Aortocaval fistula: a challenge for endovascular management

Endovascular repair of delayed traumatic aortocaval fistula

Aortocaval fistula (ACF) is an uncommon condition that can result in a number of adverse clinical sequelae. We describe a case of an ACF that occurred several years after open repair of a penetrating injury of the abdominal aorta and inferior vena cava. Whereas ACF can have sudden and catastrophic presentations, our patient had a subacute presentation of high-output heart failure. We were able to fully correct the vascular injury and heart failure physiology and symptoms with endovascular therapy.

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.

Vascular injury complicating lumbar disc surgery. A systematic review

OBJECTIVES

to review the literature concerning the early and late vascular complications of lumbar disc surgery.

METHODS

using the MEDLINE database, we reviewed all reports of vascular complications associated with surgical excision of a prolapsed disc via a posterior approach reported in the English literature since 1965.

RESULTS

we identified 98 cases of vascular complications for an incidence of 1-5 in 10000 disc operations. Early presentation is shock due to rupture of a large retroperitoneal vessel. Late complications include development of pseudoaneurysms and arteriovenous fistulas. Treatment of a vascular tear consisted mainly of primary suturing of the injured vessel. The preferred method for arteriovenous fistula and pseudoaneurysm repair was suturing from within the arterial lumen along with interposition grafting. Recently, endovascular techniques have been recommended, lowering the high morbidity and mortality related to conventional repair.

CONCLUSION

iatrogenic vascular injury during lumbar disc surgery, although rare, should be suspected if signs of circulatory instability are noted or if lumbar pain, leg oedema or high output cardiac failure develop months to years following such surgical procedures. However, these symptoms may arise during or immediately after surgery, requiring immediate intervention.

Endovascular stent-graft repair of descending thoracic aortic aneurysms: the nursing implications for care

Endovascular repair of descending thoracic aortic aneurysms is a minimally invasive procedure performed with the patient under epidural or spinal anesthesia as an alternative to the conventional left thoracotomy repair. A Dacron graft, similar to the one used in the conventional repair, is placed in the thoracic aorta with fluoroscopic guidance via the femoral or iliac artery. Once the graft is in place, the aneurysm is excluded from the general circulation, thereby preventing rupture. Endovascular repair is currently being offered at selected sites to patients who otherwise would not be candidates for surgical repair due to severe comorbidities such as cardiac, pulmonary, or renal disease. As both the technique and the devices become perfected, endovascular stent-graft repair of descending thoracic aortic aneurysms will most likely be offered as a method of treatment in both high- and low-risk patients who are anatomic candidates for the procedure. This article describes the conventional repair and the endovascular repair of descending thoracic aneurysms. It discusses the implications for nursing care in the preoperative and postoperative settings and defines guidelines for the long-term follow-up of patients who undergo endovascular repair.