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

Spontaneous Ilio-Iliac Arteriovenous Fistula from Rupture of an Iliac Aneurysm: A Systematic Review

BACKGROUND

Spontaneous arteriovenous fistulas (AVF) caused by iliac aneurysms are a rare condition with possible dramatic complications due to secondary hemodynamic changes. Diagnosis can be challenging because patients may present with progressive cardiac failure or even hemodynamic shock as primary symptom. Due to the rarity of the condition, data are scarce and treatment decisions are challenging. The aim of this systematic review is to give an overview of the symptoms, treatment possibilities, and patient outcomes.

METHODS

Literature searches were performed in PubMed, Embase, Web of Science, and Scopus. Case reports and literature reviews were included in the review. The literature review was performed by 2 independent reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A third reviewer was available in case of disagreement. The study was registered in Prospero (ID CRD42022335318). All cases of isolated, iliac atherosclerotic aneurysms with spontaneous fistulization into an iliac vein were included.

RESULTS

Fifty articles were included, resulting in 62 cases. A case from our own center was included, bringing the total up to 63 cases. Median age was 71 years, ranging from 41 to 87 years. 87.3% of patients were male, 6.3% were female, and in 6.3% sex was not reported. The duration of symptoms until presentation ranged from less than an hour to 6 years. 73.0% was treated with open surgery and 17.5% was treated by endovascular way, with 4 reinterventions in the endovascular group. There was an overall mortality rate of 9.5%.

CONCLUSIONS

Although rare, iliac AVF might cause acute therapy-resistant heart failure and hemodynamic instability. In patients with acute heart failure, especially when combined with a pulsating mass with accompanying bruit or thrill and unilateral swollen leg, an AVF should be suspected. Surgical treatment of AVF has an excellent outcome, provided that the condition had been diagnosed preoperatively.

Ruptured Iliac Arteriovenous Fistula Presenting With Thigh Pain and Swelling: Case Report

The presentation of abdominal arteriovenous fistulas is classically described as a triad of a pulsatile abdominal mass with a bruit, high-output heart failure, and regional venous hypertension with primarily open operative therapy. In the following case, we present the treatment of a patient who arrived with acute right heart failure and renal failure due to an arteriovenous fistula and who was successfully treated with endovascular repair.

Endovascular treatment of an ilio-iliac arteriovenous fistula accompanied by venous thromboembolism presenting with multiple organ failure - A case report and literature review

OBJECTIVES

Multiple organ failure is a rare manifestation of ilio-iliac arteriovenous fistula which can lead to a high rate of misdiagnosis and death.

METHODS

We reported a 61-year-old man presenting with multiple organ failure rapidly after right lower limb swelling. Computed tomography angiography showed an ilio-iliac arteriovenous fistula caused by right common iliac artery aneurysm, and venous thrombosis of bilateral common iliac veins. A bifurcated stent-graft with coil embolization of right internal iliac artery was used for repair.

RESULTS

The patient recovered rapidly and was discharged without complications. Although arteriovenous fistula persisted due to type II endoleak, aneurysm sac and inferior vena cava significantly shrunk at six months follow-up.

CONCLUSIONS

This report demonstrated that multiple organ failure may appear when the distal outflow tracts of arteriovenous fistula are obstructed. Moreover, endovascular repair is effective for reversal of multiple organ failure caused by arteriovenous fistula, even if arteriovenous fistula persists due to type II endoleak.

Impending rupture of abdominal aortic aneurysm due to spontaneous obstruction of aortocaval fistula after endovascular abdominal aortic aneurysm repair

Endovascular aortic aneurysm repair (EVAR) is a valid treatment for patients with abdominal aortic aneurysm with aortocaval fistula. However, an endoleak can be caused by persistent communication between the aneurysm and the inferior vena cava. We present a case of impending rupture due to spontaneous obstruction of an aortocaval fistula after EVAR. Spontaneous obstruction of an aortocaval fistula is rare; however, when occurs, it will cause an endoleak, followed by dilatation or impending rupture of the abdominal aortic aneurysm. EVAR alone for aortocaval fistula will sometimes not be adequate if the type II endoleak is patent.

The Successful Treatment of an Ilio-Iliac Fistula and Aneurysms Affecting the Abdominal Aortic and Iliac Arteries via Endovascular Stent Graft Repair

Spontaneous ilio-iliac arteriovenous fistula (AVF) associated with aneurysms affecting the abdominal aortic and iliac arteries is a rare condition. The classical clinical symptoms of ilio-iliac AVF include high-output heart failure, abdominal pain, abdominal bruits and thrills, a pulsatile abdominal mass, and venous congestion symptoms (leg edema and hematuria). The prompt repair of AVF is necessary to restore the patient's hemodynamics. We report a case in which a patient with aneurysms affecting the abdominal aortic and iliac arteries and an ilio-iliac AVF presented with high-output heart failure and leg ischemia and was successfully treated via endovascular stent graft repair.

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.

Traumatic arteriovenous fistula with serious haemodynamic repercussions: endovascular treatment

Major abdominal arteriovenous fistula (AVF) is a rare clinical condition defined as an abnormal communication between the aorta or iliac arteries and the inferior vena cava or the iliac or renal veins. Penetrating trauma, including iatrogenic injuries, accounts for less than 20% of these AVFs. Endovascular techniques were useful in the management of vascular lesions. The authors report the case of a patient with high-output heart failure and high-flow AVF between the left external iliac artery and the left external iliac vein manifested 17 years after a gunshot wound. Endovascular approach was satisfactorily performed with the implantation of a septal occlusion device to interrupt abnormal vascular communication and preserve artery and vein patency. There were improvement of symptoms and control images showed arteriovenous communication closure.

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.

Endovascular Repair of a Large Ilioiliac Fistula Using a Reversed Iliac Limb Endograft

Ilioiliac fistulae are a rare condition, for which diagnosis and treatment can be challenging. In this report, we describe the case of a 74-year-old patient with a high-flow fistula between the left common iliac artery and the ipsilateral common iliac vein presenting with heart failure. The fistula was probably iatrogenic, caused by prostatic surgery 1 year earlier. We describe imaging findings on computed tomography angiography and the treatment by 2 back-table reversed stent grafts. The satisfactory results demonstrated in our case and those in the literature suggest that an endovascular treatment for this rare condition should be considered as the first-line therapy.

An Ilio-iliac Arteriovenous Fistula Following Spontaneous Rupture of a Right Common Iliac Artery Aneurysm

The formation of an ilio-iliac arteriovenous fistula is a potentially lethal complication of common iliac artery aneurysm presentations. Whilst trauma predominantly accounts for the majority, spontaneous rupture of a common iliac artery aneurysm into an adjacent venous structure accounts for a small subset of patients. Urgent surgical intervention is warranted with the aim to restore arterial continuity and ideally, closure of the fistula. This case study describes the endovascular management of a spontaneous ilio-iliac arteriovenous fistula following rupture of a common iliac artery aneurysm into an adjacent vein.

Staged endovascular repair of an abdominal aortic aneurysm adjacent to a chronic high-flow iliocaval traumatic arteriovenous fistula

Large-vessel chronic traumatic arteriovenous fistulas are a rare complication after trauma. Delayed presentation can consist of one or more features of high-output cardiac failure, pulsatile abdominal mass, bruit, limb ischemia, and venous congestion. We describe a patient with a complex iliocaval fistula secondary to a remote gunshot wound associated with a large 8.5-cm aortic aneurysm. Informed consent of the patient was obtained for publication of the case.

Iliac arteriovenous fistulas after lumbar spinal surgery

Iatrogenic arteriovenous fistula (AVF) is an unusual and potentially fatal complication of lumbar spinal surgery. The presentation of these injuries is usually late, with symptoms such as leg swelling or cardiac failure. It is crucial to suspect AVF in the patient which presents to emergency with lumbar spinal surgery history. The diagnosis is often based on imaging studies such as computed tomography (CT) or magnetic resonance (MR) angiography. Surgery was the first choice of treatment, but with recent advances in stent technology endovascular approach has become widely popular. We present two cases of AVF secondary to lumbar spinal surgery, one of them presenting with overt heart failure and the other one with leg swelling.

Endovascular Repair of Iatrogenic Iliocaval Fistula Causing High-Output Cardiac Failure after Spine Fusion

The case being presented is a 35-year-old female with a 3-year history of progressive dyspnea and right-sided heart failure following spine surgery. Physical examination identified a continuous bruit in the lower abdomen radiating to her back which prompted further evaluation. Echocardiography showed normal left ventricle systolic function, enlarged right ventricle, functional tricuspid regurgitation, and moderate pulmonary hypertension. A computed tomography (CT) scan of the abdomen and pelvis demonstrated findings consistent with an arteriovenous fistula (AVF) between the right common iliac artery and the inferior vena cava. She underwent an uneventful endovascular repair without perioperative complication. The patient's symptoms resolved a few hours after the procedure and she continued to be symptom free at 3-month follow-up. This case illustrates an iatrogenic iliocaval fistula causing high-output cardiac failure which was successfully treated endovascularly with excellent clinical result.

Tratamento endovascular de aneurisma de aorta abdominal com fístula aorto-cava utilizando oclusor vascular concomitante a endoprótese bifurcada: relato de caso

Resumo As fístulas aorto-cava são entidades raras e de etiologia variada, estando frequentemente associadas a significativa morbimortalidade. Acredita-se que o aumento da tensão da parede nos grandes aneurismas resulte em reação inflamatória e aderência à veia adjacente, culminando na erosão das camadas aderidas e na formação da fístula. O tratamento cirúrgico convencional tem altas taxas de mortalidade. Embolia pulmonar paradoxal e o vazamento são complicações temidas do tratamento endovascular. O uso de oclusor vascular associado a endoprótese bifurcada é boa opção no tratamento do aneurisma de aorta abdominal com fístula aorto-cava.

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.

First use of an expandable sheath and transcaval access for transcatheter Edwards SAPIEN 3 aortic valve implantation

AIMS

We aimed to describe the first percutaneous transcaval TAVI in Europe using the expandable introducer sheath (eSheath; Edwards Lifesciences, Irvine, CA, USA) for implantation of an Edwards SAPIEN 3 aortic valve (23 mm).

METHODS AND RESULTS

A 72-year-old male patient presented with dyspnoea (NYHA III) in part due to severe aortic stenosis. Concomitant diseases were severe peripheral artery disease, severe chronic obstructive pulmonary disease (GOLD IV) and renal insufficiency, such that neither a transfemoral nor a transapical approach was considered favourable. An eSheath was introduced into the abdominal aorta via the femoral vein and the inferior vena cava. TAVI was then performed according to standard procedures. After TAVI, the veno-arterial junction was occluded with a 6 mm AMPLATZER Muscular VSD Occluder (St. Jude Medical, St. Paul, MN, USA) using an 8.5 Fr Agilis™ sheath (St. Jude Medical) inside the TAVI sheath. Aortography showed no retroperitoneal accumulation of contrast media. The femoral vein access site was closed using two prepositioned sutures (ProGlide; Abbott Vascular, Santa Clara, CA, USA). A CT scan the following day showed no retroperitoneal haemorrhage.

CONCLUSIONS

Percutaneous transcaval venous access to the aorta may provide a new access strategy for TAVI in otherwise ineligible patients and appears safe with expandable sheath technology.

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.

Endovascular occlusion of primary major pelvic arteriovenous fistula using patent ductus arteriosus occluder

The aim of the present study was to investigate the effects and safety of a patent ductus arteriosus occluder (PDAO) in the management of major abdominal arteriovenous fistula. A 56-year-old man was admitted into our hospital, presenting with impeded defecation and claudication. Computed tomographic angiography (CTA) was conducted upon admission, which revealed an aneurysm-like lesion, with the left internal iliac artery as its feeding artery. Super-selective embolization treatment was accomplished using a single PDAO. The results of the CTA at follow-up showed no recanalization of the lesion and that a PDAO was at the site. The patient had no pelvic ischemia complications.

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.

Iliocaval fistula presenting with paradoxical pulmonary embolism combined with high-output heart failure successfully treated by endovascular stent-graft repair: case report

A 51-yr-old man presented exertional dyspnea as a consequence of iliocaval fistula combined with paradoxical pulmonary embolism and high-output heart failure. Endovascular stent-graft repair was performed to cover iliocaval fistula and restore the heart function. After the procedure, dyspnea was improved and procedure related complication was not seen. A 6-month follow-up computed tomography showed regression of pulmonary thromboembolism and well-positioned stent-graft without graft migration, aortacaval communication or endoleak. Stent graft implantation should be considered an alternative of open repair surgery for treament of abdominal arteriovenous fisula, especially in patient with high risk for surgery.

Surgical repair of large aortocaval fistula with limited shunt: Case report

A 67-year-old man was admitted with severe back pain and bilateral lower limb swelling. Enhanced computed tomography showed an infrarenal abdominal aortic aneurysm (92 × 75 mm²) and a short aortocaval fistula (7 mm). Immediately afterward, circulatory collapse occurred, and the patient was rushed to the operating theater. A much larger aortocaval fistula (22 × 35 mm²) than that demonstrated by preoperative computed tomography was found and was repaired with a Dacron patch while using two balloon-tipped catheters to control bleeding. Then, the abdominal aortic aneurysm was replaced with a bifurcated graft. The patient’s postoperative course was uneventful. In this case, enhanced computed tomography detected the aortocaval fistula, but could not assess its size accurately. Successful surgical repair of an aortocaval fistula depends on early accurate delineation of the fistula and prompt control of bleeding.

Total endovascular management of ruptured aortocaval fistula: Technical challenges and case report

Purpose

Primary aortocaval fistula (ACF) is a rare complication of ruptured abdominal aortic aneurysms (rAAA). Endovascular repair for rAAA (REVAR) provides an efficient, elegant and safe option, minimizing the risk of massive bleeding with open repair.

Case report

Case 1: An 84-year-old man presented with a rAAA and ACF. He exhibited manifestations of congestive heart failure, pulmonary and renal impairment. An endovascular aortic aneurysm repair was undertaken and a bifurcated stent graft was deployed to treat the aneurysm and a second stent graft was deployed within the inferior vena cava to simultaneously seal the rAAA and the ACF. Case 2: A 73-year-old male patient presented with a rAAA and ACF. He exhibited manifestations of congestive heart failure and renal impairment with haematuria. REVAR was the plan for management. A bifurcated stent graft was used to treat the aneurysm and another bifurcated stent graft was placed within the inferior vena cava to seal the rAAA and the ACF.

Conclusion

Here in, we report the first two cases in the English literature of rAAA with ACF successfully managed with simultaneous endovascular stent-grafting of both the aorta and the inferior vena cava.

Endovascular repair of traumatic external iliac vessel pseudoaneurysm and arteriovenous fistulae

A 17-year-old male patient presenting with an abdominal gunshot wound and severe hypovolemic shock was initially operated and presented several injuries to the small bowel and cecum associated with severe hemorrhage. The patient had to be operated twice due to hypothermia, acidosis, and coagulopathy. In the late postoperative period, murmur and fremitus were observed. Angiography revealed a pseudoaneurysm associated with arteriovenous fistulae at the left external iliac vessels. Lesions were repaired with a stent graft placed in the external iliac artery, with a satisfactory outcome. Control computed tomography performed 6 months later evidenced artery integrity with closure of the fistulae. Endovascular therapy should be the preferred method in this type of vascular trauma complications.

Inferior Vena Cava Thrombosis Following Endovascular Repair of Acute Aortocaval Fistula

Acute aortocaval fistula (ACF) is a rare, life-threatening condition with a complex clinical presentation, making prompt diagnosis challenging. Primary ACF is believed to be associated with abdominal aortic aneurysm (AAA) rupture in 80% of the cases. Thrombotic complications following endovascular repair for acute ACF are rare and less widely recognized. A high index of suspicion is required for diagnosis of this postoperative complication. We describe a novel, staged management approach using endovascular aortic stent grafts (Gore Excluder; Flagstaff, CA) in both the abdominal aorta and the inferior vena cava (IVC) in a patient with a ruptured AAA and acute ACF with subsequent acute IVC thrombosis.

Aortocaval fistula: a rare cause of venous hypertension and acute renal failure

Spontaneous rupture of abdominal aortic aneurysm into the inferior vena cava is rare and is associated with high mortality and morbidity. The clinical presentation can be variable and thus the diagnosis can be difficult. It can present with symptoms and signs of an abdominal emergency, venous hypertension, or systemic hypoperfusion. The traditional method of repair has been open surgery which is associated with high rate of complications. We report a case of aortocaval fistula (ACF) presenting with acute renal failure and heart failure, which was treated successfully with a novel, endovascular approach.

Aortocaval fistula: current management strategies

BACKGROUND

There has been a trend towards favouring endovascular repair for much acute aortic pathology. We undertook a review of the literature to determine if an endovascular approach could complement the traditional treatment of aortocaval fistula (ACF), a rare complication of abdominal aortic aneurysm.

METHODS

A literature search was undertaken on PubMed using appropriate search terms. Case series and reviews reporting presentation, diagnosis and operative management (open and endovascular techniques) of ACF were selected and discussed.

RESULTS

Open surgical treatment of ACF has an associated morbidity and mortality - mainly from excessive blood loss. Open repair mortality rates are reported around 30%, but some centres report far lower rates based on preoperative diagnosis of the ACF. These rates appear to be reduced when using endovascular repair in selected cases, with success rates of up to 96%. Reiteration of the importance of diagnosis of ACF preoperatively was the common denominator with both open and endovascular repair.

CONCLUSIONS

Endovascular exclusion appears to be an efficacious means of treating ACF and averting the significant blood loss commonly encountered in conventional repair of these lesions. However, some reviews have suggested equal success with open repair. There is limited available published literature on ACF management and outcome, and likely reporting bias attached to both open and endovascular results that are published. With a randomized controlled trial unlikely to occur, a prospective registry may provide better outcome data.

Spontaneous ilio-iliac arteriovenous fistula due to an iliac artery aneurysm: a case-report

A spontaneous arterio-venous ilioiliac fistula (AVF) caused by an iliac artery aneurysm (IAA) is a rare complication. We present the case of a 75-year-old man with previous aortic surgery 11 years before who was admitted at the Emergency Department for acute gluteal pain. He was suspected for a hip problem because of cup loosening on X-ray. A lumbar CT-scan to rule out nerve compression showed an aneurysm of the left common and internal iliac artery that was ruptured into the iliac vein. The AVF was treated endovascularly under local anesthesia by a sandwich technique (covered stent at the venous side and coils at the arterial side) with good results. The case demonstrates that lifelong follow-up of a patient with previous aortic surgery is mandatory.

Simultaneous endovascular repair of an iatrogenic carotid-jugular fistula and a large iliocaval fistula presenting with multiorgan failure: a case report

INTRODUCTION

Iliocaval fistulas can complicate an iliac artery aneurysm. The clinical presentation is classically a triad of hypotension, a pulsatile mass and heart failure. In this instance, following presentation with multiorgan failure, management included the immediate use of an endovascular stent graft on discovery of the fistula.

CASE PRESENTATION

A 62-year-old Caucasian man presented to our tertiary hospital for management of iatrogenic trauma due to the insertion of a central venous line into his right common carotid artery, causing transient ischemic attack. Our patient presented to a peripheral hospital with fever, nausea, vomiting, acute renal failure, acute hepatic dysfunction and congestive heart failure. A provisional diagnosis of sepsis of unknown origin was made. There was a 6.5 cm×6.5 cm right iliac artery aneurysm present on a non-contrast computed tomography scan. An unexpected intra-operative diagnosis of an iliocaval fistula was made following the successful angiographic removal of the central line to his right common carotid artery. Closure of the iliocaval fistula and repair of the iliac aneurysm using a three-piece endovascular aortic stent graft was then undertaken as part of the same procedure. This was an unexpected presentation of an iliocaval fistula.

CONCLUSION

Our case demonstrates that endovascular repair of a large iliac artery aneurysm associated with a caval fistula is safe and effective and can be performed at the time of the diagnostic angiography. The presentation of an iliocaval fistula in this case was unusual which made the diagnosis difficult and unexpected at the time of surgery. The benefit of immediate repair, despite hemodynamic instability during anesthesia, is clear. Our patient had two coronary angiograms through his right femoral artery decades ago. Unusual iatrogenic causes of iliocaval fistulas secondary to previous coronary angiograms with wire and/or catheter manipulation should be considered in patients such as ours.

Paradoxical pulmonary embolism with spontaneous aortocaval fistula

BACKGROUND

Paradoxical pulmonary embolisms are uncommon emergencies and can occur as a consequence of an aortocaval fistula due to unrecognized dislodgement of thrombus from aortic sac into pulmonary circulation. This study reviewed current literature and therapeutic options in this emergency condition requiring prompt management and repair.

METHODS

Literature was systematically searched for paradoxical pulmonary embolism associated with aortocaval rupture.

RESULTS

Eight published cases were identified. However, many other paradoxical pulmonary emboli could have remained undiagnosed due to challenging clinical presentation. Symptoms of high-output cardiac failure and respiratory distress in the presence of large aortoiliac aneurysm and venous hypertension are findings of a possible major abdominal arteriovenous fistula with paradoxical pulmonary embolism. Successful treatment depends on prevention of new embolism and proper management of perioperative hemodynamics and massive bleeding during fistula repair. Endovascular procedures have been recently used as useful tools in this field. Cava filter placement may be a first step to prevent further thrombus dislodgements during aortocaval repair. Immediate subsequent aortic stent-grafting can allow repair of aortocaval communication and exclusion of the abdominal aortic aneurysm from circulation with successful reversal of altered hemodynamic features. However, experience (especially in the long-term) is limited.

CONCLUSIONS

Paradoxical pulmonary embolism from aortocaval fistula represents an extremely rare but true clinical emergency with high fatality rate. Recent advances in diagnostic technology and endovascular techniques can substantially improve outcomes of the disease. Clinical competence in early detection and diagnosis is essential for appropriate emergent management.