Aortocaval fistula: an unusual complication of ruptured abdominal aortic aneurysm

Abstract

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm, which erodes into the wall of the inferior vena cava, resulting in the formation of a fistula. ACF presents with various inconsistent symptoms and signs. ACF can be a diagnostic dilemma if not suspected and it is lethal if left untreated.A 60-year-old man presented with abdominal and lower back pain of sudden onset. Renal and liver functions were impaired, without signs of cardiac failure. CT angiography revealed an abdominal aneurysm rupture into the inferior vena cava. Patient underwent a successful open repair: ACF ligation from within the aneurysmal sac and an aorto-bi-iliac bypass using a Dacron graft. Renal and liver functions improved and the patient was discharged on the eighth postoperative day. A month later, the patient was fit and well with normal liver and renal functions.Despite progress made in the endovascular treatment of ACF, complications still persist with a reported endoleak rate of 50%. Open repair is still a valid method for ACF repair in patients fit to undergo laparotomy and general anaesthesia. In this case, the patient was fit and along the lack of a suitable stent graft, the vascular team performed an open repair with good results.Open repair of an ACF is a valid treatment method for patients who are fit enough to undergo laparotomy and general anaesthesia, and avoids complications related to endovascular repair, such as endoleaks.

Endovascular management of aortocaval fistula complicating abdominal aortic aneurysm presenting as an acute renal failure

“…Most ACF had been repaired primarily in an open intervention and the literature accounted the surgical mortality to be as high as 16–66% [ 5 ]. A primary/spontaneous ACF occurs in 1% of AAA cases and 6% of ruptured AAA cases, being thus responsible for 80% of all ACF cases [ 6 ]. It is believed that increased tension in the walls of large aneurysms can cause an inflammatory reaction resulting in adhesion to the adjacent vein and culminating in erosion of the adherent layers and fistula formation [ 1 ].…”

“…Both conventional open surgery and endovascular repair can be used for the treatment of Aortocaval fistula [ 6 ]. Conventional surgical intervention has high mortality rates, whereas endoleaks and paradoxical pulmonary embolism are the main concerning complications of endovascular treatment.…”

“…However, open repair can be preferred against EVAR, when comorbidities affecting the cardiovascular and respiratory system are absent. Especially in younger patients, constant follow-up and reintervention, which are often required after endovascular surgery, can be avoided with open repair [ 6 ]. On the other hand close attention must be paid to the presence of superficial vein dilation, safe visualization of the renal arteries, and hemodynamic perturbances on stent graft deployment during EVAR [ 11 ].Our patient was successfully treated with endovascular stent graft repair and no endoleak into the aneurysmal sac was detected on control angiography.…”

Fístula aortocava en un devastador aneurisma abdominal: reporte de caso y revisión de la literatura

“…Las opciones de tratamiento incluyen la cirugía abierta y el tratamiento endovascular (10,11). El manejo quirúrgico de la fístula aortocava depende de varios factores que incluyen la forma de presentación clínica, morbilidades, la anatomía quirúrgica y la estabilidad del paciente dentro de la sala de operaciones (12). Este manejo se realiza dependiendo de las morbilidades del paciente y la tolerancia al procedimiento quirúrgico; estas decisiones se toman de forma similar al manejo de los aneurismas de aorta que se reparan de forma electiva.…”

“…Este manejo se realiza dependiendo de las morbilidades del paciente y la tolerancia al procedimiento quirúrgico; estas decisiones se toman de forma similar al manejo de los aneurismas de aorta que se reparan de forma electiva. En pacientes jóvenes y saludables se prefiere la reparación abierta, mientras que en los pacientes con múltiples morbilidades se prefiere la reparación endovascular, otro aspecto depende de si la anatomía quirúrgica es favorable o no para la reparación endovascular, ya que para los pacientes con cuello hostil se prefiere la reparación abierta, lo cual es acorde a las decisiones tomadas por otros grupos que han manejado esta patología y la literatura vigente (12).…”