Conservative management of persistent aortocaval fistula after endovascular aortic repair

Abstract

Endovascular repair is a valid alternative for patients with abdominal aortic aneurysms. However, in patients with concomitant aortocaval fistulas, type II endoleaks may result in a persistent communication between the aneurysm sac and the inferior vena cava. In these patients, prompt closure of the persistent fistula has been advocated. We present a patient with an abdominal aortic aneurysm, with aortocaval fistula, who was managed endovascularly. Aneurysm sac shrinkage was observed despite persistent aortocaval communication due to type II endoleak. This case demonstrates that conservative management of type II endoleaks associated with persistent aortocaval fistulas is possible and may result in favorable aneurysm sac remodelling.

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

“…18 This type of leakage appears to be subject to different dynamics, by which the low pressure of the venous system provides an exit route for retrograde flow from the aortic branches, reduces tension at the aorta wall and facilitates spontaneous resolution. 19 However, some authors suggest that, even after release of the endograft, blood flow into the aneurysm sac may be exacerbated through the fistula, which would require a second procedure to repair. To address this, ElKassaby et al and Silveira et al proposed concurrent treatment of the aneurysm and the aortocaval fistula, using an endograft from the arterial and venous sides, which proved feasible and may be more effective than endovascular treatment of the aorta alone.…”

Ruptured Iliac Artery Aneurysm Presenting as Acute Right Heart Failure and Cardiac Arrest

“…5 However, in another study, aneurysmal sac shrinkage did occur despite a type II endoleak. 6 One case report described a patient unsuitable for endovascular aortic repair after which from inside the vein the fistula was covered with a stent graft followed by an open interposition graft of the ruptured aneurysm reducing blood loss significantly. 7 Mortality rates of 30e40% are still favorable compared with retroperitoneal or intraperitoneal ruptured abdominal aortic aneurysm repairs.…”

Staged Hybrid Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula

“…In the presence of ACF, endovascular repair is accompanied by the theoretical concern of high flow T2Es, which could lead to persistent aortocaval communication. T2Es occur after EVAR and are caused by retrograde flow of collateral arteries into the excluded aneurysm sac, leading to repressurization and consequent aneurysm growth and, ultimately, possible rupture [5]. Without surgical intervention, a T2E in the setting of persistent aortocaval communication may lead to high-output cardiac failure and sac growth.…”

“…The emergent management of these cases, therefore, presents a unique and difficult challenge. As described above, endovascular placement of a stent graft can potentially act as an initial damage control therapy in the setting of a life-threatening ruptured AAA and may create a role for the staged repair of concomitant, but not immediately life-threatening lesions, such as ac-Several case reports and case series describe successful EVAR or open surgical repair of unruptured AAAs with ACF [5,6]and many cases can be found of AAA with contained ruptures into the inferior vena cava (IVC) repaired via both endovascular [7] and open approaches [1]. However, reports of AAA complicated by both a free rupture into the retroperitonium and aortocaval fistulization are extremely rare.…”