Spontaneous Aortocaval Fistula : A Case Report

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CASE REPORT
Spontaneous Aortocaval Fistula : A Case Report
Mohammed A. Rashaideh , Omar N. Al-Zoubi , Eman H. Shaqdih
Abstract:
Spontaneous Aortocaval fistula ( ACF) is a rare complication in Abdominal aortic aneurysm
and associated with high morbidity and mortality. The diagnosis can be difficult due to variable presentation . it can present as acute symptoms of heart failure, renal failure , abdominal
pain and lower limbs venous hypertension ,with pulsatile tender abdominal mass . We present a case of spontaneous aortocaval fistula in a 50 year old male patient who presented with
symptoms and signs of heart failure and abdominal pain of 2 weeks duration, was urgently
treated using transperitoneal repair of aortocaval fistula (ACF) and aortic aneurysm.
Keywords: Aortocaval fistula, , heart failure, venous hypertention.
King Hussin Medical
Center (KHMC) ,Royal
Medical Services( RMS)
/Amman-Jordan.
M A Rashaideh
ON Al-Zoubi
EH Shaqdih
Correspondence:
Mohammed Rashaideh,
MD, Vascular Department,
King Hussein medical
center( KHMC), Royal
medical services(RMS). /
Amman, Jordan.
Tel: +962795121977 ,
Email: drmohahmed@
gmail.com
Pak J Surg 2014; 30(1):103-105
Introduction:
Spontaneous aortocaval fistula ( ACF) is a rare
complication of abdominal aortic aneurysm reported in 1% of all aortic aneurysms and in 4%
in ruptured aortic aneurysms.1,2 Preoperative
diagnosis is very important to avoid excessive
blood loss during surgical repair. Patients usually present with abdominal pain and pulsatile
mass associated with symptoms and signs of
heart failure.1,3 Computed Tomography Angiogram (CTA) findings of early Inferior vena cava
(IVC) contrast enhancement and obvious communication between the aorta and the inferior
vena cava( IVC) confirm the diagnosis. Perioperative avoidance of massive blood loss, hemodynamic instability and venous thrombosis with
pulmonary embolism is crucial for successful
surgical repair. Surgical technique of repairing
the fistula from within the sac first and then repairing the aneurysm is well standardized .
Case Report:
A 50 year old male patient with a long standing
smoking history and hypertention presented
to emergency department with 2 weeks duration of abdominal pain and bilateral lower limb
edema and recent history of shortness of breath
with chest pain.
on physical examination the patient was stable
but found to have tachycardia with heart rate
of 120/min, tachypnea, massive bilateral lower
limb edema and pulsatile abdominal mass with
machinery murmur all over the abdomen , chest
auscultation revealed diffuse bilateral rales and
crackels with decreased air entry on lower chest.
ECG was normal except for tachycardia, chest
X-Ray(CXR) revealed bilateral pleural effusion
and signs of pulmonary edema( Figure 1). Oxygen saturation was 90%. All routine laboratory
results were normal.
Abdominal ultrasound showed large abdominal
aortic aneurysm. Computed Tomography Angiogram (CTA) of chest ,abdomen and lower
limbs done and revealed early enhancement of
IVC( Figure 2), clear communication between
lower abdominal aorta and IVC( Figure 3) and
bilateral pleural effusion ( Figure 4).
After diagnosis of Aortocaval fistula was confirmed, Patient was prepared and underwent
urgent surgical repair using midline laparatomy
with transperitoneal control of infra-renal aorta
and IVC then opening of the aneurysmal sac
done with compressive control of the IVC us-
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MA Rashaideh , ON Al-Zoubi, EH Shaqdih
Figure 1: Chest X-Ray showing Figure 2: CTA showing early en- Figure 3: CTA showing the com- Figure 4: CTA showing bilateral
bilateral effusion and pulmonary hancement of the IVC.
munication between the Aorta and pleural effusion
edema
IVC
ing sponge on sticks, closure of the fistula done
using prolene 3/0. then repair of the aneurysm
using interposition dacron tube graft.
Post operative course was smooth and the patient was discharged on 6th day on oral anticoagulation to prevent deep venous thrombosis.
On follow-up visit after 2 weeks patient was
doing well with dramatic improvement of his
symptoms and signs of heart failure.
Discussion:
The most common cause of communication between the abdominal aorta (or iliac arteries) and
adjacent venous system, is aneurysm erosion.5,6
Other causes include: neoplasm, penetrating
and blunt trauma Iatrogenic injury as a complication of lumbar disc surgery and diagnostic
procedures.7,8
The typical clinical presentation includes sudden onset of abdominal pain, shortness of
breath, and a pulsatile Abdominal mass with an
machinery-like bruit and thrill . symptoms are
related to the hemodynamics of the large communication between the high resistant (arterial)
system and low resistant (venous) system resulting in decrease in peripheral arterial resistance
and increase in venous pressure and eventually
increase in heart rate , stroke volume which lead
to ventricular hypertrophy and heart failure.
Diagnosis is suspected based on clinical symptoms and signs but contrast enhanced tomography (CTA) is diagnostic most of the time,
pathognomic signs include early enhancement
of the IVC and loss of fatty planes between the
aorta and IVC.9
Patients with aortocaval fistula should urgently
operated with gentle dissection and exposure
of the aorta and IVC to avoid frank rupture and
mural thrombus dislodgment to the IVC. Control of the aorta is done in the usual manner
but IVC control is best done using compressive
maneuver with sponges from within the sac to
avoid blood loss, pulmonary embolism and the
devastating venous injury. Repair of the fistula
is best underwent from within the sac then aneurysm repair is done as usual using synthetic
graft.
Complications of surgical repair of ACF reported such as venous thrombosis (16%), leg edema(30%), and venous claudication were well
tolerated in most patients.10
Although many reports were published describing endovascular repair of aortocaval fistula this
procedure is still a concern regarding incidence
of pulmonary embolism due to manipulation of
the mural thrombus and dislodgment to the venous system , and due to the persistence of type
II endoleak.
Conclusion:
Although aortocaval fistula is a rare complication of aortic aneurysms, high index of clinical
suspicion, preoperative diagnosis and urgent
repair with gentle and special intraopertive techniques is crucial to avoid the high rate of perioperative complications and mortality.
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