The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.02.011
Visual Diagnosis in Emergency Medicine
BEDSIDE ULTRASOUND DIAGNOSIS OF AN AORTOCAVAL FISTULA IN THE EMERGENCY DEPARTMENT Daniel J. Egan, MD,* Turandot Saul, MD, RDMS,† Daniel Herbert-Cohen, MD,‡ and Resa E. Lewiss, MD† *Department of Emergency Medicine, NYU School of Medicine, New York, New York, †Department of Emergency Medicine, Mount Sinai St. Luke’s Roosevelt Hospital Center, New York, New York, and ‡Department of Emergency Medicine, Lutheran Hospital, Brooklyn, New York Reprint Address: Daniel J. Egan, MD, Department of Emergency Medicine, NYU School of Medicine, 462 First Avenue, Suite A345, New York, NY 10016
were normal. On abdominal inspection, a well-healed midline laparotomy scar was noted, without any skin color change, swelling, or hernias. There was superficial abdominal wall tenderness without any discreet mass in the location where the patient felt a lump. To the right of the midline and below the costal margin, a nontender pulsatile mass was noted with a thrill and bruit. Peripheral pulses were equal in all extremities and there was no edema. The neurologic examination was normal. The patient first noticed the pulsatile mass 4 years earlier but had never sought medical evaluation. The emergency physician then performed a bedside ultrasound examination of the abdominal aorta. An area of saccular aneurysmal dilation was identified on each side of the abdominal aorta (Figure 1). The right-sided aneurysm extended into a markedly enlarged inferior vena cava (IVC). An area of communication was noted between the right-sided aneurysm and the IVC suspicious for an aortocaval fistula (Figure 2). Color Doppler interrogation of the area showed turbulent flow in the area of the communication (Video 1). There was no free intraperitoneal fluid identified. The Vascular Surgery service was consulted. Computed tomography (CT) confirmed the bedside diagnosis of bilateral infrarenal abdominal aortic saccular aneurysms, with the right aneurysm connecting to the IVC by a 1-cm fistula (Figures 3, 4). The IVC was markedly
CASE REPORT A 27-year-old man presented to the Emergency Department with abdominal pain for 4 days. The pain began acutely after sit-ups in the area of a midline scar. He described it as tearing, nonradiating, constant, and worsened by moving, laughing, or coughing. He rated his pain as a 2 out of 10. The patient denied any associated fever, chills, nausea, vomiting, diarrhea, or change in bowel habits. He had never had similar pain. The patient also reported that he felt a lump on his left upper abdomen, neither in the region of his scar nor his pain. The patient denied any medical history except for an exploratory laparotomy 11 years prior for a penetrating abdominal injury from an ice pick. The patient was comfortable and in no distress. Vital signs included an oral temperature of 36.7 C (98.1 F), blood pressure of 108/42 mm Hg, heart rate of 81 beats/ min, respiratory rate of 16 breaths/min, and oxygen saturation of 98% on room air. Cardiac and lung examinations
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 26 September 2013; FINAL SUBMISSION RECEIVED: 6 January 2014; ACCEPTED: 10 February 2014 1
2
D. J. Egan et al.
Figure 1. Transverse ultrasound image of the proximal abdominal aorta. The aorta is associated with a saccular aneurysm on both side walls. The right-sided aneurysm connects with a distended inferior vena cava (IVC).
enlarged with associated distension of the intrahepatic veins. The CT scan did not demonstrate evidence of vascular rupture. The patient was admitted to the Vascular Surgery service for planned surgical intervention. DISCUSSION Approximately 80% of cases of aortocaval fistulae occur as a result of an abdominal aortic aneurysm (AAA) (1,2). With increasing intravascular pressure, the AAA erodes into the wall of the IVC, creating a fistula in 1% of nonruptured and 6% of ruptured AAAs (1). Aortocaval fistulae may also develop from bullet fragments or stab wounds causing vascular injury in penetrating trauma (2–4). Patients may present years after exploratory laparotomy (3). A lumbar laminectomy procedure is the most common iatrogenic cause of an aortocaval fistula (2–4).
Figure 2. Transverse ultrasound image of the proximal abdominal aorta. A fistula is visible between a saccular aneurysm of the aorta and the inferior vena cava (IVC) (*).
Figure 3. Computed tomography angiogram image of the upper abdomen. A 1-cm fistula connects the right saccular aortic aneurysm to the inferior vena cava (IVC) (*).
Classically, patients present with abdominal pain (often from AAA rupture), a pulsatile abdominal mass, and an abdominal bruit (1,5). Untreated, aortocaval fistulae may lead to multiple complications, including
Figure 4. Computed tomography angiogram threedimensional reconstruction. A fistula connects the aorta with the inferior vena cava (IVC) (*).
Ultrasound Diagnosis of Aortocaval Fistula
renal insufficiency, high-output cardiac failure, lowerextremity edema, paradoxical pulmonary emboli, and death (1,5,6). CT angiography is the gold standard for diagnosis, though may be a challenging study to obtain, as renal insufficiency is seen in up to 11.8–33% of cases (5). The diagnosis is missed preoperatively as often as 52% of the time, complicating surgical management of AAA repair when the fistula is discovered intraoperatively (7). Fistulae may be corrected with either open or endovascular surgical techniques, although the endovascular repair seems to have better patient outcomes (2,8). Magnetic resonance angiography may be considered if CT angiography is contraindicated (5). Additionally, diagnoses made by Doppler ultrasonography performed in the radiology department have been reported, including one case of a 16-year-old presenting with blunt abdominal trauma several months after a fall (9,10). In this report, we present the first case of an emergency physician diagnosis of aortocaval fistula using bedside ultrasound. Immediately after making the diagnosis, the emergency physicians promptly obtained specialist consultation and performed additional imaging for operative planning. REFERENCES 1. Akwei S, Altaf N, Tennant W, MacSweeney S, Braithwaite B. Emergency endovascular repair of aortocaval fistula–a single center experience. Vasc Endovascular Surg 2011;45:442–5.
3 2. Brightwell RE, Pegna V, Boyne N. Aortocaval fistula: current management strategies. ANZ J Surg 2013;83:31–83. 3. Spencer TA, Smyth SH, Wittich G, Hunter GC. Delayed presentation of traumatic aortocaval fistula: a report of two cases and a review of the associated compensatory hemodynamic and structural changes. J Vasc Surg 2006;43:836–43. 4. Waldrop JL Jr, Dart BW 4th, Barker DE. Endovascular stent graft treatment of a traumatic aortocaval fistula. Ann Vasc Surg 2005; 19:562–5. 5. Bhatia M, Platon A, Khabiri E, Becker C, Poletti P-A. Contrast enhanced ultrasonography versus MR angiography in aortocaval fistula: case report. Abdom Imaging 2010;35:376–80. 6. Thet Y, Ranjit A, Ravi R, Khand A. High output cardiac failure and paradoxical pulmonary emboli secondary to aortocaval fistula. Postgrad Med J 2012;88:613–88. 7. Lebon A, Agueznai M, Labombarda F. High-output heart failure resulting from chronic aortocaval fistula. Circulation 2013;127: 527–8. 8. Antoniou GA, Koutsias S, Karathanos C, Sfyroeras GS, Vretzakis G, Giannoukas AD. Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review. J Endovasc Ther 2009;16:514–6. 9. Daxini BV, Desai AG, Sharma S. Echo-Doppler diagnosis of aortocaval fistula following blunt trauma to abdomen. Am Heart J 1989; 118:843–4. 10. Bolognesi R, Tsialtas D, Manca C. Diagnosis of an aorto-caval fistula by echo 2D color Doppler flow imaging and echocardiographic probe. Cardiology 1991;79:151–79.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10. 1016/j.jemermed.2014.02.011.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
http://dx.doi.org/10.1016/j.jemermed.2014.02.011
Visual Diagnosis in Emergency Medicine
BEDSIDE ULTRASOUND DIAGNOSIS OF AN AORTOCAVAL FISTULA IN THE EMERGENCY DEPARTMENT Daniel J. Egan, MD,* Turandot Saul, MD, RDMS,† Daniel Herbert-Cohen, MD,‡ and Resa E. Lewiss, MD† *Department of Emergency Medicine, NYU School of Medicine, New York, New York, †Department of Emergency Medicine, Mount Sinai St. Luke’s Roosevelt Hospital Center, New York, New York, and ‡Department of Emergency Medicine, Lutheran Hospital, Brooklyn, New York Reprint Address: Daniel J. Egan, MD, Department of Emergency Medicine, NYU School of Medicine, 462 First Avenue, Suite A345, New York, NY 10016
were normal. On abdominal inspection, a well-healed midline laparotomy scar was noted, without any skin color change, swelling, or hernias. There was superficial abdominal wall tenderness without any discreet mass in the location where the patient felt a lump. To the right of the midline and below the costal margin, a nontender pulsatile mass was noted with a thrill and bruit. Peripheral pulses were equal in all extremities and there was no edema. The neurologic examination was normal. The patient first noticed the pulsatile mass 4 years earlier but had never sought medical evaluation. The emergency physician then performed a bedside ultrasound examination of the abdominal aorta. An area of saccular aneurysmal dilation was identified on each side of the abdominal aorta (Figure 1). The right-sided aneurysm extended into a markedly enlarged inferior vena cava (IVC). An area of communication was noted between the right-sided aneurysm and the IVC suspicious for an aortocaval fistula (Figure 2). Color Doppler interrogation of the area showed turbulent flow in the area of the communication (Video 1). There was no free intraperitoneal fluid identified. The Vascular Surgery service was consulted. Computed tomography (CT) confirmed the bedside diagnosis of bilateral infrarenal abdominal aortic saccular aneurysms, with the right aneurysm connecting to the IVC by a 1-cm fistula (Figures 3, 4). The IVC was markedly
CASE REPORT A 27-year-old man presented to the Emergency Department with abdominal pain for 4 days. The pain began acutely after sit-ups in the area of a midline scar. He described it as tearing, nonradiating, constant, and worsened by moving, laughing, or coughing. He rated his pain as a 2 out of 10. The patient denied any associated fever, chills, nausea, vomiting, diarrhea, or change in bowel habits. He had never had similar pain. The patient also reported that he felt a lump on his left upper abdomen, neither in the region of his scar nor his pain. The patient denied any medical history except for an exploratory laparotomy 11 years prior for a penetrating abdominal injury from an ice pick. The patient was comfortable and in no distress. Vital signs included an oral temperature of 36.7 C (98.1 F), blood pressure of 108/42 mm Hg, heart rate of 81 beats/ min, respiratory rate of 16 breaths/min, and oxygen saturation of 98% on room air. Cardiac and lung examinations
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 26 September 2013; FINAL SUBMISSION RECEIVED: 6 January 2014; ACCEPTED: 10 February 2014 1
2
D. J. Egan et al.
Figure 1. Transverse ultrasound image of the proximal abdominal aorta. The aorta is associated with a saccular aneurysm on both side walls. The right-sided aneurysm connects with a distended inferior vena cava (IVC).
enlarged with associated distension of the intrahepatic veins. The CT scan did not demonstrate evidence of vascular rupture. The patient was admitted to the Vascular Surgery service for planned surgical intervention. DISCUSSION Approximately 80% of cases of aortocaval fistulae occur as a result of an abdominal aortic aneurysm (AAA) (1,2). With increasing intravascular pressure, the AAA erodes into the wall of the IVC, creating a fistula in 1% of nonruptured and 6% of ruptured AAAs (1). Aortocaval fistulae may also develop from bullet fragments or stab wounds causing vascular injury in penetrating trauma (2–4). Patients may present years after exploratory laparotomy (3). A lumbar laminectomy procedure is the most common iatrogenic cause of an aortocaval fistula (2–4).
Figure 2. Transverse ultrasound image of the proximal abdominal aorta. A fistula is visible between a saccular aneurysm of the aorta and the inferior vena cava (IVC) (*).
Figure 3. Computed tomography angiogram image of the upper abdomen. A 1-cm fistula connects the right saccular aortic aneurysm to the inferior vena cava (IVC) (*).
Classically, patients present with abdominal pain (often from AAA rupture), a pulsatile abdominal mass, and an abdominal bruit (1,5). Untreated, aortocaval fistulae may lead to multiple complications, including
Figure 4. Computed tomography angiogram threedimensional reconstruction. A fistula connects the aorta with the inferior vena cava (IVC) (*).
Ultrasound Diagnosis of Aortocaval Fistula
renal insufficiency, high-output cardiac failure, lowerextremity edema, paradoxical pulmonary emboli, and death (1,5,6). CT angiography is the gold standard for diagnosis, though may be a challenging study to obtain, as renal insufficiency is seen in up to 11.8–33% of cases (5). The diagnosis is missed preoperatively as often as 52% of the time, complicating surgical management of AAA repair when the fistula is discovered intraoperatively (7). Fistulae may be corrected with either open or endovascular surgical techniques, although the endovascular repair seems to have better patient outcomes (2,8). Magnetic resonance angiography may be considered if CT angiography is contraindicated (5). Additionally, diagnoses made by Doppler ultrasonography performed in the radiology department have been reported, including one case of a 16-year-old presenting with blunt abdominal trauma several months after a fall (9,10). In this report, we present the first case of an emergency physician diagnosis of aortocaval fistula using bedside ultrasound. Immediately after making the diagnosis, the emergency physicians promptly obtained specialist consultation and performed additional imaging for operative planning. REFERENCES 1. Akwei S, Altaf N, Tennant W, MacSweeney S, Braithwaite B. Emergency endovascular repair of aortocaval fistula–a single center experience. Vasc Endovascular Surg 2011;45:442–5.
3 2. Brightwell RE, Pegna V, Boyne N. Aortocaval fistula: current management strategies. ANZ J Surg 2013;83:31–83. 3. Spencer TA, Smyth SH, Wittich G, Hunter GC. Delayed presentation of traumatic aortocaval fistula: a report of two cases and a review of the associated compensatory hemodynamic and structural changes. J Vasc Surg 2006;43:836–43. 4. Waldrop JL Jr, Dart BW 4th, Barker DE. Endovascular stent graft treatment of a traumatic aortocaval fistula. Ann Vasc Surg 2005; 19:562–5. 5. Bhatia M, Platon A, Khabiri E, Becker C, Poletti P-A. Contrast enhanced ultrasonography versus MR angiography in aortocaval fistula: case report. Abdom Imaging 2010;35:376–80. 6. Thet Y, Ranjit A, Ravi R, Khand A. High output cardiac failure and paradoxical pulmonary emboli secondary to aortocaval fistula. Postgrad Med J 2012;88:613–88. 7. Lebon A, Agueznai M, Labombarda F. High-output heart failure resulting from chronic aortocaval fistula. Circulation 2013;127: 527–8. 8. Antoniou GA, Koutsias S, Karathanos C, Sfyroeras GS, Vretzakis G, Giannoukas AD. Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review. J Endovasc Ther 2009;16:514–6. 9. Daxini BV, Desai AG, Sharma S. Echo-Doppler diagnosis of aortocaval fistula following blunt trauma to abdomen. Am Heart J 1989; 118:843–4. 10. Bolognesi R, Tsialtas D, Manca C. Diagnosis of an aorto-caval fistula by echo 2D color Doppler flow imaging and echocardiographic probe. Cardiology 1991;79:151–79.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10. 1016/j.jemermed.2014.02.011.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
