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

Endovascular aneurysm repair of aortocaval fistula presenting with lower limb edema: A case report

Aortocaval fistula (ACF) due to a ruptured abdominal aortic aneurysm is an uncommon medical condition that can be fatal if not diagnosed. ACF has several atypical signs and symptoms, making it challenging to diagnose, and an early diagnosis notably improves outcomes. We report a case of a 64-year-old man presenting with a 1-day history of lower back pain, hypotension, and lower limb edema. Computed tomography angiography demonstrated an abdominal aortic aneurysm with ACF. An urgent endovascular aneurysm repair was successfully performed to treat the ACF in this patient. Eighteen months later, the patient had an intact stent, normalized renal function, and no edema.

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.

Treatment of Aortocaval Fistula Secondary to Abdominal Aortic Aneurysm: A Systematic Review

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.

Endovascular Repair for Abdominal Aneurysm with Concomitant Aortoiliac Vein Fistula Diagnosed by Four-Dimensional Computed Tomography

A 78-year-old man complaining of left leg swelling was diagnosed with an abdominal aortic aneurysm with an irregular margin. A four-dimensional computed tomography (CT) showed an aortoiliac vein fistula. An AFX stent graft was urgently implanted, and a Viabahn VBX was inserted into the left iliac vein. The aneurysmal sac was embolized. After the procedure, enhanced CT confirmed a patent stent graft without any endoleak or fistula. The patient was discharged ambulatory. An aortoiliac vein fistula is a differential diagnosis for leg edema, and a four-dimensional CT is beneficial in diagnosing the condition.

High Output Heart Failure Secondary to Aorto-Caval Fistula Treated With an Amplatzer Septal Occluder: Case Report and Review of Literature

Aorto-caval fistula (ACF) is a rare cause of high output heart failure (HOHF). 80 % of cases are due to ruptured abdominal aortic aneurysm, while 10 to 20% are traumatic or congenital. Early diagnosis and treatment are crucial in order to prevent the progression to HOHF. Open surgical repair has been the mainstay therapy of arterio-venous fistulas including aorto-caval fistula; however endovascular approach has become an evolving therapeutic option in the last 20 years. Here, we present a case of high output heart failure secondary to traumatic aorto-caval fistula due to shrapnel injury to the abdomen. Our patient was managed with endovascular approach by the deployment of amplatzer septal occluder that excluded completely the fistula, resulting in the progressive improvement of HOHF. In this manuscript, we review etiologies of high output heart failure and summarize cases of aorto-caval fistula treated with amplatzer septal occluder reported in literature. We also highlight the importance of this endovascular device in the presence of metallic foreign body in the aorta.

A rare case of paradoxical pulmonary embolism in spontaneous aortocaval fistula

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA), occurring in less than 1% of all AAAs.

Paradoxical embolism can rarely be associated with ACF, pulmonary embolism may originate from dislodgment of thrombotic material from the AAA in the inferior vena cava (IVC) through the ACF.

We report a case of a patient admitted to the emergency department with abdominal pain and shortness of breath who immediately underwent thoraco-abdominal CT. Imaging allowed a prompt pre-operative diagnosis of an ACF between an AAA and the IVC, also identifying CT signs of right heart overload and the presence of a paradoxical pulmonary embolism.

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.

Endovascular Management of a Ruptured Iliac Aneurysm With an Inferior Vena Cava Fistula

Aortocaval fistula is uncommon and often associated with a ruptured iliac or abdominal aortic aneurysm. It has a high mortality secondary to the aneurysmal rupture but also to a high output heart failure. Open surgery has been the standard; however, endovascular management has emerged with lower mortality. We present a patient with a ruptured iliac aneurysm and an inferior vena cava fistula successfully treated with an endograft with embolization of the right hypogastric artery. The patient arrested on induction and was resuscitated with aortic balloon inflation. Endovascular therapy can be safely used in the management of iliac/aortocaval fistula.

Acute Aortocaval Fistula Secondary to Chronic Type 1 B Abdominal Aortic Aneurysm Endoleak

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysms (AAA), involving less than 1% of all AAA and is associated with high morbidity and mortality; it is even more uncommon, following endovascular aneurysm repair. The clinical presentation can be variable and making the diagnosis can be difficult. It can present with symptoms and signs of an abdominal emergency or systemic hypoperfusion. The traditional method of repair has been open surgery, which is associated with a high mortality rate. Endovascular repair has become more common, but results are difficult to interpret due to the low incidence of ACF. A high index of suspicion is imperative to avoid delay in diagnosis and care.

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.

Surgical Repair of a 13-cm Infrarenal Abdominal Aortic Aneurysm with Aortocaval Fistula in a 63-Year-Old Tuba Player

Infrarenal abdominal aortic aneurysm with aortocaval fistula, a rare condition, can be fatal without prompt intervention. The clinical symptoms are complex and varied, so diagnosis is typically confirmed by use of contrast-enhanced multidetector computed tomography. We report our surgical repair of a 13-cm-diameter infrarenal abdominal aortic aneurysm and aortocaval fistula in a 63-year-old orchestral tuba player who had 2 classic symptoms of the condition. The unruptured aneurysm and fistula were complicated by acutely angled vessels, so we performed surgery rather than endovascular repair. The patient recovered fully and was discharged from the hospital. This infrarenal aneurysm with aortocaval fistula is perhaps the largest to have been treated successfully by means of open surgery. In addition to our patient's case, we discuss the history and treatment considerations of this rare combined condition.

Surgical Repair of Aortocaval Fistula Presenting with Cardiogenic Shock

Aortocaval fistula (ACF) occurs in <1% of all abdominal aortic aneurysms (AAAs), and in 3% to 7% of all ruptured AAAs. The triad of clinical findings of AAA with ACF are abdominal pain, abdominal machinery bruit, and a pulsating abdominal mass. Other findings include pelvic venous hypertension (hematuria, oliguria, scrotal edema), lower-limb edema with or without arterial insufficiency or venous thrombus, shock, congestive heart failure, and cardiac arrest. Surgery is the main treatment modality. We report successful surgical treatment in a patient with a ruptured AAA with ACF who presented with cardiogenic shock.

Bridging stent repair of type III endoleak causing aortocaval fistula after branched aortic endovascular repair

A 62-year-old man presented to our department with abdominal pain and diarrhea for 3 weeks on a background of previous branched endovascular repair for a thoracoabdominal aneurysm. A triple-phase computed tomography scan of his abdomen and pelvis showed a large aortocaval fistula caused by a type III endoleak from a dislodged superior mesenteric artery stent. He was successfully treated with a BeGraft (Bentley Innomed, Hechingen, Germany) by using an endovascular technique.

Emergent Endovascular Repair of Challenging Aortocaval Fistula With Hostile Anatomy

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.

Percutaneous fenestrated endovascular aortic graft treatment of aortocaval fistula with aortic pseudoaneurysms secondary to penetrating trauma

Aortocaval fistula (ACF) is a lethal complication of aortic aneurysmal disease. Traditional treatment of ACF involves open surgical approaches to fistula ligation and repair of the great vessels, with a high mortality secondary to bleeding and cardiac compromise. We present the case of a 28-year-old man with a chronic ACF with concomitant aortic pseudoaneurysms secondary to penetrating trauma treated with a fenestrated endograft.

Aortocaval Fistula Resulting From Rupture of Abdominal Aortic Dissecting Aneurysm Treated by Delayed Endovascular Repair: A Case Report

Aortocaval fistula (ACF) after rupture of an abdominal aortic dissecting aneurysm is a rare emergency situation, which has a high mortality. However, the diagnosis is usually delayed, which increases the difficulties of treatment. We describe a case that successfully delayed use of endovascular aneurysm repair (EVAR) for ACF resulting from rupture of abdominal aortic dissecting aneurysm.We describe a special case of a 70-year-old male with an abdominal aortic dissecting aneurysm rupturing into inferior vena cava (IVC). On account of his atypical presentation, the diagnosis had been delayed for half a year. Due to severe metabolic sequelaes of the ACF and preexisting conditions, the traditional open repair was too risky. Minimally invasive EVAR was performed with a successful result. There were no endoleak or fistula at the follow-up of 9th month.EVAR is the most suitable method in patients with ACF from rupture of abdominal aortic dissecting aneurysm. Further educational programs should be developed, which may give rise to earlier diagnosis and treatment with better outcomes.

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.

A Case Report of Delayed Diagnosed Chronic Aortocaval Fistula: A Rare Complication of Penetrating Trauma to the Abdomen

Chronic aortocaval fistula (ACP) is a rare complication of penetrating trauma to the abdomen. We report a case of traumatic ACP presenting with pulmonary hypertension and right heart failure symptoms 15 years after the initial penetrating injury. Although symptoms of pulmonary hypertension started 5 years ago, it was wrongly diagnosed and treated as chronic obstructive pulmonary disease. The presence of a continuous abdominal bruit and history of penetrating abdominal trauma gave rise to suspicion of a fistula, which was confirmed by computed tomography and angiography. Percutaneous closure of ACP was planned, but the patient died of severe pneumonia. The clinical presentation of chronic ACP can vary from being asymptomatic to symptoms related to pulmonary hypertension, right heart failure, and pulmonary embolism; thus, definitive diagnosis can be challenging.

Traumatic aortocaval fistula from gunshot wound, complicated by bullet embolization to the right ventricle

Aortocaval fistulas are most commonly the result of spontaneous rupture or erosion of an abdominal aortic aneurysm into the inferior vena cava (80-90%). The remaining 10-20% of aortocaval fistulas are usually the result of penetrating or iatrogenic trauma from gunshot or stab wounds. We report the case of a 19-year-old male, status post multiple gunshot wounds. To our knowledge, this is the first case report of bullet embolization to the right ventricle from a traumatic aortocaval fistula. We discuss pertinent imaging findings and management of both aortocaval fistulas and bullet emboli.

Peritonitis as presentation of aorto-caval fistula with Salmonella choleraesuis-associated abdominal aortic aneurysm

BACKGROUND

The majority of aorto-caval fistulae occur spontaneously, either as a result of rupture of an existing atherosclerotic abdominal aortic aneurysm into the vena cava or secondary to iatrogenic injuries during peripheral angiography or surgery. Aorto-caval fistula from an infected aortic aneurysm is a rare scenario, but potentially lethal.

METHODS

Case report and review of the literature.

CASE REPORT

A 63-year-old female with diabetes mellitus and liver cirrhosis was admitted for intractable abdominal pain with rebound tenderness. A computed tomography scan demonstrated an abdominal aortic aneurysm and ill-defined peri-aortic fluid with air density and evidence of a fistula between the aorta and the inferior vena cava. Salmonella cholerasuis had been isolated from a blood culture at a previous admission. Urgent endovascular exclusion of the aorto-caval fistula was carried out, and the infra-renal abdominal aneurysm was repaired using a Cook Zenith TX2 aortic stent graft. She received parenteral ceftriaxone for four weeks.

CONCLUSIONS

This case shows acceptable short-term results after endovascular repair of a Salmonella-infected aorto-caval fistula.

Delayed Endovascular Aneurysm Repair for Aorto-caval Fistula with Correction of Physiologic and Metabolic Abnormalities: A Disease Process Review

Reports regarding the management of ruptured abdominal aortic aneurysm with aorto-caval fistula (ACF) outline various treatment options and high mortality rates associated with this condition. This case illustrates a patient with a large ACF secondary to a prior rupture into the inferior vena cava with a delayed presentation. Because of preexisting conditions and severe metabolic sequelae of the ACF, palliative care was considered by the medical team. Minimally invasive endovascular techniques and prompt treatment resulted in a successful outcome with complete resolution of physiologic and metabolic abnormalities.

Management of type II endoleak after endovascular repair of arteriocaval fistula complicating aortoiliac aneurysm: case report and literature review

Endovascular treatment for arteriocaval fistula (ACF) has become the preferred alternative to open repair. However, endoleaks sometimes occur and maintain the ACF. A 64-year-old man presented with persistent fistula after placement of a bifurcated stent-graft for ACF complicating an aortoiliac aneurysm that was maintained by endoleaks from the inferior mesenteric and lumbar arteries. Transarterial embolization of the aneurysm sac and inferior mesenteric artery successfully resolved the problem without any complications observed over 16 months of follow-up. A literature review and discussion of the management options for this entity are presented. A combination of inflow and outflow control is important to obtain better long-term outcomes.

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.

Clinical manifestations of aortocaval fistulas in ruptured abdominal aortic aneurysm: report of two cases

Aortocaval fistula (ACF) is an unusual complication of ruptured abdominal aortic aneurysm (AAA), involving less than 3-6% of all ruptured cases. The clinical presentation is often obscure, depending on the coexistence of retroperitoneal rupture and hemodynamic instability. Prompt preoperative diagnosis is essential in order to plan the operative approach and improve patient's outcome. We report the surgical treatment of two patients presented in the emergency department with ACF due to ruptured AAA, each with different clinical presentation, emphasizing the high index of suspicion needed by the clinician to early diagnose and treat this often lethal condition. Operative strategy and special considerations in the management of this subgroup of patients are also discussed.

Endovascular Repair of Contained Abdominal Aortic Aneurysm Rupture With Aortocaval Fistula Presenting With High-Output Heart Failure

Aortocava fistula is a rare condition ranging from 0.22% to 6% of all ruptured aortic aneurysms. Recognition and diagnosis of this entity can often be difficult and requires heightened clinical suspicion to ensure that prompt surgical management leads to a favorable outcome. We herein describe the diagnosis and the technical points of successful endovascular management of aortocaval fistula in the setting of a ruptured abdominal aortic aneurysm.

Endovascular Repair of a Streptococcus pneumonia-Induced Aortitis Complicated by an Iliacocaval Fistula

Purpose: To describe the successful endovascular treatment and follow-up of a patient with a Streptococcus pneumonia-induced right iliacocaval fistula. Case report: A 82-year-old man was diagnosed with a right iliacocaval fistula, as a result of Streptoccocus pneumoniae infection of the distal aorta and proximal right common iliac artery. After antibiotic treatment, he was initially unsuccessfully treated with balloon expandable covered stents. Then, the fistula was excluded by an aortamonoiliac endograft to the left common iliac artery, and occluders in the distal and proximal right common iliac artery followed by a femoral–femoral crossover bypass. Postoperatively patient was treated with prolonged antibiotics. After a follow-up of 20 months, there are no signs of active infection, endoleak, or fistula, both clinically and on 2-deoxy-2-[F18]fluoro-d-glucose positron emission tomography/computed tomography. Conclusion: In selected patients, complicated infectious disease of the aorto-iliac tract may be treated successfully with an endograft and prolonged antibiotics.