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Dakis K, Nana P, Kouvelos G, Behrendt CA, Kölbel T, Giannoukas A, Spanos K. Treatment of Aortocaval Fistula Secondary to Abdominal Aortic Aneurysm: A Systematic Review. Ann Vasc Surg 2023; 90:204-217. [PMID: 36496094 DOI: 10.1016/j.avsg.2022.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Aortocaval fistula (ACF) secondary to an abdominal aortic aneurysm is a rare complication, inadvertently caused by a rupture into the inferior vena cava. Different treatment modalities have been applied toward the repair of such lesions, including open surgical and endovascular repair. The aim of this study was to report on ACF treatment and to analyze its early and mid-term outcomes. METHODS A systematic search of the English medical literature published between 2000 and 2022 was undertaken, using PubMed, SCOPUS, and CENTRAL databases as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. A study protocol was registered in PROSPERO (CRD42022329058). Studies reporting on primary ACF outcomes following open surgical or endovascular repair were included. The ROBINS-I tool was applied for risk of bias assessment. Outcomes included technical success, 30-day and mid-term survival, endoleak following endovascular repair, and reintervention rates. RESULTS In total, 110 case studies, incorporating 196 patients (mean age; 66.2 years, males 96%) were included. Open surgical repair was applied in 78% (153/196). From the available data, technical success rate for each modality was 99% (152/153) and 100% (43/43), respectively. Open and endovascular repair demonstrated 87.5% (126/144) and 97.6% (42/43) 30-day survival, respectively, while mid-term survival was 86% (74/86) and 95.2% (20/21), respectively (medial follow-up: 14 months [1-54 months]). Endoleaks were reported in 19 endovascular cases (39.5%). Type II endoleak was the most frequent with a rate at 32.5% (14/43). Reintervention rates were 2.5% (4/151) and 35.7% (15/42) for open and endovascular repair, respectively. CONCLUSIONS Only few case studies were published on the treatment of this rare condition, while almost all invasive procedures were performed in males. Management of ACF repair with both open and endovascular approach was associated with excellent technical success rate and acceptable early and mid-term survival outcomes. Reintervention remained an issue for patients who were managed endovascularly.
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Affiliation(s)
- Konstantinos Dakis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Petroula Nana
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christian-Alexander Behrendt
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Athanasios Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Novel Utility of Amplatzer Septal Occlusion Device to Treat Persistent Aortocaval Fistula following Ruptured Endovascular Aortic Aneurysm Repair (rEVAR). Ann Vasc Surg 2019; 65:283.e7-283.e11. [PMID: 31678543 DOI: 10.1016/j.avsg.2019.10.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 09/02/2019] [Accepted: 10/19/2019] [Indexed: 11/20/2022]
Abstract
Aortocaval fistulas following endovascular repair of ruptured abdominal aortic aneurysms (rAAA) are rare. We herein describe repair using an Amplatzer Septal Occluder in a 68-year-old male who presented to the emergency department 6 months after ruptured endovascular aneurysm repair (rEVAR) with right heart failure. With the assistance of diagnostic angiography and intravascular ultrasound, the patient was found to have a 1.2 cm diameter aortocaval fistula and a type-II endoleak. His aortocaval fistula was successfully closed using an Amplatzer septal occluder device after failure of attempted closure with an Amplatzer plug and coiling of the aneurysm sac. His symptoms of heart failure improved, and he was discharged to an acute rehabilitation unit. Follow-up at 3 months demonstrated continued improvement in heart failure symptoms, and a small persistent type II endoleak. Aortocaval fistulae are a potentially fatal complication of rAAA. We discuss the sequelae and treatment strategies of aortocaval fistulas following rEVAR including the use of the Amplatzer Septal Occluder.
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3
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Open Surgery and Endovascular Techniques in Treatment of Acute Abdominal Arteriovenous Fistulas. Ann Vasc Surg 2019; 61:427-433. [PMID: 31207397 DOI: 10.1016/j.avsg.2019.03.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/19/2019] [Accepted: 03/26/2019] [Indexed: 11/21/2022]
Abstract
Acute abdominal arteriovenous fistulas in the setting of ruptured abdominal aortic aneurysms are a life-threatening condition; thus, a prompt diagnosis is required for proper treatment. Open, endovascular, and hybrid repair have been proposed for their management, with pros and cons for each method. In particular, the evolution of endoluminal techniques guarantees an increasing feasibility of these procedures, and a significant reduction in morbidity and mortality rates was usually associated with open surgery. Nevertheless, some concerns still remain regarding the midterm and long-term follow-up. The aim of this article was to review and compare the reported clinical and technical results of conventional open surgery and endoluminal techniques in this scenario and to report the case of an acute aorto-iliac fistula due to a ruptured common iliac artery aneurysm into the iliac vein that was managed by endovascular repair at our institution.
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Wang Y, Yu W, Li Y, Wang H. Emergent Endovascular Repair of Challenging Aortocaval Fistula With Hostile Anatomy. Vasc Endovascular Surg 2017; 51:255-260. [PMID: 28486843 DOI: 10.1177/1538574417701323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortocaval fistula (ACF) is a rare complication. Endovascular repair is an option for this fatal condition. However, endoleak and persistent fistula may occur and lead to technical failure. We performed endovascular repair for 3 cases of challenging ACF with hostile anatomy. Patient 1 was an 80-year-old man who complained of abdominal distension and lower limb edema for 15 days. He had renal and cardiac dysfunction. Computed tomography angiography (CTA) showed an ACF and extreme tortuosity of right iliac artery. The super-stiff guidewire could not pass the right iliac artery. We performed endovascular repair and an occluder was used to block the right external iliac artery. Postoperative CTA showed migration of the occluder, and we ligated the right external iliac artery. The patient survived for 5 years. Patient 2 was a 78-year-old man who complained of an acute abdominal pain for 30 hours. Computed tomography angiography showed great neck angulation (63.3°) and a huge aneurysm (9.9 cm in diameter). A type 1A endoleak occurred and an aortic cuff was deployed at the proximal seal zone. Meanwhile, a type 3 endoleak occurred because of the migration and detachment of the left iliac limb. Another stent-graft was deployed to connect the iliac limb. The patient was followed up for 1 year and remained in a good condition. Patient 3 was a 74-year-old man who experienced severe abdominal pain for 1 day. Computed tomography angiography showed great neck angulation (66°) and a huge aneurysm (10.1 cm in diameter). A type 1A endoleak occurred, and an aortic cuff was deployed at the proximal seal zone. The patient was followed up for 6 months. In conclusion, ACF is a rare but a fatal condition. Acute cases and chronic cases with instable hemodynamics need urgent diagnosis and surgical intervention. Endovascular repair is an efficacious alternative to the traditional open repair.
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Affiliation(s)
- Yuewei Wang
- 1 Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenjuan Yu
- 2 Department of Pathology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yongxin Li
- 1 Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haofu Wang
- 1 Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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5
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Zhou W, Bush RL, Terramani TT, Lin PH, Lumsden AB. Treatment Options of Iatrogenic Pelvic Vein Injuries: Conventional Operative Versus Endovascular Approach. Vasc Endovascular Surg 2016; 38:569-73. [PMID: 15592639 DOI: 10.1177/153857440403800612] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Iatrogenic injury to the iliac vein or inferior vena cava (IVC), which may occur during abdominal operations or posterior orthopedic procedures, can have devastating consequences. Operative management is challenging and may be associated with significant morbidity. The authors report herein 3 cases of iatrogenic pelvic vein injuries that were managed with different treatment approaches. Both traditional open surgical therapy and endovascular techniques are described.
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Affiliation(s)
- Wei Zhou
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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6
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Larzon T, Jansson H, Holmström B, Lund P, Norgren L, Arfvidsson B, Berggren L, Nydahl A, Eriksson T, Jonsson T, Stenberg B. Salvage of an Acutely Ruptured Thoracic Aortic Aneurysm during CPR. J Endovasc Ther 2016. [DOI: 10.1177/15266028020090s211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To report the successful endovascular treatment of a ruptured thoracic aortic aneurysm during cardiopulmonary resuscitation. Case Report: A 72-year-old woman with a type B aortic dissection treated conservatively for 8 years was referred for rupture of a 16-cm aneurysm of the descending thoracic aorta. During transfer to the operating room, the patient suffered cardiac arrest; cardiopulmonary resuscitation (CPR) was initiated. A few minutes later during CPR, the surgical procedure began with a cutdown of the right femoral artery and insertion of a guidewire and an aortic occlusion balloon, which was inflated at the origin of the left subclavian artery (LSA). Blood pressure was immediately measurable. By only partially deflating the occluding balloon, a thoracic stent-graft was advanced above it and deployed at the origin of the LSA while rapidly deflating and retracting the occluding balloon. Three stent-grafts were required to cover 27 cm of the descending aorta. The patient was partly ventilator dependent for 3 months due to a massive pleural hematoma that was not evacuated. At the 10-month follow-up, the patient is fully recovered without any sign of respiratory dysfunction or any other sequela. CT scans reveal that the massive hematoma is almost completely resolved. Conclusions: This case illustrates that optimal collaboration between anesthesiologists, interventional radiologists, and vascular surgeons with appropriate resources can significantly expand the possibilities of emergent treatment in the face of aortic rupture.
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Affiliation(s)
| | - Håkan Jansson
- Department of Radiology, Örebro University Hospital, Orebro, Sweden
| | - Björn Holmström
- Department of Anesthesiology, Örebro University Hospital, Orebro, Sweden
| | - Philip Lund
- Department of Anesthesiology, Örebro University Hospital, Orebro, Sweden
| | | | | | - Lars Berggren
- Department of Anesthesiology, Örebro University Hospital, Orebro, Sweden
| | - Anders Nydahl
- Department of Anesthesiology, Örebro University Hospital, Orebro, Sweden
| | - Tomas Eriksson
- Department of Radiology, Örebro University Hospital, Orebro, Sweden
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7
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Leon LR, Arslan B, Ley E, Labropoulos N. Endovascular Therapy of Spontaneous Aortocaval Fistulae Associated with Abdominal Aortic Aneurysms. Vascular 2016; 15:35-40. [PMID: 17382053 DOI: 10.2310/6670.2007.00011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Luis R Leon
- Department of Vascular Surgery, Southern Arizona Veterans' Affairs Health Care System, 3601 South 6th Avenue, Tucson, AZ 85723, USA.
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8
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Orion KC, Beaulieu RJ, Black JH. Aortocaval Fistula: Is Endovascular Repair the Preferred Solution? Ann Vasc Surg 2016; 31:221-8. [PMID: 26597238 PMCID: PMC4860718 DOI: 10.1016/j.avsg.2015.09.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/26/2015] [Accepted: 09/07/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND To compare outcomes of open and endovascular repair of aortocaval fistulas (ACFs) in the setting of abdominal aortic aneurysms (AAAs). METHODS A literature review was undertaken on Pubmed from 1999 to 2014 to identify reported cases of both endovascular and open repair of ACF, including the index case, presented here. Primary outcomes for endovascular repair were: complications, presence of endoleak, and death. Primary outcomes for open repair were: complications and death. RESULTS Forty articles were reviewed with a total of 67 patients, including the index case. Endovascular approach was used in 26 patients (39%). Endoleaks were present in 50%, whereas similarly 46% of patients had a reported complication. Five deaths (19%) occurred in the endovascular group. Open repair was performed in 41 cases (61%). The rate of complication and the death in open repair were 36% and 12%, respectively (P = 0.327 and P = 0.910, respectively) compared with endovascular. Mean follow-up was 7.7 months for the endovascular group and 8.5 months in the open group. CONCLUSIONS Previous demonstrations of high morbidity and mortality with open repair of ACF in the setting of AAA have motivated endovascular approaches. However, endoleaks are a significant problem and were present in 50% of ACF cases. The continued presence of an endoleak in the setting of an ACF may result in persistence of the ACF, unlikely thrombosis of the endoleak, and continued sac enlargement. Endovascular repair presents theoretical benefit, yet is not associated with a reduced rate of complication or death versus open repair in this contemporary review.
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Affiliation(s)
| | - Robert J Beaulieu
- Department of General Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - James H Black
- Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD.
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9
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Abstract
Purpose: To review the different outcomes of the endovascular repair of major abdominal arteriovenous fistulas (AVFs). Methods: An online systematic review of the literature was undertaken to identify all reported cases of endovascular repair of major AVFs, covering 9 major databases as well as relevant journals up to September 2013. Our own case was included. The primary outcome was technical success and mortality, the secondary outcome was the rate of complications and the operators’ recommendations. Results: Forty-eight articles were reviewed totaling a number of 54 patients including our own. The most common fistula site was the aortocaval segment. Aortic stent grafts were used in 78% of patients. Technical success was 94%. Intraoperative mortality was 0% with a 90-day mortality of 10%, half of which were not related to the primary pathology. Of the successful procedures, 12% of patients had major complications. One died before reintervention. All others had uneventful recoveries; 21% had minor complications treated conservatively. The majority of authors were in favor of this treatment modality.
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10
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Madani A, Leung S, Obrand D. Open repair of inflammatory abdominal aortic aneurysm and aortocaval fistula using retrograde balloon occlusion. Vasc Endovascular Surg 2013; 48:80-2. [PMID: 24142957 DOI: 10.1177/1538574413508828] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this report is to describe a novel endovascular technique used to minimize blood loss during the open repair of an aortocaval fistula (ACF) in the context of an inflammatory abdominal aortic aneurysm (AAA). CASE REPORT We describe a patient who presented to our hospital with a symptomatic infrarenal AAA which was discovered intraoperatively to contain a large ACF. The patient underwent successful transperitoneal open repair of the AAA with balloon occlusion of the inferior vena cava to obtain distal control of the vessel. CONCLUSIONS Retrograde balloon occlusion of the inferior vena cava can be used to control hemorrhage during the open repair of an ACF, especially in the challenging setting of an inflammatory AAA.
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Affiliation(s)
- Amin Madani
- 1Division of General Surgery, McGill University Health Center, Montreal, Quebec, Canada
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11
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van de Luijtgaarden KM, Bastos Gonçalves F, Rouwet EV, Hendriks JM, ten Raa S, Verhagen HJ. Conservative management of persistent aortocaval fistula after endovascular aortic repair. J Vasc Surg 2013; 58:1080-3. [DOI: 10.1016/j.jvs.2012.10.138] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 10/10/2012] [Accepted: 10/14/2012] [Indexed: 10/27/2022]
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Janczak D, Chabowski M, Szydelko T, Garcarek J. Endovascular exclusion of a large spontaneous aortocaval fistula in a patient with a ruptured aortic aneurysm. Vascular 2013; 22:202-5. [DOI: 10.1177/1708538113478749] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A primary aortocaval fistula (ACF) is present in less than 1% of all abdominal aortic aneurysms (AAA). The case of a 62-year-old patient with a ruptured AAA and ACF was reported. A stent-graft was implanted into the abdominal aorta. An inferior vena cava filter was inserted to prevent pulmonary embolism. The patient made a smooth recovery. The follow-up computed tomographic scan three months later did not reveal any evidence of endoleaks or that the fistula was still present. Hemodynamic changes with regard to transient acute liver impairment were discovered (renal and liver parameters were presented). Endovascular exclusion appears to be an effective option in the treatment of an aortocaval fistula in comparison to conventional open repair.
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Affiliation(s)
- Dariusz Janczak
- Surgery Department, 4th Military Teaching Hospital, 5 Weigla Street, 50-981 Wroclaw, Poland
- Department of Clinical Proceedings, Faculty of Health Science, Medical University Wroclaw, 50-367 Wroclaw, Poland
| | - Mariusz Chabowski
- Surgery Department, 4th Military Teaching Hospital, 5 Weigla Street, 50-981 Wroclaw, Poland
| | - Tomasz Szydelko
- Surgery Department, 4th Military Teaching Hospital, 5 Weigla Street, 50-981 Wroclaw, Poland
| | - Jerzy Garcarek
- Surgery Department, 4th Military Teaching Hospital, 5 Weigla Street, 50-981 Wroclaw, Poland
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Rapacciuolo A, De Angelis MC, di Pietro E, Puglia R, Di Tommaso E, Ruggiero D, Amato B, Iannelli G. Percutaneous treatment of a aorto-caval fistula in a old high risk patient. BMC Surg 2012; 12 Suppl 1:S32. [PMID: 23173555 PMCID: PMC3499279 DOI: 10.1186/1471-2482-12-s1-s32] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background To remark the feasibility of endovascular treatment of an aorto-caval fistula in a old high risk patient with “hostile” abdomen for previous surgeries. Methods In September 2009 a 81-years-old patient was admitted in emergency at our department because of abdominal pain and massive oedema of the lower extremities associated to dyspnoea (New York Heart Association (NYHA) functional class III). A CT scan showed an aorto-caval fistula involving the abdominal aorta below the renal arteries. This abnormal communication was likely due to the previous abdominal surgeries, was complicated by occlusion of the inferior vena cava at the diaphragm and was responsible for the massive oedema of the lower extremities. Because of unstable conditions and hostile abdomen the patient was considered unfit for conventional surgery and an endovascular approach was planned. After unsuccessful attempt by positioning of an Amplatzer vascular ring into the fistula, a Medtronic covered stent-grafts were implanted from the renal arteries to the both common iliac arteries. The patient had an impressive improvement characterized by a 18 Kg weight loss and a complete restoration of the functional capacity (from NYHA class III to NYHA class I) associated to a complete resolution of the lower extremities oedema as confirmed at the a month-CT-scan. Conclusion Endovascular surgery of aorto-caval fistula represents a good option in alternative to conventional surgery mostly in old high risk patient.
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Affiliation(s)
- Antonio Rapacciuolo
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Federico II University of Naples, Italy
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Akwei S, Altaf N, Tennant W, MacSweeney S, Braithwaite B. Emergency endovascular repair of aortocaval fistula--a single center experience. Vasc Endovascular Surg 2011; 45:442-6. [PMID: 21571773 DOI: 10.1177/1538574411407087] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To review the outcomes of patients undergoing emergency endovascular repair of aortocaval fistula (ACF) secondary to abdominal aortic aneurysm (AAA). CASE REPORT Four consecutive patients who underwent emergency endovascular repair of ACF associated with AAA in a tertiary institution between 2002 and 2009. Of the 4 patients, 3 had initially been misdiagnosed and managed for several days by other specialists for their symptoms prior to diagnosis of their ACF. Three patients died in the early postoperative period. The fourth patient made a satisfactory postoperative recovery but subsequently required further endovascular surgery to treat a persistent type 1 endoleak. CONCLUSIONS Our experience illustrates the importance of early diagnosis and management of ACF. Even in experienced hands, the management of spontaneous ACF associated with AAA is challenging. Endovascular surgery may still have a role in improving outcomes in these patients.
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Antoniou GA, Koutsias S, Karathanos C, Sfyroeras GS, Vretzakis G, Giannoukas AD. Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review. J Endovasc Ther 2009; 16:514-23. [PMID: 19702345 DOI: 10.1583/09-2725.1] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the outcomes of endovascular stent-graft repair of major abdominal arteriovenous fistulas. METHODS The English literature was systematically searched using the MEDLINE electronic database up to January 2009. All reports on endovascular stent-graft repair of major abdominal arteriovenous fistula were considered. Our experience of abdominal arteriovenous fistula was involved in the data analysis. The primary outcome measures were technical success and perioperative, 30-day, and overall mortality. RESULTS Data for the final analysis were extracted from 21 papers reporting on 22 patients and from the medical records of a patient treated at our institution. The most common causal associations of these fistulae were the presence of an aortoiliac aneurysm and previous endovascular aneurysm repair, accounting for 56% and 13% of all associations, respectively. The technical success rate was 96% (22/23). No perioperative or 30-day mortality was noticed during a mean follow-up of 9 months. The most common procedure-related complication was type II endoleak, which was found in 22% (5/23) of the patients. This event was either self limiting or required minimal percutaneous intervention. CONCLUSION Endovascular stent-graft repair of major abdominal arteriovenous fistula is a safe and effective treatment option, with good short- and midterm results. However, no long-term data exist, and larger series are required to draw solid conclusions regarding the outcomes of this method.
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Affiliation(s)
- George A Antoniou
- Departments of Vascular Surgery, University of Thessaly Medical School, Larissa, Greece
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Guzzardi G, Fossaceca R, Divenuto I, Musiani A, Brustia P, Carriero A. Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula. Cardiovasc Intervent Radiol 2009; 33:853-6. [PMID: 19572169 DOI: 10.1007/s00270-009-9640-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 06/01/2009] [Accepted: 06/08/2009] [Indexed: 11/29/2022]
Affiliation(s)
- Giuseppe Guzzardi
- Institute of Interventional Radiology, Maggiore della Carità Hospital, Corso Mazzini 18, 28100 Novara, Italy.
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Aorto-caval fistula from acute rupture of an abdominal aortic aneurysm treated with a hybrid approach. J Vasc Surg 2009; 49:1574-6. [DOI: 10.1016/j.jvs.2008.12.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 12/29/2008] [Accepted: 12/30/2008] [Indexed: 11/20/2022]
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Endovascular Treatment of Ruptured Abdominal Aneurysm into the Inferior Vena Cava in Patient After Stent Graft Placement. Cardiovasc Intervent Radiol 2009; 32:776-80. [DOI: 10.1007/s00270-009-9525-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 12/08/2008] [Accepted: 01/16/2009] [Indexed: 11/30/2022]
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19
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Anesthetic management of a patient with aortocaval fistula. J Anesth 2009; 23:111-4. [DOI: 10.1007/s00540-008-0711-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 10/17/2008] [Indexed: 12/11/2022]
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20
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Clevert DA, Stickel M, Flach P, Strautz T, Horng A, Jauch KW, Reiser M. Contrast-enhanced ultrasound in detection and follow-up of an infrarenal abdominal aortic aneurysm with aorto-caval fistula and endovascular treatment. Cardiovasc Intervent Radiol 2007; 30:480-4. [PMID: 17205366 DOI: 10.1007/s00270-006-0143-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
An aorto-caval fistula is a rare complication of a symptomatic or ruptured infrarenal aortic aneurysm having a frequency of 3-6%. Patients typically present with clinical signs of diffuse abdominal pain associated with increasing venous congestion and tachycardia, rapid cardiopulmonary decompensation with acute dyspnea, and an audible machinerylike bruit. Perioperative mortality is high, ranging from 20% to 60%. We report a case of an endovascular aortic repair in a patient with a symptomatic infrarenal aortic aneurysm and an aorto-caval fistula. Contrast-enhanced ultrasound seems to be a promising new diagnostic option for the diagnosis and preoperative treatment planning for patients with abdominal aortic aneurysms with rupture into the inferior vena cava. It is in addition to computed tomography angiography. It might allow a more rapid and noninvasive diagnosis, especially for patients in intensive care because of its bedside availability. Because the examination is dynamic, additional information about blood flow between the aorta and inferior cava vein can be evaluated.
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Affiliation(s)
- D-A Clevert
- Department of Clinical Radiology, University of Munich-Grosshadern Campus, Munich, Germany.
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21
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Pinto DM, Bez LG, Dias Júnior JO, Lopes CDS, Mandil A. Aneurisma ilíaco associado a fístula arteriovenosa. J Vasc Bras 2007. [DOI: 10.1590/s1677-54492007000300016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A ruptura dos aneurismas aorto-ilíacos para a veia ilíaca ou veia cava é uma complicação pouco comum. A hipertensão venosa leva a vários sinais e sintomas, o que dificulta o diagnóstico pré-operatório, tais como edema do membro inferior, dispnéia, hematúria, sinais de insuficiência renal ou cardíaca. Sopro abdominal é a chave do diagnóstico clínico, associado à massa pulsátil e dor abdominal. O reconhecimento da fístula arteriovenosa no pré-operatório é importante para o planejamento cirúrgico. Relatamos um caso de aneurisma da artéria ilíaca comum e interna direita associado a fístula para veia ilíaca comum, cursando, inicialmente, com edema do membro inferior direito e dispnéia, o que levou ao diagnóstico incorreto de trombose venosa profunda.
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22
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Kopp R, Weidenhagen R, Hoffmann R, Waggershauser T, Meimarakis G, Andrassy J, Clevert D, Czerner S, Jauch KW. Immediate Endovascular Treatment of an Aortoiliac Aneurysm Ruptured into the Inferior Vena Cava. Ann Vasc Surg 2006; 20:525-8. [PMID: 16732443 DOI: 10.1007/s10016-006-9061-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Revised: 07/12/2005] [Accepted: 02/27/2006] [Indexed: 05/09/2023]
Abstract
An aortocaval fistula is a severe complication of an aortoiliac aneurysm, usually associated with high perioperative morbidity and mortality during open operative repair. We describe the successful endovascular treatment of a symptomatic infrarenal aortic aneurysm ruptured into the inferior vena cava with secondary interventional coiling of a persistent type II endoleak because of retrograde perfusion of the inferior mesenteric artery. Endovascular exclusion of ruptured abdominal aneurysms seems to be a valuable treatment option for selected patients even with complicated vascular conditions like an aortocaval fistula.
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Affiliation(s)
- Reinhard Kopp
- Department of Surgery, Klinikum Grosshadern, University of Munich, Munich, Germany.
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23
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Vetrhus M, McWilliams R, Tan CK, Brennan J, Gilling-Smith G, Harris PL. Endovascular repair of abdominal aortic aneurysms with aortocaval fistula. Eur J Vasc Endovasc Surg 2005; 30:640-3. [PMID: 16168683 DOI: 10.1016/j.ejvs.2005.07.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 07/16/2005] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To examine the risk of high-flow type II endoleak following endovascular repair of abdominal aortic aneurysm with aortocaval fistula. DESIGN Case reports. SUBJECTS Two patients with abdominal aortic aneurysms with aortocaval fistula. METHODS Both patients had an endovascular repair of their aortic aneurysms. RESULTS The aneurysms were successfully treated in both patients, without any endoleak on completion angiography. Apart from a transient type II lumbar endoleak in one of the patients, no endoleak was found after 3 and 12 month follow-up. Seven other cases have been published, reporting one type II and one type Ic endoleak. CONCLUSION We found no evidence that endovascular repair of abdominal aortic aneurysm with aortocaval fistula is associated with a higher incidence of persistent endoleak.
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Affiliation(s)
- M Vetrhus
- Regional Vascular unit, Royal Liverpool, University Hospital, Liverpool, UK.
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24
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Ferrari M, Berchiolli R, Sardella SG, Cioni R, Petruzzi P, Del Corso A, Di Mitri R, Croce C, Romagnani F, Adami D, Mosca F. Endovascular Repair of an Aorto–Left Renal Vein Fistula Due to a Ruptured Abdominal Aortic Aneurysm After EVAR. J Endovasc Ther 2005; 12:512-5. [PMID: 16048385 DOI: 10.1583/05-1554.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To report an unusual late complication of endovascular aneurysm repair: an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein following sac expansion due to a type III endoleak. CASE REPORT A 79-year-old man developed an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein 67 months after endovascular aneurysm exclusion (EVAR). Aneurysm rupture was due to disconnection between the right iliac limb and an extender cuff. The problem was repaired percutaneously with another endograft bridging the two prostheses. At 16 months, the aneurysm sac diameter was decreased; there was no evidence of the AV fistula, and the patient was free from any complication related to the EVAR. CONCLUSIONS This case emphasizes the need of close surveillance even in the late postoperative course of these patients. Moreover, this rare event confirmed that endovascular techniques can play an important role in treating emergent complications.
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Affiliation(s)
- Mauro Ferrari
- Unit of Vascular Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
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25
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Waldrop JL, Dart BW, Barker DE. Endovascular Stent Graft Treatment of a Traumatic Aortocaval Fistula. Ann Vasc Surg 2005; 19:562-5. [PMID: 15981116 DOI: 10.1007/s10016-005-5025-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Aortocaval fistula (ACF) is an infrequently reported sequela of trauma. Most ACF have been repaired via an open approach. During the past 10 years, there has been one reported case of spontaneous ACF and two cases of traumatic ACF repaired using an endovascular technique. We present a third case of traumatic ACF repaired with an endovascular stent graft. A 40-year-old male sustained two gunshot wounds to the right chest and one to the right upper abdomen. He was taken from the emergency department directly to the operating room, where an exploratory laparotomy was performed. Through-and-through injuries to the stomach and transverse colon were repaired primarily. Subsequently, the patient developed abdominal compartment syndrome. An urgent exploratory laparotomy was performed, revealing a nonbleeding hematoma on the posterior lateral surface of the right lobe of the liver, which was left undisturbed. Open abdominal management was instituted with vacuum pack closure. On the nineteenth hospital day, the patient again had a significant decrease in hematocrit. An aortogram was performed in order to evaluate the patient for intrahepatic arterial bleeding amenable to transcatheter embolization. There was no evidence of hepatic arterial bleeding. However, a supraceliac ACF was identified. The patient was taken to the operating room, and an AneuRx aortic extension cuff was advanced under fluoroscopy and deployed to cover the fistula. Completion angiography revealed total obliteration of the ACF and appropriate placement of the stent graft. Postoperatively, the patient was returned to the intensive care unit, where his hospital course was complicated by ventilator-associated pneumonia and sepsis. Repeat computed tomographic scanning 6 months and 1 year following this repair demonstrated patency of the graft without evidence of graft migration or aortocaval communication. Further research and experience are necessary with this technique regarding long-term outcome and technical aspects. In particular, the sizing problems associated with repair of acute traumatic ACF in emergency situations should be addressed. The endovascular approach provides an attractive and exciting alternative to traditional methods for repair of ACF.
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Affiliation(s)
- Jimmy L Waldrop
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, Tennessee 37403, USA
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26
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Hinchliffe RJ, Braithwaite BD, Hopkinson BR. The endovascular management of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2003; 25:191-201. [PMID: 12623329 DOI: 10.1053/ejvs.2002.1846] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Endovascular aneurysm repair (EVAR) is a controversial technique, which remains the subject of a number of prospective randomised trials. Although questions remain regarding its long-term durability objective evidence exists which demonstrates its reduced physiological impact compared with conventional open repair. If this technique could be used in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. A review of the literature identified a limited experience with EVAR of ruptured AAA. Only a small number of case series with selected patients exist. The majority of patients were haemodynamically stable. However, the selective use of aortic occlusion balloons allowed successful endovascular management in a small number of unstable cases. All investigators had access to an "off the shelf" endovascular stent-graft (EVG). Per-operative mortality ranged from 9 to 45% and may reflect increasing experience and patient selection. A number of patients who underwent successful EVAR were turned down for open repair. A number of important lessons have been learned from these studies but questions remain regarding patient suitability and staffing issues. If these difficulties can be surmounted then the technique may offer an alternative to open repair.
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27
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Duxbury MS, Wells IP, Roobottom C, Marshall A, Lambert AW. Endovascular repair of spontaneous non-aneurysmal aortocaval fistula. Eur J Vasc Endovasc Surg 2002; 24:276-8. [PMID: 12217293 DOI: 10.1053/ejvs.2002.1708] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- M S Duxbury
- Vascular Surgical Unit, Derriford Hospital, Plymouth, Devon, PL6 8DH, UK
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Larzon T, Jansson H, Holmström B, Lund P, Norgren L, Arfvidsson B, Berggren L, Nydahl A, Eriksson T, Jonsson T, Stenberg B. Salvage of an Acutely Ruptured Thoracic Aortic Aneurysm During CPR. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550-9.sp3.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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29
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Gandini R, Ippoliti A, Pampana E, Ascoli Marchetti A, Pistolese GR, Simonetti G. Emergency Endograft Placement for Recurrent Aortocaval Fistula After Conventional AAA Repair. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550(2002)009<0208:eepfra>2.0.co;2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gandini R, Ippoliti A, Pampana E, Ascoli Marchetti A, Raimondo Pistolese G, Simonetti G. Emergency endograft placement for recurrent aortocaval fistula after conventional AAA repair. J Endovasc Ther 2002; 9:208-11. [PMID: 12010102 DOI: 10.1177/152660280200900212] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report a novel case in which a stent-graft was used to emergently treat an aortocaval fistula that recurred after conventional abdominal aortic aneurysm (AAA) repair. CASE REPORT A 67-year-old man was treated urgently for ruptured AAA with surgical placement of a 16-mm Dacron interposition graft. During the procedure, an aortocaval fistula was repaired primarily. The patient was discharged in satisfactory condition but returned 20 days later with dyspnea, bilateral perimalleolar edema, and a bruit in the mesogastric region. The high flow fistula was again present just above the aortic bifurcation at the distal anastomosis of the existing graft. The patient's condition deteriorated rapidly, so a bifurcated Vanguard stent-graft was deployed in an emergency procedure. Subsequent imaging confirmed satisfactory closure of the fistula. The patient was discharged 8 days after endograft placement, and he continues to be without signs of fistula recurrence at 2 years. CONCLUSIONS Endograft treatment of vascular lesions in the acute setting is becoming more common as our experience with the devices grows. Endovascular repair of primary aortocaval fistulas appears to be an efficacious and minimally invasive means of dealing with these lesions in AAA patients.
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Affiliation(s)
- Roberto Gandini
- Department of Radiology, Tor Vergata University, Rome, Italy.
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31
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Orend KH, Kotsis T, Scharrer-Pamler R, Kapfer X, Liewald F, Görich J, Sunder-Plassmann L. Endovascular repair of aortic rupture due to trauma and aneurysm. Eur J Vasc Endovasc Surg 2002; 23:61-7. [PMID: 11748950 DOI: 10.1053/ejvs.2001.1546] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to report a single centre experience with endovascular repair of the ruptured descending thoracic and abdominal aorta. DESIGN prospective non-randomised study in a university hospital. MATERIAL AND METHODS between 1995 and 2000, endovascular treatment was utilised for 231 aortic repairs; in 37 cases (16%) endografting was conducted on an emergency basis for 21 ruptured infrarenal aortic aneurysms, 15 ruptured descending thoracic aortic lesions, and 1 ruptured thoracoabdominal aortic aneurysm. The feasibility of endovascular treatment and the prostheses' size were determined, based on preoperative spiral CT and intraoperative angiography, both obtained in each patient. RESULTS endografting was successfully completed in 35 patients (95%). Primary conversion to open repair was necessary in 2 patients (5%). Postoperative 30-day mortality rate was 11% (4 deaths). No patient developed postoperative temporary or permanent paraplegia. In 2 patients (5%) primary endoleaks required overstenting and in 6 patients (16%) secondary surgical interventions were required. Mean follow-up was 19 months (1-70 months); three deaths occurred within three months postoperatively (1-year survival rate 81+/-6%). In one case, secondary conversion to open repair was necessary 14 months postoperatively. CONCLUSION the feasibility of endoluminal repair of the ruptured aorta has been demonstrated. Endoluminal treatment may reduce morbidity and mortality, and may in time become the procedure of choice in certain centres. However, further follow-up is required to determine the long-term efficacy.
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Affiliation(s)
- K H Orend
- Department of Thoracic and Vascular Surgery, University of Ulm, Ulm, Sweden
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32
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Rodriguez JA, Olsen DM, Ramaiah V, Vranic M, Thompson CS, DiMugno L, Diethrich EB. A ruptured abdominal aortic aneurysm repaired with a bifurcated unibody endoluminal graft. Eur J Vasc Endovasc Surg 2001; 22:463-5. [PMID: 11735186 DOI: 10.1053/ejvs.2001.1497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J A Rodriguez
- Arizona Heart Institute, 2632 North 20th Street, Phoenix, AZ 85006, U.S.A
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White RA, Donayre CE, Walot I, Kopchok G, Woody J. Abdominal pain and hemoperitoneum: sole presenting symptoms for "leaking AAA" after endovascular repair. J Endovasc Ther 2001; 8:131-4. [PMID: 11357971 DOI: 10.1177/152660280100800205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To describe an unusual presentation of impending aortic endograft rupture and successful endovascular rescue. CASE REPORT A 77-year-old man with an enlarging aortic aneurysm was treated with a Talent bifurcated endoprosthesis; a moderate endoleak that appeared to be related to either proximal or distal fixation sites was noted in the body of the aneurysm. The patient was observed for 1 month, and repeat imaging demonstrated persistent endoleak without major increase in the aneurysm diameter. Another examination was scheduled for 3 months hence, but, 2 months later, the patient presented with abdominal pain and a hemoperitoneum. A proximal extension cuff resolved the leak and led to resolution of the hemoperitoneum. CONCLUSIONS A leaking aneurysm can be repaired using endovascular techniques in patients with an existing endograft. The need for frequent imaging surveillance of patients with endoleak is underscored.
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Affiliation(s)
- R A White
- Division of Surgery, Harbor-UCLA Medical Center, Torrance, California 90509-9823, USA.
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34
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White RA, Donayre CE, Walot I, Kopchok G, Woody J. Abdominal Pain and Hemoperitoneum: Sole Presenting Symptoms for “Leaking AAA” After Endovascular Repair. J Endovasc Ther 2001. [DOI: 10.1583/1545-1550(2001)008<0131:apahsp>2.0.co;2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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35
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Lau LL, O'reilly MJ, Johnston LC, Lee B. Endovascular stent-graft repair of primary aortocaval fistula with an abdominal aortoiliac aneurysm. J Vasc Surg 2001; 33:425-8. [PMID: 11174799 DOI: 10.1067/mva.2001.111485] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A primary aortocaval fistula is present in less than 1% of all abdominal aortic aneurysms. Until recently, surgical repair was the only method of treatment and was associated with a high incidence of morbidity and mortality. With the rapid development of aortic stent-graft technique, endovascular stent-graft repair may offer an alternative to the management of this often fatal condition. We report a case of an aortoiliac aneurysm with an aortocaval fistula successfully treated with endovascular stent-grafting. The unique hemodynamic changes, technical problems, and complications associated with this case are discussed, and the literature is reviewed.
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Affiliation(s)
- L L Lau
- Vascular Surgery Unit, and the Department of Radiology, Belfast City Hospital, Northern Ireland.
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