Emergency endograft placement for recurrent aortocaval fistula after conventional AAA repair

An unusual complication after endovascular aneurysm repair for giant abdominal aortic aneurysm with aortocaval fistula: High bilirubin levels

Abdominal aortic aneurysm has among its rare complications the aortocaval fistula. It is observed in less than 1% of all abdominal aortic aneurysms and represents 3%–7% of clinical presentation in case of rupture. A male patient was presented to the emergency department with pulsating mass with continuous vascular systo-diastolic bruit, located in the lower part of abdomen with the back pain radiating anteriorly in lower abdomen. After diagnosis of abdominal aortic aneurysm with aortocaval fistula, a trimodular Endurant endograft was placed. Migration of the endoprosthesis was treated with Endoanchor and endovascular aneurysm sealing device. In the postoperative course, the patient had jaundice due to high bilirubin levels, cholestasis and increased hepatocyte cytolysis: aspartate aminotransferase and alanine aminotransferase. The treatment with appropriate continuous filtration rapidly reduced bilirubin values and the patient gradually improved.

Open Surgery and Endovascular Techniques in Treatment of Acute Abdominal Arteriovenous Fistulas

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.

Endovascular Management of Para-prosthetic Aortocaval Fistula: Case Report and Systematic Review of the Literature

The aim of this article is to report a case of asymptomatic para-anastomotic aortocaval fistula (ACF) treated by endovascular aortic repair, and to review data of the literature on arteriovenous fistulae secondary to abdominal aortic surgery. A 78-year-old male complained of worsening pain in the right lower limb since 2 months. He presented a history of right femoropopliteal bypass for peripheral arterial occlusive disease and elective surgical treatment for a non-ruptured infrarenal aortic aneurysm (Dacron tube graft). Duplex ultrasound revealed an occlusion of the right common femoral artery and bypass graft. The digital subtraction angiography confirmed these findings and showed progression of the contrast medium from the aorta to the inferior vena cava at aortic carrefour level, suggestive of ACF. An abdomen/pelvis computed tomography angiogram (CTA) confirmed the arteriovenous communication at distal anastomosis of the aortoaortic Dacron graft. An urgent endovascular placement of AFX™ (Endologix, Inc., Irvine, CA) aorto-biiliac stent graft was performed, associated with endarterectomy of the right common and deep femoral artery. The postoperative course was regular without complications. The 5-day and 1-month CTA showed complete exclusion of the ACF. A systematic review of the literature was also performed regarding ACF secondary to aortic surgery.

Treatment Options of Iatrogenic Pelvic Vein Injuries: Conventional Operative Versus Endovascular Approach

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.

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.

Aortocaval Fistula: Is Endovascular Repair the Preferred Solution?

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.

Endovascular Treatment of Major Abdominal Arteriovenous Fistulas

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.

Open repair of inflammatory abdominal aortic aneurysm and aortocaval fistula using retrograde balloon occlusion

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.

Emergency endovascular repair of aortocaval fistula--a single center experience

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.

Endovascular treatment of an iliocaval arteriovenous fistula presenting with multiple organ failure

Iliocaval arteriovenous fistula is an uncommon, but challenging condition. The most common cause is spontaneous rupture of the iliac artery into the venous system due to aneurismal dilatation. We report a case of iliocaval fistula after previous aortic surgery presenting as acute liver failure as most prominent part of multiple organ failure and successful endovascular repair.

Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review

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.

Immediate Endovascular Treatment of an Aortoiliac Aneurysm Ruptured into the Inferior Vena Cava

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.

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.

Endovascular Repair of an Aorto–Left Renal Vein Fistula Due to a Ruptured Abdominal Aortic Aneurysm After EVAR

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.

Transcatheter Closure of Aortocaval Fistula With the Amplatzer Duct Occluder

PURPOSE

To report percutaneous closure of aortocaval fistulas with the Amplatzer Duct Occluder.

CASE REPORTS

An aortocaval fistula was diagnosed after surgical repair of an abdominal aortic aneurysm in a 73-year-old man. A 3-year-old girl was treated for a congenital aortocaval fistula in another case. An 8 x 6-mm Amplatzer Duct Occluder was introduced via a 6-F introducer in each case, successfully occluding the fistulous track. Both patients are well and without any echocardiographic evidence of a shunt at 6 months.

CONCLUSIONS

In selected patients, transcatheter closure of aortocaval fistula with the Amplatzer Duct Occluder could be an alternative to open surgery. Further evaluation is necessary.