Endovascular Treatment of an Aortic Aneurysm Ruptured Into the Inferior Vena Cava

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.

Twenty years of experience in the treatment of spontaneous aorto-venous fistulas in a developing country

BACKGROUND

One of the rare forms of abdominal aortic aneurysm (AAA) rupture is the rupture into great abdominal veins such as the inferior vein cava (IVC), the iliac veins, or the left renal vein, with the formation of direct or indirect aorto-caval fistula (ACF). The purpose of the present study was to summarize 20 years of experience at a single referral center for vascular surgery in a developing country, and to discuss the clinical presentation, diagnosis, treatment options, and outcome of patients with spontaneous aorto-venous fistulas (AVF) caused by ruptured aortic aneurysms.

MATERIALS AND METHODS

Retrospective database review identified 50 patients treated in our institution for aorto-venous fistulas (AVF) caused by spontaneous AAA rupture in the 20 years 1991-2010. Pulsating abdominal mass and low back pain were the leading symptoms on admission in our patients. Signs of shock, congestive heart failure, or pelvic and lower extremity venous hypertension were present in 48%, 26%, and 75% of the patients, respectively. Diagnosis of AVF was based on physical examination, duplex ultrasonography, conventional angiography, or multislice computed tomography (MSCT). In 40% of the patients the presence of AVF has not been recognized before surgery. All patients were treated with open surgery.

RESULTS

After proximal and distal bleeding control the fistula was closed with direct suture (92%) or patch angioplasty (8%). Aortic reconstruction followed with tubular (22%) or bifurcated (78%) synthetic graft. Six (12%) patients died. The causes of death were excessive intraoperative blood loss, myocardial infarction, left colon gangrene and multiple organ failure.

CONCLUSIONS

Spontaneous AVFs caused by aneurysmal rupture are not uncommon, and they require prompt surgical or endovascular treatment. Routine use of multislice CT in patients with acute aortic syndrome is probably the best way to the correct diagnosis of aorto-venous fistulas and planning of the optimal treatment.

Inflammatory infrarenal aortic aneurysm with aortocaval fistula

This is a report of an open repair of an inflammatory infrarenal aneurysm with a large rupture into the vena cava. Preoperative imaging with contrast-enhanced computed tomography revealed the presence of the fistula and was an important aid in pre- and perioperative planning.

Aortocaval Fistula After Stent-Graft Repair

PURPOSE

To report an aortocaval fistula after stent-graft repair and the feasibility of interventional treatment.

CASE REPORT

A 78-year-old man with a 61-mm infrarenal aortic aneurysm (AA) was treated successfully with a Zenith bifurcated stent-graft. Three years later, the patient presented with deteriorating renal function and acute bronchial obstruction. Computed tomography showed an aortic diameter increased to 90 mm, dilatation of the inferior vena cava, and a distal type I endoleak. The patient's condition quickly deteriorated, and emergent imaging found a fistula with brisk flow between the aneurysm sac and the left iliac vein within a distal type I endoleak. During emergency endovascular repair, iliac extensions were implanted in the right common iliac artery and left external iliac artery. The left hypogastric artery was coil embolized to exclude flow into the aneurysm sac. After positioning the extensions, cardiac function improved, and the fistula was no longer palpable. The cardiac indices and renal function normalized, and he was discharged 20 days after admission.

CONCLUSION

Aortocaval fistulas are a rare complication of AA stent-graft repair and may be successfully treated by interventional means.

Acute aortic abnormalities

Aneurysm and type B dissections account for most acute abdominal aortic abnormalities. The postsurgical aorta deserves special attention owing to the risk of complications. Most aortic abnormalities presenting acutely are emergencies that carry a high risk of mortality, and imaging plays a critical role in patient evaluation. Modern helical CT scanners provide excellent spatial resolution, are readily available, and allow for rapid imaging. For these reasons, helical CT angiography is the imaging modality of choice for initial evaluation of the acute aorta.