Endovascular treatment of iatrogenic iliocaval fistula post lumbar disc surgery

Abstract

A 39-year-old patient presented with a history of right-side heart failure (dyspnea and orthopnea), right lower extremity deep vein thrombosis, and hepatic impairment. A physical exam showed increased jugular venous pressure, hepatomegaly, and bilateral lower limb pitting edema. A computed tomography angiograph revealed an arteriovenous communication between the right iliac artery and inferior vena cava (IVC) at the level of L4/L5. The patient was diagnosed with a large arteriovenous fistula (AVF), which developed post lumbar disc surgery. Fistulas between the common iliac arteries and IVC are very rare post lumbar disc surgery. Acquired iliocaval AVF is much more difficult to treat surgically because of the risk of massive hemorrhage. The patient underwent a successful endovascular stent graft repair. The patient’s symptoms of heart failure including exertional dyspnea and orthopnea were resolved 6 months post surgery.

Endovascular repair of an ilio-iliac arteriovenous fistula following rupture of common iliac artery aneurysm with an aortic extension cuff in common iliac vein

“…This complicated condition is considered difficult to treat by conventional EVAR since it cannot block the blood flow from the vein to the aneurysm sac. The alternative solution to this is by graft stenting in the vein, but this can only be considered in traumatic or iatrogenic injury-related cases [13–15] . In aneurysm-associated IIAVF cases, backflow occurs from the vein of the IIAVF into the aneurysm sac even after blocking the blood flow with a stent-graft, which may cause sac enlargement or delayed rupture.…”

“…The alternative solution to this is by graft stenting in the vein, but this can only be considered in traumatic or iatrogenic injury-related cases. [13][14][15] In aneurysm-associated IIAVF cases, backflow occurs from the vein of the IIAVF into the aneurysm sac even after blocking the blood flow with a stent-graft, which may cause sac enlargement or delayed rupture. Thus, theoretically, a type II endoleak occurs and stent-grafts must be placed on both sides around the iliac artery and vein defects.…”

Endovascular Occlusion of Iliocaval Confluence During Surgical Repair of Iliocaval Fistula due to Ruptured Abdominal Aortoiliac Aneurysm

“…Aortocaval (ACF) or iliocaval (ICF) arteriovenous fistula can be caused by erosion by an enlarged or aneurysmal atherosclerotic aorta, low-velocity trauma, connective tissue disorders, and iatrogenic injury during lumbar disc surgery. [1][2][3][4] They are rare, lifethreatening complications that occur in <1% of abdominal aortoiliac artery aneurysms (AIAAs) and in 3-7% of cases of AIAA rupture. 1,5,6 Classic symptoms such as abdominal and/or back pain, a pulsatile mass and an abdominal machinery bruit, present in only 40% of cases.…”

Iatrogenic Iliac Arteriovenous Fistula Management after Lumbar Discectomy Surgeries: A Case Report and Review of the Literature

“…History and physical examination findings can suggest IAVF; most patients undergo computed tomography angiography (CTA) and digital subtraction angiography (DSA) examinations to confirm the potential diagnosis and rule out differential diagnoses (86.4%) [Yan 2019]. Most authors have reported that endovascular repair should be the first line of treatment of IAVF after LDS [Alshabatat 2019]. Because of the wide availability of covered stents, endovascular repair has replaced conventional surgery and is preferred in the treatment of IAVF with delayed presentation.…”