. Axial contrast-enhanced arterial phase MDCT scan shows 11-cm venous varix (V) in pelvis displacing bladder (B) to right.

 

Figure 2
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  		Fig. 1B —35-year-old man presented with swelling of left leg. CT angiography was ordered for evaluation of pelvic mass. Patient had history of gunshot wound to buttocks 14 years earlier. Axial contrast-enhanced arterial phase MDCT scan obtained through upper thighs shows evidence of arteriovenous fistula with enlarged left femoral artery and vein and early filling of left femoral vein. Note mild enlargement of left upper thigh musculature (arrows).

 

Figure 3
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  		Fig. 1C —35-year-old man presented with swelling of left leg. CT angiography was ordered for evaluation of pelvic mass. Patient had history of gunshot wound to buttocks 14 years earlier. Three-dimensional reconstruction of arterial phase data set with volume rendering from anterior perspective depicts enlarged left femoral artery and vein, large venous varix (V) in pelvis, and early opacification of inferior vena cava (IVC) (arrow), all findings reflecting fistulous communication between left superficial femoral artery and vein.

 

Figure 4
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  		Fig. 1D —35-year-old man presented with swelling of left leg. CT angiography was ordered for evaluation of pelvic mass. Patient had history of gunshot wound to buttocks 14 years earlier. Left anterior oblique volume-rendered image elucidates connection (black arrow) of large pelvic varix (V) to left femoral vein. Early filling of IVC (white arrow) is noted.

 

Figure 5
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  		Fig. 1E —35-year-old man presented with swelling of left leg. CT angiography was ordered for evaluation of pelvic mass. Patient had history of gunshot wound to buttocks 14 years earlier. Anterior coronal volume-rendered reconstruction with bones edited from data set shows fistulous communication between femoral artery and vein (arrowheads), large venous varix (V) in pelvis, and early filling of IVC (arrow).

 

Figure 6
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  		Fig. 2A —44-year-old man was referred for CT after incidental detection of suspected right internal iliac artery arteriovenous (AV) fistula seen during performance of cerebral angiographic study. Pertinent history was pelvic fracture 20 years earlier. Axial contrast-enhanced arterial phase MDCT scan at S1 level shows evidence of hypertrophy of right gluteus medius (MED) muscle and, to lesser degree, right gluteus maximus muscle. Dilated pelvic veins are consistent with right internal iliac artery AV fistula.

 

Figure 7
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  		Fig. 2B —44-year-old man was referred for CT after incidental detection of suspected right internal iliac artery arteriovenous (AV) fistula seen during performance of cerebral angiographic study. Pertinent history was pelvic fracture 20 years earlier. Anterior coronal volume-rendered CT angiogram reveals enlargement of right internal iliac artery and vein and early filling of inferior vena cava (IVC) (arrow). Evidence of prior right acetabular fracture with extensive heterotopic bone is also shown.

 

Figure 8
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  		Fig. 2C —44-year-old man was referred for CT after incidental detection of suspected right internal iliac artery arteriovenous (AV) fistula seen during performance of cerebral angiographic study. Pertinent history was pelvic fracture 20 years earlier. Coronal volume-rendered CT angiogram from posterior orientation shows right-sided venous varicosity (arrowheads) due to internal iliac AV fistula and posttraumatic heterotopic bone on right. Bullet fragment (arrow) is seen in left buttocks. (Fig. 2 continues on next page)

 

Figure 9
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  		Fig. 2D —44-year-old man was referred for CT after incidental detection of suspected right internal iliac artery arteriovenous (AV) fistula seen during performance of cerebral angiographic study. Pertinent history was pelvic fracture 20 years earlier. Anterior oblique volume-rendered CT angiogram with bones edited from data set shows fistulous communication between internal iliac artery and vein and enlarged internal iliac artery, vein, and IVC (arrow).

 

Figure 10
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  		Fig. 2E —44-year-old man was referred for CT after incidental detection of suspected right internal iliac artery arteriovenous (AV) fistula seen during performance of cerebral angiographic study. Pertinent history was pelvic fracture 20 years earlier. Anterior oblique 3D reconstruction using maximum intensity projection shows right internal iliac AV fistulous communication and early filling of IVC (arrow).

 

Figure 11
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  		Fig. 2F —44-year-old man was referred for CT after incidental detection of suspected right internal iliac artery arteriovenous (AV) fistula seen during performance of cerebral angiographic study. Pertinent history was pelvic fracture 20 years earlier. Posterior coronal volume-rendered CT angiogram with overlying bone structures removed from image better defines site of communication of AV fistula. Early filling of IVC (arrow) is noted.

 

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