A primary aortocaval fistula is present in less than 1% of all abdominal aortic aneurysms. Until recently, surgical repair was the only method of treatment and was associated with a high incidence of morbidity and mortality. With the rapid development of aortic stent-graft technique, endovascular stent-graft repair may offer an alternative to the management of this often fatal condition. We report a case of an aortoiliac aneurysm with an aortocaval fistula successfully treated with endovascular stent-grafting. The unique hemodynamic changes, technical problems, and complications associated with this case are discussed, and the literature is reviewed.

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We have investigated the value of cardiopulmonary exercise testing in the pre-operative assessment to patients for abdominal aortic aneurysm repair. Thirty-six patients were entered into the study. All had a pre-operative clinical assessment and investigations including chest radiograph, electrocardiograph, spirometry and echocardiogram with measurement of left ventricular ejection fraction. Each patient performed a symptom limited treadmill exercise test using a STEEP protocol with on-line measurement of respiratory gas exchange. Patients were followed up for 12 months post-operatively by review of casenotes. Thirty out of 36 patients had surgical repair of abdominal aortic aneurysm. There was 1 death in the perioperative period and 2 deaths in the following 12 months. Seven other patients suffered post-operative complications. There were no significant differences in left ventricular ejection fraction, spirometry and peak achieved oxygen consumption (PVO2) between those patients who died or who had post-operative complications and those who had not. However, PVO2 < 20 ml/min/kg was found in 70 per cent of patients who had complications compared with 50 per cent of those who had not. Also 4 patients considered medically unfit for surgery all had PVO2 < 20 ml/min/kg. Cardiopulmonary exercise testing with measurement of PVO2 may be helpful in identifying patients more at risk of post-operative complications but should not be used in isolation without through clinical assessment.

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