Ruptured Iliac Artery Aneurysm Presenting as Acute Right Heart Failure and Cardiac Arrest Maarten J.A. Loos,1 Marian Scheer,2 Jordanus A. van der Vliet,3 and Michiel C. Warle,3 Veldhoven, Arnhem, and Nijmegen, The Netherlands
Aortocaval fistula due to aneurysmal degradation can result in obscure clinical signs but with lifethreatening sequelae. Our patient presented with multiple cardiac arrests because of sudden right heart decompensation after a ruptured iliac aneurysm into the adjacent iliac vein. He fully recovered after emergency open surgical repair. High awareness with subtle clinical signs is of great importance.
Spontaneous rupture of a common iliac artery aneurysm into the adjacent vein is a rare event, occurring in 2e4% of all ruptured aneurysms1. Signs and symptoms result from venous hypertension and form a life-threatening condition. Urgent treatment is warranted and consists in open surgical, endovascular, or hybrid repair. We describe a case with cardiac arrest after a rupture of an isolated iliac aneurysm into the iliac vein.
Funding: None. Conflicts of Interest: The authors of this article have no conflicts of interest to disclose. 1 Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands. 2 Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands. 3 Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. Correspondence to: Michiel C. Warle, MD, PhD, Division of Vascular & Transplant Surgery, Department of Surgery, Radboud University Nijmegen Medical Center, Geert Grooteplein-Zuid 10, Nijmegen 6525 GA, The Netherlands; E-mail: [email protected]
Ann Vasc Surg 2015; 29: 363.e5e363.e7 http://dx.doi.org/10.1016/j.avsg.2014.08.029 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: July 3, 2014; manuscript accepted: August 27, 2014; published online: November 22, 2014.
CASE REPORT A 68-year-old male patient presented at the emergency department with collapse, hypotension, and bradycardia. His medical history was uneventful. The previous day he had suddenly developed left-sided abdominal pain. On his way to the hospital, he collapsed with cardiac arrest after which successful cardiac resuscitation was performed. An abdominal ultrasound revealed an isolated left common iliac artery aneurysm and a dilated inferior caval vein. A computed tomography (CT) scan revealed a left common iliac artery aneurysm ruptured into the common iliac vein (Fig. 1). Another 2 episodes of pulseless electric activity ensued, which were treated successfully. Immediate transfer to the operating theater took place. Laparotomy was performed and a thrill over a widened caval vein was felt. After cross clamping the caval vein, and subsequently, the distal aorta hemodynamics significantly improved. The common iliac aneurysm was exposed and a Satinsky clamp was placed over the arteriovenous fistula. The aneurysm was opened and a large tear in the iliac artery wall communicating with the iliac vein was noticed (Fig. 2). The fistula was closed from inside the artery and a Dacron tube prosthesis was anastomosed between the aortic and iliac bifurcation. Postoperatively, the patient remained hemodynamically stable. At the intensive care unit, a cardiac arrest cooling protocol was initiated. He developed acute kidney failure, which made a complete recovery after continuous hemodialysis. His initial postanoxic encephalopathy improved after a week. Nine days after the event, he was transferred to the surgical ward, where he made a remarkable recovery. After a few weeks, he
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Fig. 1. Left common iliac artery aneurysm ruptured into the common iliac vein.
Fig. 2. Ventral view of opened left iliac aneurysm with a large tear in the dorsal iliac artery wall communicating with the iliac vein.
was discharged from the hospital. At 2-month follow-up, he is still in good health.
Annals of Vascular Surgery
been described in the literature. This is probably because of the rarity of both ilioeiliac fistula and cardiac arrest as the initial clinical sign. Aortocaval fistula is encountered much more often with an estimated incidence of 2e4% in all ruptured abdominal aortic aneurysms.1 Iatrogenic fistula due to penetrating injury or lumbar disk surgery has also been described.2 Cardiac arrest as the presenting sign of acute arteriovenous fistula is rare. The triad of rapid-onset high-output cardiac failure, pulsatile pelvic mass accompanied by a thrill and bruit, and unilateral lower extremity edema or venous engorgement is classic.3 However, these features may be absent in approximately half of the patients. Ghilardi et al.4 describe 26 cases of rupture of an abdominal aorta aneurysm into an abdominal vein: pain was always present, an abdominal murmur or thrill in 62% of the patients and edema of 1 or both the lower limbs in 35%. One patient died of cardiac arrest. Absence of classic features, together with the rarity of fistula formation may cause a diagnostic delay. A CT scan can provide valuable information showing contrast in both aorta and vein. Urgent surgical treatment should follow. This includes open repair of the fistula usually with a Dacron interposition graft and direct suturing of the fistula from inside the artery. In general, such repairs are accompanied with major blood loss, and embolization of aneurysmal debris through the fistula should be prevented. In the past decade, endovascular aortic repair or hybrid techniques have been described. In case of anatomic suitability and certain hemodynamic stability, total endovascular repair can be considered. However, persisting type II endoleak necessitating additional suturing of the fistula may be necessary.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. In conclusion, there should be a high awareness to subtle signs of aortocaval or ilioeiliac fistula making the initial diagnosis difficult. Yet, as demonstrated in the presented case, surgical treatment can result in a full recovery despite multiple cardiac arrests.
DISCUSSION
REFERENCES
To our knowledge, cardiac arrest as the initial sign of an iliac aneurysm ruptured into the iliac vein has not
1. Davis PM, Gloviczki P, Cherry KJ Jr, et al. Aorto-caval and ilio-iliac arteriovenous fistulae. Am J Surg 1998;176:115e8.
Vol. 29, No. 2, February 2015
2. Kwon TW, Sung KB, Cho YP, et al. Large vessel injury following operation for a herniated lumbar disc. Ann Vasc Surg 2003;17:438e44. 3. McAuley CE, Peitzman AB, deVries EJ, et al. The syndrome of spontaneous iliac arteriovenous fistula: a distinct clinical and pathophysiologic entity. Surgery 1986;99: 373e7. 4. Ghilardi G, Scorza R, Bortolani E, et al. Rupture of abdominal aortic aneurysms into the major abdominal veins. J Cardiovasc Surg 1993;34:39e47.
Case reports 363.e7
5. Jeuri€ens-van de Ven SAH, Schouten van der Velden AP, Schultze Kool LJM, et al. Persisting aorto-caval fistula after EVAR maintained by a type II endoleak. Ann Vasc Surg 2011;25:1142e7. 6. Van de Luijtgaarden KM, Bastos Gonc¸alves F, Rouwet EV, et al. Conservative management of persistent aortocaval fistula after endovascular repair. J Vasc Surg 2013;58:1080e3. 7. Siepe M, Koeppe S, Eurringer W, et al. Aorto-caval fistula from an acute rupture of an abdominal aortic aneurysm treated with hybrid approach. J Vasc Surg 2009;49:1574e6.
Aortocaval fistula due to aneurysmal degradation can result in obscure clinical signs but with lifethreatening sequelae. Our patient presented with multiple cardiac arrests because of sudden right heart decompensation after a ruptured iliac aneurysm into the adjacent iliac vein. He fully recovered after emergency open surgical repair. High awareness with subtle clinical signs is of great importance.
Spontaneous rupture of a common iliac artery aneurysm into the adjacent vein is a rare event, occurring in 2e4% of all ruptured aneurysms1. Signs and symptoms result from venous hypertension and form a life-threatening condition. Urgent treatment is warranted and consists in open surgical, endovascular, or hybrid repair. We describe a case with cardiac arrest after a rupture of an isolated iliac aneurysm into the iliac vein.
Funding: None. Conflicts of Interest: The authors of this article have no conflicts of interest to disclose. 1 Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands. 2 Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands. 3 Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. Correspondence to: Michiel C. Warle, MD, PhD, Division of Vascular & Transplant Surgery, Department of Surgery, Radboud University Nijmegen Medical Center, Geert Grooteplein-Zuid 10, Nijmegen 6525 GA, The Netherlands; E-mail: [email protected]
Ann Vasc Surg 2015; 29: 363.e5e363.e7 http://dx.doi.org/10.1016/j.avsg.2014.08.029 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: July 3, 2014; manuscript accepted: August 27, 2014; published online: November 22, 2014.
CASE REPORT A 68-year-old male patient presented at the emergency department with collapse, hypotension, and bradycardia. His medical history was uneventful. The previous day he had suddenly developed left-sided abdominal pain. On his way to the hospital, he collapsed with cardiac arrest after which successful cardiac resuscitation was performed. An abdominal ultrasound revealed an isolated left common iliac artery aneurysm and a dilated inferior caval vein. A computed tomography (CT) scan revealed a left common iliac artery aneurysm ruptured into the common iliac vein (Fig. 1). Another 2 episodes of pulseless electric activity ensued, which were treated successfully. Immediate transfer to the operating theater took place. Laparotomy was performed and a thrill over a widened caval vein was felt. After cross clamping the caval vein, and subsequently, the distal aorta hemodynamics significantly improved. The common iliac aneurysm was exposed and a Satinsky clamp was placed over the arteriovenous fistula. The aneurysm was opened and a large tear in the iliac artery wall communicating with the iliac vein was noticed (Fig. 2). The fistula was closed from inside the artery and a Dacron tube prosthesis was anastomosed between the aortic and iliac bifurcation. Postoperatively, the patient remained hemodynamically stable. At the intensive care unit, a cardiac arrest cooling protocol was initiated. He developed acute kidney failure, which made a complete recovery after continuous hemodialysis. His initial postanoxic encephalopathy improved after a week. Nine days after the event, he was transferred to the surgical ward, where he made a remarkable recovery. After a few weeks, he
363.e5
363.e6 Case reports
Fig. 1. Left common iliac artery aneurysm ruptured into the common iliac vein.
Fig. 2. Ventral view of opened left iliac aneurysm with a large tear in the dorsal iliac artery wall communicating with the iliac vein.
was discharged from the hospital. At 2-month follow-up, he is still in good health.
Annals of Vascular Surgery
been described in the literature. This is probably because of the rarity of both ilioeiliac fistula and cardiac arrest as the initial clinical sign. Aortocaval fistula is encountered much more often with an estimated incidence of 2e4% in all ruptured abdominal aortic aneurysms.1 Iatrogenic fistula due to penetrating injury or lumbar disk surgery has also been described.2 Cardiac arrest as the presenting sign of acute arteriovenous fistula is rare. The triad of rapid-onset high-output cardiac failure, pulsatile pelvic mass accompanied by a thrill and bruit, and unilateral lower extremity edema or venous engorgement is classic.3 However, these features may be absent in approximately half of the patients. Ghilardi et al.4 describe 26 cases of rupture of an abdominal aorta aneurysm into an abdominal vein: pain was always present, an abdominal murmur or thrill in 62% of the patients and edema of 1 or both the lower limbs in 35%. One patient died of cardiac arrest. Absence of classic features, together with the rarity of fistula formation may cause a diagnostic delay. A CT scan can provide valuable information showing contrast in both aorta and vein. Urgent surgical treatment should follow. This includes open repair of the fistula usually with a Dacron interposition graft and direct suturing of the fistula from inside the artery. In general, such repairs are accompanied with major blood loss, and embolization of aneurysmal debris through the fistula should be prevented. In the past decade, endovascular aortic repair or hybrid techniques have been described. In case of anatomic suitability and certain hemodynamic stability, total endovascular repair can be considered. However, persisting type II endoleak necessitating additional suturing of the fistula may be necessary.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. In conclusion, there should be a high awareness to subtle signs of aortocaval or ilioeiliac fistula making the initial diagnosis difficult. Yet, as demonstrated in the presented case, surgical treatment can result in a full recovery despite multiple cardiac arrests.
DISCUSSION
REFERENCES
To our knowledge, cardiac arrest as the initial sign of an iliac aneurysm ruptured into the iliac vein has not
1. Davis PM, Gloviczki P, Cherry KJ Jr, et al. Aorto-caval and ilio-iliac arteriovenous fistulae. Am J Surg 1998;176:115e8.
Vol. 29, No. 2, February 2015
2. Kwon TW, Sung KB, Cho YP, et al. Large vessel injury following operation for a herniated lumbar disc. Ann Vasc Surg 2003;17:438e44. 3. McAuley CE, Peitzman AB, deVries EJ, et al. The syndrome of spontaneous iliac arteriovenous fistula: a distinct clinical and pathophysiologic entity. Surgery 1986;99: 373e7. 4. Ghilardi G, Scorza R, Bortolani E, et al. Rupture of abdominal aortic aneurysms into the major abdominal veins. J Cardiovasc Surg 1993;34:39e47.
Case reports 363.e7
5. Jeuri€ens-van de Ven SAH, Schouten van der Velden AP, Schultze Kool LJM, et al. Persisting aorto-caval fistula after EVAR maintained by a type II endoleak. Ann Vasc Surg 2011;25:1142e7. 6. Van de Luijtgaarden KM, Bastos Gonc¸alves F, Rouwet EV, et al. Conservative management of persistent aortocaval fistula after endovascular repair. J Vasc Surg 2013;58:1080e3. 7. Siepe M, Koeppe S, Eurringer W, et al. Aorto-caval fistula from an acute rupture of an abdominal aortic aneurysm treated with hybrid approach. J Vasc Surg 2009;49:1574e6.
