Interact CardioVasc Thorac Surg 2007;6:682-684. doi:10.1510/icvts.2007.153064
© 2007 European Association of Cardio-Thoracic Surgery
Case report - Aortic and aneurysmal |
Management of an aorto-caval fistula from a ruptured aortic false aneurysm using a covered stent graft
Ikuo Fukuda*,
Masahito Minakawa,
Kozo Fukui and
Yasuyuki Suzuki
Department of Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
Received 31 January 2007;
received in revised form 4 June 2007;
accepted 29 June 2007
*Corresponding author. Tel.: +81-172-39-5074; fax: +81-172-37-8340.
E-mail address: ikuofuku{at}cc.hirosaki-u.ac.jp (I. Fukuda).
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Abstract
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An aorto-caval fistula caused by a ruptured false aneurysm of the abdominal aorta was reported. A 70-year-old male who had a history of aorto-femoral bypass was admitted because of right lower abdominal pain. Enhanced computed tomography scans revealed aorto-caval fistula. The patient exhibited high output heart failure and acute renal failure. Stent-grafting for abdominal aorta was performed. Intra- and postoperative examination revealed no leakage from the aorta to the vena cava. Endoluminal treatment for aorto-caval fistula is efficacious as less invasive treatment.
Key Words: Aorto-caval fistula; Stent-grafting; Ruptured abdominal aneurysm; False aneurysm
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1. Introduction
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Aorto-caval fistula is a life-threatening complication of the abdominal aortic aneurysm. Mortality from an open surgical procedure is high because of massive blood loss during the operation and postoperative multiple organ failure. We herein report a case of aorto-caval fistula treated by stent-graft placement successfully.
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2. Case report
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A 70-year-old male was admitted because of right lower abdominal pain in March, 2003. He had a history of partial gastrectomy for a duodenal ulcer in 1969 and aorto-right femoral bypass for atherosclerotic occlusion of the right external iliac artery in 1971. He also underwent left femoro-right popliteal bypass for occlusion of the graft and the right superficial femoral artery in 2001. Anastomosis to the right deep femoral artery was skipped due to severe adhesion and diffuse atherosclerosis of the deep femoral artery. Physical examination on admission showed a blood pressure of 150/70 mmHg. A pulsating mass with continuous vascular bruit was recognized at the right lower abdomen and edema of bilateral lower extremities was notable. Chest X-ray revealed moderate pulmonary edema. Contrast-enhanced CT revealed a mass outside of the abdominal aorta with a simultaneous enhancement of the inferior vena cava (Fig. 1). Blood chemistry revealed elevation of serum creatinine (2.3 mg/dl) and urea nitrogen (58 mg/dl). Severe anemia, anuria and metabolic acidosis were also noted. Although surgical intervention for aorto-caval fistula was needed, open surgery seemed to be too invasive because of intra-peritoneal adhesions and poor preoperative condition. Therefore, we chose stent-grafting as a treatment for aorto-caval fistula as a less invasive procedure. Beforehand, coil embolization of the right common and internal iliac artery was performed. Then, a single limb stent graft was placed from the infrarenal abdominal aorta to the left external iliac artery via the left femoral artery. The stent graft was manufactured by a 24-mm ultra thin woven Dacron graft (porocity 150 cc/cm2/min, WTST-2420, Ube Junken, Ube, Japan) and four Z stents. Double GZV-30-50 stents (William Cook Europe APS, Bjaeverskov, Denmark) which had 30 mm in diameter and 50 mm in length were used for body, and double GZV-20-50 stents (William Cook) which had 20 mm in diameter and 50 mm in length were used for limb. Z stents were anchored to the graft with an interrupted 5-0 Prolene suture at every corner of the stents. The tapered shape of the graft was made by folding and suturing of the distal side. A 20 French size sheath introducer (CI20L60TP, Medikit Co. Ltd., Tokyo, Japan) was used. Intra-operative angiography, postoperative CT and angiography revealed disappearance of leakage from the aorta to the vena cava (Fig. 2). Postoperative course was uneventful and renal function and the edema of limbs improved immediately. No endoleak was detected on CT two years after stent-graft placement. The patient had no symptoms of leg ischemia and recurrence of aorto-caval fistula for four years.
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Fig. 1. Enhanced CT scan. It demonstrates the saccular aneurysm of the abdominal aorta with retroperitoneal hematoma (a) and simultaneous enhancement of the vena cava (b).
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Fig. 2. Postoperative angiography demonstrating no leakage around the stent graft (a). The left femoro-right popliteal bypass was patent (b).
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3. Discussion
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Aorto-caval fistula due to ruptured abdominal aortic aneurysm is rare but frequently is a fatal complication. Surgical treatments of aorto-caval fistula are direct closure of the fistula under occlusion of the inferior vena cava with occlusive balloon or aortic exclusion [1, 2]. Early surgical mortality is as high as 22–51% in the literature [1].
In nearly half of cases, diagnosis of aorto-caval fistula was established not before but during the operation [1]. In our case, preoperative diagnosis was obtained by characteristic clinical symptoms and contrast-enhanced CT. Early surgical intervention was possible before severe deterioration of the patient's general condition occurred.
Aortocaval fistula formation occurs in 3–4% of patients with ruptured abdominal aneurysms [1]. In approximately 90% of the spontaneous cases, the fistula was caused by erosion or rupture of an atherosclerotic infra-renal aortic aneurysm into the vena cava [3]. In our case, the abdominal aorta was not dilated itself and an enhanced mass with retroperitoneal hematoma was recognized. Since the patient underwent aorto-femoral bypass and this mass was located close to the proximal anastomotic site, we considered this fistula was caused by rupture of preexisting anastomotic false aneurysm into the vena cava. Report of successful endovascular repair for postoperative false aneurysm is rare [4].
Problems in the treatment of aorto-caval fistula include poor patient's condition due to hemorrhagic shock, high-output heart failure, renal failure and intra-operative bleeding. Hemostasis is frequently difficult to obtain because of adhesion between the aorta and vena cava. There were several points responsible for success of stent-graft placement in this case. The aneurysm was localized because it originated from dehiscence of the previous anastomotic site. Therefore, the stent graft had fitted tightly to the aorta resulting in prevention of endoleak from lumbar arteries and the inferior mesenteric artery. Because the common and internal iliac artery were patent, precedent embolization of these arteries was effective to control endoleak. Recanalization of the right common and internal iliac artery was not shown on the CT scan at two years after the embolization.
In aorto-caval fistula caused by ruptured atherosclerotic abdominal aneurysm, the necessity for embolization of the lumber artery and inferior mesenteric artery prior to the stent-graft placement to prevent type II endoleak is controversial. Umscheid et al. reported successful endovascular obliteration of fistula without type II endoleak [5].
In conclusion, stent-graft placement for aorto-caval fistula is an effective option to avoid catastrophic bleeding and hemodynamic deterioration during an operation.
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References
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- Alexander JJ, Imbembo AL. Aorto-vena cava fistula. Surgery 1989; 105:1–12.[Medline]
- Woolley DS, Spence RK. Aortocaval fistula treated by aortic exclusion. J Vasc Surg 1995; 22:639–642.[CrossRef][Medline]
- Miani S, Giorgetti PL, Arpesani A, Giuffrida GF, Biasi GM, Ruberti U. Spontaneous aorto-caval fistulas from ruptured abdominal aortic aneurysms. Eur J Vasc Surg 1994; 8:36–40.[CrossRef][Medline]
- Gandini R, Ippoliti A, Pampana E, Marchetti AA, Pistolese GR, Simonetti G. Emergency endograft placement for recurrent aortocaval fistula after conventional AAA repair. J Endovasc Ther 2002; 9:208–211.[CrossRef][Medline]
- Umscheid T, Stelter WJ. Endovascular treatment of an aortic aneurysm ruptured into the vena cava. J Endovasc Ther 2000; 7:31–35.[Medline]
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Abstract
1. Introduction