Surgery for Ruptured Abdominal Aortic Aneurysm with an Aortocaval and Iliac Vein Fistula

Abstract

The purpose of this study was evaluate the operative procedure and outcome of abdominal aortic aneurysm (AAA) patients with aortocaval fistula (ACF) and iliac vein fistula. From 1982 through 2004, we experienced five AAA patients associated with spontaneous aortocaval and aortoiliac venous fistula who underwent repair of AAA. Three patients were in hypovolemic shock, including one patient with cardiopulmonary arrest on admission who required cardiopulmonary resuscitation before surgery. These three ACF patients with hypovolemic shock underwent emergency operation and two patients with stable hemodynamic state underwent urgent operation. One of two ACF patients with stable condition was associated with unstable angina. One AAA patient with ACF-complicated angina underwent AAA repair with coronary artery bypass grafting; the remaining four patients underwent 3 bifurcated graft and 1 tube graft implantation. All surgical treatment of the fistula included direct closure within the aorta under digital compression in four patients and inferior vena cava clamp in one. The mortality rate was 25%. One ACF patient with retroperitoneal hematoma died of bleeding. Survival for ACF depends on early diagnosis and prompt surgical repair. Aortocaval fistula complicated with a rupture of aneurysm into retroperitoneal space had a severe fatal prognosis compared with uncomplicated ACF.

A rare presentation of a rare complication of ruptured AAA... how cardiology comes into play

“…Reported mortality rates are in the range of 16-66% [4][5]9] and significantly higher than with rupture into the retroperitoneal cavity [3][4]7].…”

“…Most publications are case reports or reviews, reporting an incidence of 0.22-6% of spontaneous aortocaval fistula in presence of abdominal aortic aneurysm rupture [5][6][7][8]. Patients usually are male and 60 to 70 years old [4][5][7][8][9][10].…”

“…The arteriovenous short circuit dramatically reduces the peripheral resistance which subsequently leads to hyper-dynamic cardiac shock/failure as well as hypoperfusion of the kidneys with renal insufficiency [3,5,7]. Cardiac arrest may occur, in particular in the presence of coronary artery disease.…”

“…Decision making in these patients can be difficult as symptoms of circulatory and respiratory failure mask the classic symptoms of abdominal aortic aneurysm rupture with features of haemorrhagic shock with lower back pain, abdominal pain, palpitations. Clinical examination may show a pulsating abdominal mass with bruits, an elevated central venous pressure, oedemas, hematuria or oliguria and scrotal oedemas [5][6][7][9][10]. Deep palpation and auscultation of the abdomen in all quadrants, inguinal region and the kidneys should be considered in every patient.…”

Surgical Repair of Ruptured Abdominal Aortic Aneurysm with Non-Bleeding Aortocaval Fistula

“…[2][3][4] Other findings associated with an ACF include hematuria, elevation of the jugular venous pressure, pulmonary edema, ascites, pulsating varicose veins, and edema of the lower limbs. 5) A large shunt can cause high-output congestive heart failure.…”