A new approach for aortocaval fistula from ruptured abdominal aortic aneurysm. Balloon occlusion technique under echogram guidance

Contemporary uses of inferior vena cava balloon occlusion

The evolution of the hybrid operative environment has expanded the utility of inferior vena cava balloon occlusion (IVCBO) in contemporary surgical practice. First described in the management of acute decompensated heart failure and venous thromboembolism, IVCBO has been utilised in deployment of thoracic endoprosthesis, repair of aorto-caval fistula, management of inferior vena cava (IVC) tumour thrombus and abdominal IVC trauma. More recently, IVCBO has also been utilised as a therapeutic strategy to assist patients with reduced ejection fraction and exercise tolerance in the form of an implantable device. Here we present a narrative review of the physiological impact of IVCBO as well as its historical, contemporary and future uses. The contemporary utilisation of IVCBO is a novel example of employing endovascular technology in the hybrid operative environment; paramount for the modern vascular surgeon who is now increasingly involved in multi-disciplinary management of complex clinical presentations.

[Aorto-cava fistula complicating abdominal aorta aneurysm]

We report here a case of aorto-cava fistula complicating the rupture of a sub-renal aortic aneurysm into the inferior vena cava, which is a rare complication of aortic abdominal aneurysms with often-fatal outcome. Abdominal computed tomography with multi-planar reconstructions remains the firstline-imaging tool allowing positive diagnosis and preoperative planning. Treatment may be surgical or endovascular.

Endovascular Therapy of Spontaneous Aortocaval Fistulae Associated with Abdominal Aortic Aneurysms

We report a case of an abdominal aortic aneurysm (AAA) associated with an aortocaval fistula managed with endovascular techniques. The patient had a known AAA, and on the latest computed follow-up tomographic scan, evidence of fistulization between the aorta and the vena cava was suggested, which was later corroborated by standard contrast angiography. His comorbidities precluded an open repair, and this prompted consideration for an endovascular intervention. Successful exclusion of the AAA was performed, with no evidence of endoleaks or persistence of the fistula. The endovascular approach provides an efficacious alternative to traditional methods for repair of an aortocaval fistula, which is especially important in elderly patients with several comorbidities.

Aorto-left renal vein fistula caused by a ruptured abdominal aortic aneurysm

Retroaortic left renal vein is a malformation in which the left renal vein courses dorsal to the abdominal aorta. In patients with abdominal aortic aneurysm, an aorto-left renal vein fistula can form if the left renal vein is sandwiched between the aneurysm wall and lumbar vertebrae. The patient was an 84-year-old man with lower back pain. We performed a contrast-enhanced computed tomography (CT), although renal dysfunction was noted. The CT showed a ruptured juxta-renal abdominal aortic with aorto-left renal vein fistula. This clinical condition can cause severe renal dysfunction, in spite of which an enhanced contrasted CT scan would be extremely informative preoperatively.

Cause of a rare acute renal insufficiency: Rupture aortocaval fistula

Introduction

Abdominal aortic aneurysms can be complicated by some conditions and aortocaval fistula is one of them. Aortocaval fistula is an unusual entity.

Case Report

A male patient was admitted to the hospital for abdominal pain and leg oedema of three days duration. In addition, severe anuria was also noted. We determined a fistula from the right lateral wall of aneurysm to the distal of vena cava inferior. The aortocaval fistula was closed with pledged-reinforced 4/0 polypropylene suture in the aneurysmal wall. At the postoperative 10th day, he was discharged with normal renal function.

Discussion

After a long-term untreated fistula, right-sided heart failure, acute renal and hepatic insufficiency, deep vein thrombosis and pulmonary thrombo-embolism can be seen in these patients. Increased venous pressure should be the reason for decreased arterial flow results in renal insufficiency. Emergency intervention in these patients saves the patient’s life as well as prevents irreversible organ failure.

Percutaneous balloon occlusion of the inferior vena cava as an adjunct for treating ruptured type IV thoracoabdominal aneurysm and aortocaval fistula

Spontaneous aortocaval fistulas are rare and thoracoabdominal aneurysms eroding into the inferior vena cava are rarer still. We describe a patient who presented to our hospital with a fistula between a Type IV thoracoabdominal aneurysm and the inferior vena cava. Expanding endovascular capabilities of vascular surgeons enabled us to insert proximal and distal occluding balloon catheters into the vena cava which greatly minimized blood loss.

Spontaneous ilioiliac arteriovenous fistulas

A69-year-old previously healthy man came to the emergency room because of sudden pain in the right groin for 6 hours. He was in shock and had a tender pulsatile mass distally in the right iliac fossa. The creatinine level was in the normal range. Electrocardiography showed sinus tachycardia and normal P-waves, but no signs of myocardial ischaemia or ventricular hypertrophy. His systolic blood pressure was <70 mmHg. The central venous pressure was not measured. Emergency operation revealed a 6 × 8 cm right-sided common iliac aneurysm which had ruptured into the right common iliac vein and also retroperitoneally. A gigantic haematoma had formed in the mesentery of the small intestine and because of the tension from the haematoma the right kidney was separated from both the aorta and the inferior vena cava during dissection and retraction of the tissues. The left common iliac artery was also aneurysmatic and the aorta was ectatic. At operation an endoaneurysmal closure of the 2 cm long fistula was performed and a bifurcated aortoiliac bypass graft was inserted. The right kidney was removed. The patient lost 9 litres of blood during the operation which lasted 165 minutes. The patient died the day after the operation after anuria had developed.

Multiple aortocaval fistulas associated with a ruptured abdominal aneurysm in a patient with Ehlers-Danlos syndrome

Aortocaval fistula (ACF) is a rare complication of spontaneous abdominal aortic aneurysm (AAA) rupture, with an incidence of 2-4%. A unique case of ruptured AAA complicated by multiple aortovenous fistulas involving the inferior vena cava and left internal iliac vein is presented, and is the first published report of a patient with Ehlers-Danlos syndrome undergoing surgical treatment for an ACF.

Aortocaval fistula in ruptured aneurysms

OBJECTIVES

to study incidence, clinical presentation and problems in management of aortocaval fistula in our series.

DESIGN

retrospective study.

MATERIALS

during a seven-year period, 112 patients operated on for abdominal aortic aneurysm, including four patients with aortocaval fistula.

METHODS

standard repair of aortocaval fistula from inside the aneurysmal sac was the preferred operative technique.

RESULTS

the incidence of aortocaval fistula was 3.6%. Three cases were found incidentally during emergency surgery for ruptured aneurysms; the fourth case was an isolated aortocaval fistula associated with inferior vena cava thrombosis, diagnosed preoperatively by angiography. In this case, inferior vena cava ligation instead of standard aortocaval repair was performed.

CONCLUSIONS

Aortocaval fistulas, although rare, should be kept in mind, because clinical diagnosis is often difficult. Furthermore, unsuspected problems during repair may necessitate appropriate change in operative technique.

Acute renal impairment due to a primary aortocaval fistula is normalised after a successful operation

OBJECTIVES

To study renal function in patients with aortocaval fistula, before and after surgery.

DESIGN

Retrospective study.

MATERIAL AND METHODS

During the last 22 years nine male patients (median age 67, age range 50-72) with spontaneous aortocaval fistula in combination with AAA were operated upon. This constitutes 4% of the patients with ruptured AAA and 1.5% of all patients with AAA.

RESULTS

A preoperative diagnosis of aortocaval fistula was established in three of the nine cases. The medium duration of symptoms prior to surgery was 5 days (range 4 h-14 days). The fistula was combined with an extravasating ruptured AAA in only three patients. Seven of the patients had acute renal insufficiency, with creatinine levels of in median 292 mumol (IQR 218-342). Creatinine declined to 172 mumol/l (IQR 170-313) on the fifth postoperative day in uncomplicated cases and to 86 mumol at discharge. One patient died due to multi-organ failure, whereas the other left hospital well and alive with normal renal function.

CONCLUSION

Acute preoperative renal insufficiency due to an aortocaval fistula in patients with AAA is often due to venous congestion, and is normalised after successful surgery.