Case Study
Ruptured abdominal aortic aneurysm and aortoiliac vein fistula
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(4) 449–451 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313513599 aan.sagepub.com
Takayuki Gyoten1, Toshio Doi1, Akio Yamashita2, Kazuaki Fukahara2, Keiju Kotoh3 and Naoki Yoshimura2
Abstract A 67-year-old man was admitted with severe abdominal pain and back pain. Computed tomography showed an infrarenal abdominal aortic aneurysm (8.4 8.3 cm) and a large retroperitoneal hematoma. Immediately afterwards, the patient suffered circulatory collapse and was rushed to the operating theater. A fistula communicating with the left iliac vein was found. It was repaired with a Dacron patch while balloon-tipped catheters controlled the bleeding. The abdominal aortic aneurysm was replaced with a bifurcated graft. The postoperative course was uneventful. There have been few reports of successful repair of a ruptured abdominal aortic aneurysm associated with aortoiliac arteriovenous fistula.
Keywords Aortic aneurysm, abdominal, aortic rupture, arteriovenous fistula, blood vessel prosthesis implantation, iliac artery, venae cavae
Introduction Rupture of an abdominal aortic aneurysm (AAA) or iliac aneurysm into the inferior vena cava (IVC) or iliac vein is rare, accounting for 3% to 4% of all ruptured abdominal aneurysms.1 Classic symptoms of aortoiliac arteriovenous fistula (AVF) are relatively uncommon, so a preoperative diagnosis is only made in 0% to 50% of patients.2 AVF associated with retroperitoneal rupture of an AAA has a much worse prognosis than uncomplicated AVF. Here we report the successful repair of a ruptured AAA associated with an aortoiliac AVF and discuss the surgical modifications required in this emergency situation.
Case report A 67-year-old man with hypertension was admitted 6 h after the onset of severe abdominal pain and back pain. He was anemic (hemoglobin 8.4 gdL 1) with a low systolic blood pressure of 80 mm Hg and a central venous pressure of 15 cm H2O. Both common femoral arteries were palpable, he had no leg edema, and there was a soft abdominal bruit. Computed tomography (CT) showed an infrarenal AAA (8.4 8.3 cm) with a large contained retroperitoneal hematoma and IVC compression by the aneurysm (Figure 1). Angiography was
not performed. Just after CT, circulatory collapse occurred and the patient was rushed to the operating theater. The AAA (8.5 9.0 cm) and a large retroperitoneal hematoma were identified via the transperitoneal approach. After heparinization, the infrarenal aorta was clamped, the aneurysm was opened, and the bilateral common iliac arteries were occluded with balloontipped catheters. Then we detected a fistula that communicated with the left iliac vein via a 2.0-cm intimal defect in the posterior aortic wall at 1.0 cm proximal to the bifurcation. Massive venous bleeding was controlled by another balloon-tipped catheter (Figure 2), and the fistula was closed with a Dacron patch and running sutures of 5/0 polypropylene. The AAA was replaced with a 16 8-mm bifurcated Hemashield graft (Boston Scientific, Boston, MA, USA). Aortic 1 Department of Cardiovascular Surgery, JA Nagano Koseiren Shinonoi General Hospital, Nagano, Japan 2 First Department of Surgery, University of Toyama, Toyama, Japan 3 Department of Cardiovascular Surgery, Bando Hospital, Toyama, Japan
Corresponding author: Takayuki Gyoten, Department of Cardiovascular Surgery, JA Nagano Koseiren Shinonoi General Hospital, Nagano, Japan 666-1 Shinonoiai, Nagano, 388-8004, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at University College London on June 5, 2016
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Asian Cardiovascular & Thoracic Annals 23(4)
Figure 1. Computed tomography showing the ruptured abdominal aortic aneurysm (8.4 8.3 cm) and a large retroperitoneal hematoma (arrow). The inferior vena cava (arrowhead) is compressed by the abdominal aortic aneurysm.
clamp time was 32 min and operating time was 214 min. The patient recovered uneventfully and was discharged on postoperative day 18.
Discussion Since the first successful repair of an aortocaval fistula in the 1950s, several reports of abdominal AVF have been published. Aortoiliac AVF is a rare but life-threatening, complication of AAA. An AVF is found during surgery in 1% of all AAA patients and in 4% of those with ruptured aneurysms.3 Early mortality ranges from 16% to 66%, while the surgical mortality rate is 22% to 51%.4 McAuley and colleagues5 reported a triad of signs associated with aortoiliac AVF: high-output cardiac failure, a pulsatile abdominal mass accompanied by a thrill and bruit, and unilateral lower extremity ischemia or venous engorgement. Brewster and colleagues1 reported cardiac failure, abdominal bruit, and lower extremity edema in 35%, 80%, and 40% of their patients, respectively; our patient only had a soft abdominal bruit. Multidetector row CT can usually detect a fistula, it is valuable for diagnosing AVF and provides details of the vascular anatomy. In contrast, Calligaro and colleagues6 reported that unenhanced CT cannot detect AVF. Our patient could not undergo multidetector row CT because of poor renal function, so we did not detect the AVF preoperatively. Emergency surgery is essential in patients with hemodynamic collapse. According to Robertson and colleagues,7 fistulas larger than 1.5 cm in diameter are incompatible with survival due to progressive hemodynamic changes, including a sudden increase of IVC
Figure 2. Intraoperative photograph. A balloon-tipped catheter is inserted through the fistula to control bleeding. The fistula is 2.0 cm in diameter.
pressure and blood flow with renal venous hypertension, pulmonary congestion, and expansion of interstitial fluid. Interestingly, our patient had a large AVF (2 cm), but his central venous pressure was normal. Congestive heart failure may not have developed because IVC compression by the aneurysm prevented venous pressure elevation. Surgical treatment of AAA with AVF includes repair of the fistula, usually by direct suture, and aneurysm replacement with a prosthetic graft. Venous bleeding from the fistula can be massive, so careful control with digital compression, embolic material, or balloon catheters is essential.6 We tried direct digital compression but the fistula was too large, so we employed a balloon-tipped catheter to control the bleeding before closing the fistula. Some reports have described endovascular repair of AVF with a covered wall stent, and this might become an attractive alternative in the future, especially in elderly patients with comorbidities.8 Successful surgery for ruptured AAA associated with AVF depends on early detection and prompt control of bleeding. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Brewster DC, Cambria RP, Moncure AC, et al. Aortocaval and iliac arteriovenous fistulas: recognition and treatment. J Vasc Surg 1991; 13: 253–264. 2. Gilling-Smith GL and Mansfield AO. Spontaneous abdominal arteriovenous fistulae: report of eight cases
Downloaded from aan.sagepub.com at University College London on June 5, 2016
Gyoten et al.
3.
4. 5.
6.
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and review of the literature [Review]. Br J Surg 1991; 78: 421–425. Baker WH, Sharzer LA and Ehrenhaft JL. Aortocaval fistula as a complication of abdominal aortic aneurysms. Surgery 1972; 72: 933–938. Alexander JJ and Imbembo AL. Aorta-vena cava fistula [Review]. Surgery 1989; 105: 1–12. McAuley CE, Peitzman AB, deVries EJ, Silver MR, Steed DL and Webster MW. The syndrome of spontaneous iliac arteriovenous fistula: a distinct clinical and pathophysiologic entity. Surgery 1986; 99: 373–377. Calligaro KD, Savarese RP and DeLaurentis DA. Unusual aspects of aortovenous fistulas associated with
ruptured abdominal aortic aneurysms [Review]. J Vasc Surg 1990; 12: 586–590. 7. Robertson MG. Spontaneous rupture of an abdominal aortic aneurysm into the inferior vena cava. Report of a case, with successful repair. Am J Med 1967; 42: 1011–1016. 8. Hart JP, Wallis F, Kenny B, O’Sullivan B, Burke PE and Grace PA. Endovascular exclusion of iliac artery to iliac vein fistula after lumbar disk surgery. J Vasc Surg 2003; 37: 1091–1093.
Downloaded from aan.sagepub.com at University College London on June 5, 2016
Ruptured abdominal aortic aneurysm and aortoiliac vein fistula
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(4) 449–451 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313513599 aan.sagepub.com
Takayuki Gyoten1, Toshio Doi1, Akio Yamashita2, Kazuaki Fukahara2, Keiju Kotoh3 and Naoki Yoshimura2
Abstract A 67-year-old man was admitted with severe abdominal pain and back pain. Computed tomography showed an infrarenal abdominal aortic aneurysm (8.4 8.3 cm) and a large retroperitoneal hematoma. Immediately afterwards, the patient suffered circulatory collapse and was rushed to the operating theater. A fistula communicating with the left iliac vein was found. It was repaired with a Dacron patch while balloon-tipped catheters controlled the bleeding. The abdominal aortic aneurysm was replaced with a bifurcated graft. The postoperative course was uneventful. There have been few reports of successful repair of a ruptured abdominal aortic aneurysm associated with aortoiliac arteriovenous fistula.
Keywords Aortic aneurysm, abdominal, aortic rupture, arteriovenous fistula, blood vessel prosthesis implantation, iliac artery, venae cavae
Introduction Rupture of an abdominal aortic aneurysm (AAA) or iliac aneurysm into the inferior vena cava (IVC) or iliac vein is rare, accounting for 3% to 4% of all ruptured abdominal aneurysms.1 Classic symptoms of aortoiliac arteriovenous fistula (AVF) are relatively uncommon, so a preoperative diagnosis is only made in 0% to 50% of patients.2 AVF associated with retroperitoneal rupture of an AAA has a much worse prognosis than uncomplicated AVF. Here we report the successful repair of a ruptured AAA associated with an aortoiliac AVF and discuss the surgical modifications required in this emergency situation.
Case report A 67-year-old man with hypertension was admitted 6 h after the onset of severe abdominal pain and back pain. He was anemic (hemoglobin 8.4 gdL 1) with a low systolic blood pressure of 80 mm Hg and a central venous pressure of 15 cm H2O. Both common femoral arteries were palpable, he had no leg edema, and there was a soft abdominal bruit. Computed tomography (CT) showed an infrarenal AAA (8.4 8.3 cm) with a large contained retroperitoneal hematoma and IVC compression by the aneurysm (Figure 1). Angiography was
not performed. Just after CT, circulatory collapse occurred and the patient was rushed to the operating theater. The AAA (8.5 9.0 cm) and a large retroperitoneal hematoma were identified via the transperitoneal approach. After heparinization, the infrarenal aorta was clamped, the aneurysm was opened, and the bilateral common iliac arteries were occluded with balloontipped catheters. Then we detected a fistula that communicated with the left iliac vein via a 2.0-cm intimal defect in the posterior aortic wall at 1.0 cm proximal to the bifurcation. Massive venous bleeding was controlled by another balloon-tipped catheter (Figure 2), and the fistula was closed with a Dacron patch and running sutures of 5/0 polypropylene. The AAA was replaced with a 16 8-mm bifurcated Hemashield graft (Boston Scientific, Boston, MA, USA). Aortic 1 Department of Cardiovascular Surgery, JA Nagano Koseiren Shinonoi General Hospital, Nagano, Japan 2 First Department of Surgery, University of Toyama, Toyama, Japan 3 Department of Cardiovascular Surgery, Bando Hospital, Toyama, Japan
Corresponding author: Takayuki Gyoten, Department of Cardiovascular Surgery, JA Nagano Koseiren Shinonoi General Hospital, Nagano, Japan 666-1 Shinonoiai, Nagano, 388-8004, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at University College London on June 5, 2016
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Asian Cardiovascular & Thoracic Annals 23(4)
Figure 1. Computed tomography showing the ruptured abdominal aortic aneurysm (8.4 8.3 cm) and a large retroperitoneal hematoma (arrow). The inferior vena cava (arrowhead) is compressed by the abdominal aortic aneurysm.
clamp time was 32 min and operating time was 214 min. The patient recovered uneventfully and was discharged on postoperative day 18.
Discussion Since the first successful repair of an aortocaval fistula in the 1950s, several reports of abdominal AVF have been published. Aortoiliac AVF is a rare but life-threatening, complication of AAA. An AVF is found during surgery in 1% of all AAA patients and in 4% of those with ruptured aneurysms.3 Early mortality ranges from 16% to 66%, while the surgical mortality rate is 22% to 51%.4 McAuley and colleagues5 reported a triad of signs associated with aortoiliac AVF: high-output cardiac failure, a pulsatile abdominal mass accompanied by a thrill and bruit, and unilateral lower extremity ischemia or venous engorgement. Brewster and colleagues1 reported cardiac failure, abdominal bruit, and lower extremity edema in 35%, 80%, and 40% of their patients, respectively; our patient only had a soft abdominal bruit. Multidetector row CT can usually detect a fistula, it is valuable for diagnosing AVF and provides details of the vascular anatomy. In contrast, Calligaro and colleagues6 reported that unenhanced CT cannot detect AVF. Our patient could not undergo multidetector row CT because of poor renal function, so we did not detect the AVF preoperatively. Emergency surgery is essential in patients with hemodynamic collapse. According to Robertson and colleagues,7 fistulas larger than 1.5 cm in diameter are incompatible with survival due to progressive hemodynamic changes, including a sudden increase of IVC
Figure 2. Intraoperative photograph. A balloon-tipped catheter is inserted through the fistula to control bleeding. The fistula is 2.0 cm in diameter.
pressure and blood flow with renal venous hypertension, pulmonary congestion, and expansion of interstitial fluid. Interestingly, our patient had a large AVF (2 cm), but his central venous pressure was normal. Congestive heart failure may not have developed because IVC compression by the aneurysm prevented venous pressure elevation. Surgical treatment of AAA with AVF includes repair of the fistula, usually by direct suture, and aneurysm replacement with a prosthetic graft. Venous bleeding from the fistula can be massive, so careful control with digital compression, embolic material, or balloon catheters is essential.6 We tried direct digital compression but the fistula was too large, so we employed a balloon-tipped catheter to control the bleeding before closing the fistula. Some reports have described endovascular repair of AVF with a covered wall stent, and this might become an attractive alternative in the future, especially in elderly patients with comorbidities.8 Successful surgery for ruptured AAA associated with AVF depends on early detection and prompt control of bleeding. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Brewster DC, Cambria RP, Moncure AC, et al. Aortocaval and iliac arteriovenous fistulas: recognition and treatment. J Vasc Surg 1991; 13: 253–264. 2. Gilling-Smith GL and Mansfield AO. Spontaneous abdominal arteriovenous fistulae: report of eight cases
Downloaded from aan.sagepub.com at University College London on June 5, 2016
Gyoten et al.
3.
4. 5.
6.
451
and review of the literature [Review]. Br J Surg 1991; 78: 421–425. Baker WH, Sharzer LA and Ehrenhaft JL. Aortocaval fistula as a complication of abdominal aortic aneurysms. Surgery 1972; 72: 933–938. Alexander JJ and Imbembo AL. Aorta-vena cava fistula [Review]. Surgery 1989; 105: 1–12. McAuley CE, Peitzman AB, deVries EJ, Silver MR, Steed DL and Webster MW. The syndrome of spontaneous iliac arteriovenous fistula: a distinct clinical and pathophysiologic entity. Surgery 1986; 99: 373–377. Calligaro KD, Savarese RP and DeLaurentis DA. Unusual aspects of aortovenous fistulas associated with
ruptured abdominal aortic aneurysms [Review]. J Vasc Surg 1990; 12: 586–590. 7. Robertson MG. Spontaneous rupture of an abdominal aortic aneurysm into the inferior vena cava. Report of a case, with successful repair. Am J Med 1967; 42: 1011–1016. 8. Hart JP, Wallis F, Kenny B, O’Sullivan B, Burke PE and Grace PA. Endovascular exclusion of iliac artery to iliac vein fistula after lumbar disk surgery. J Vasc Surg 2003; 37: 1091–1093.
Downloaded from aan.sagepub.com at University College London on June 5, 2016
