High-Output Heart Failure from A Decade-Old Traumatic AV Fistula: A Case Report

Chronic traumatic arteriovenous fistulas (AVFs) are uncommon but potentially devastating sequelae of penetrating vascular injuries. Persistent high-flow shunting can lead to progressive cardiopulmonary remodeling, pulmonary hypertension, atrial arrhythmias, and high-output heart failure (HOHF).

We report a 41-year-old male with a chronic high-flow AVF between the left mid-superficial femoral artery and superficial femoral vein secondary to a gunshot wound sustained over a decade prior. Initially managed nonoperatively and later lost to follow-up, he presented with HOHF, atrial fibrillation with rapid ventricular response, pulmonary hypertension. The fistula resulted in extensive venous dilation of the left thigh with marked proximal venous enlargement involving the iliac veins, inferior vena cava, and a large pelvic venous varix, consistent with chronic high-flow shunting. The maximum diameter of the left iliac vein measured 8.7 cm. Preoperative echocardiography demonstrated preserved ejection fraction (50-55%), biatrial enlargement, moderate tricuspid regurgitation, and elevated pulmonary artery pressures. He underwent planned endovascular repair with invasive hemodynamic monitoring, including right heart catheterization and intraoperative transesophageal echocardiography. Following fistula closure, pulmonary artery pressures decreased (33/20 mmHg to 22/15 mmHg) and cardiac output improved (14.9 L/min to 8.6 L/min). Postoperative recovery was uneventful with controlled hemodynamic management in the cardiovascular ICU. Four-month follow-up imaging showed significant reduction in iliac vein diameter (8.7 cm to 6.2 cm).

This case highlights the cardiovascular consequences of long-standing traumatic AVFs and underscores the importance of multidisciplinary planning and vigilant perioperative management. Notably, significant hemodynamic improvement can occur even after prolonged high-flow states, emphasizing the potential reversibility of cardiopulmonary remodeling with timely intervention.