Abstract
Background
One of the rare forms of abdominal aortic aneurysm (AAA) rupture is the rupture into great abdominal veins such as the inferior vein cava (IVC), the iliac veins, or the left renal vein, with the formation of direct or indirect aorto-caval fistula (ACF). The purpose of the present study was to summarize 20 years of experience at a single referral center for vascular surgery in a developing country, and to discuss the clinical presentation, diagnosis, treatment options, and outcome of patients with spontaneous aorto-venous fistulas (AVF) caused by ruptured aortic aneurysms.
Materials and methods
Retrospective database review identified 50 patients treated in our institution for aorto-venous fistulas (AVF) caused by spontaneous AAA rupture in the 20 years 1991–2010. Pulsating abdominal mass and low back pain were the leading symptoms on admission in our patients. Signs of shock, congestive heart failure, or pelvic and lower extremity venous hypertension were present in 48%, 26%, and 75% of the patients, respectively. Diagnosis of AVF was based on physical examination, duplex ultrasonography, conventional angiography, or multislice computed tomography (MSCT). In 40% of the patients the presence of AVF has not been recognized before surgery. All patients were treated with open surgery.
Results
After proximal and distal bleeding control the fistula was closed with direct suture (92%) or patch angioplasty (8%). Aortic reconstruction followed with tubular (22%) or bifurcated (78%) synthetic graft. Six (12%) patients died. The causes of death were excessive intraoperative blood loss, myocardial infarction, left colon gangrene and multiple organ failure.
Conclusions
Spontaneous AVFs caused by aneurysmal rupture are not uncommon, and they require prompt surgical or endovascular treatment. Routine use of multislice CT in patients with acute aortic syndrome is probably the best way to the correct diagnosis of aorto-venous fistulas and planning of the optimal treatment.
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References
Markovic M, Davidovic L, Maksimovic Z et al (2004) Ruptured abdominal aortic aeneurysm. Predictors of survival in 229 consecutive surgical patients. Herz 29:123–129
Burke AM, Jamieson GG (1983) Aortocaval fistula associated with ruptured aortic aneurysm. Br J Surg 70:431–433
Matsubara J, Nagaske M, Nakatoni B et al (1991) Aorto-caval fistula resulting from rupture of an abdominal aortic aneurysm: report and review of Japanese reported cases. Eur J Vasc Surg 5:601–604
Scmidt R, Bruks C, Walter M et al (1994) Aorto-caval fistula—an uncommon complication of infrarenal aortic aneurysm. Thorac Cardiovasc Surg 42:208–211
Miani S, Giorgetti PL, Arpesani A et al (1994) Spontaneous aorto-caval fistulas from ruptured abdominal aortic aneurysms. Eur J Vasc Surg 8:36–44
Takazawa A, Sakahashi H, Toyama A (2001) Surgical repair of a concealed aortocaval fistula associated with an abdominal aortic aneurysm: report of two cases. Surg Today 31:842–844
Davidovic LB, Kostic DM, Cvetkovic SD et al (2002) Aorto-caval fistulas. Cardiovasc Surg 10:555–560
Syme J (1831) Case of spontaneous varicose aneurysm. Edinb Med Surg J 36:104–105
DeBakey ME, Cooley DA, Morris GC Jr et al (1958) Arteriovenous fistula involving the abdominal aorta. Report of four cases with successful repair. Ann Surg 147:656–658
Brewster DC, Cambria RP, Moncure AC et al (1991) Aortocaval and iliac arteriovenous fistulas: recognition and treatment. J Vasc Surg 13:253–265
Davis PM, Glowiczki P, Cerry U Jr et al (1998) Aorto-caval and ilio-caval arteriovenous fistulae. Am J Surg 176:115–118
DeMonti M, Longhi F, Ruberti U (1993) Rupture of abdominal aortic aneurysm into the major abdominal veins. J Cardiovasc Surg 34:39–47
Baker WH, Sharzer LA, Ehrenhaft JL (1972) Aortocaval fistula as a complication of abdominal aortic aneurysms. Surgery 72:933
Viar WN, Lombardo TA (1952) Abdominal aortic aneurysm with rupture into the inferior vena cava. Circulation 5:287–289
Crawford ES, Turell DJ, Alexander JK (1963) Aorto-inferior vena caval fistula of neoplastic origin: hemodynamic and coronary blood flow studies. Circulation 27:414–421
Leigh-Smith S, Smith RC (2000) Aorto caval fistula—the “bursting heart syndrome”. J Accid Emerg Med 17:223–225
Nenhaus HP, Javid H (1968) The distinct syndrome of spontaneous abdominal aortocaval fistula. Am J Med 44:464–473
van Driel M, van Gelder B, Yma A et al (1984) Hematuria as a presenting symptom of an aortic-vena caval fistula from ruptured aortic aneurysm. J Urol 132:774–775
Dardik H, Dardik I, Strom MG et al (1972) Intravenous rupture of arteriosclerotic aneurysms of the abdominal aorta. Surgery 80:647–651
Brewster DC, Ottinger LW, Darling RC (1991) Hematuria as a sign of aorto-caval fistula. Ann Surg 186:766–771
Kanbay M, Gürden, Boyvat F et al (2004) Spontaneous aortocaval fistula presenting with acute liver and renal failure: a case report. Turk J Gastroenterol 15:169–172
Naraynsingh V, Ramdass MJ (2007) Venous gangrene secondary to an aorto-caval fistula. Emerg Med J 24:597
Abela R, Edin S, Khan A et al (2003) Priapism at age 94. J R Soc Med 96:407–408
Weinbaum FI, Riles TS, Imporato AM (1984) Asymptomatic vena cava fistulization complicating abdominal aortic aneurysm. Surgery 96:126–128
Mohr LL, Smith LL (1975) Arteriovenous fistula from rupture of abdominal aortic aneurysm. Arch Surg 110:806–812
Toshihiro I, Teruhiro A, Hideharu A et al (2001) Aortocaval fistula in associated with ruptured abdominal aortic aneurysm diagnosed by ultrasonography. Jpn J Phlebol 12:83–87
Ravi R, Peter SB, Swaminathan TS et al (2006) Spontaneous aortocaval fistula due to abdominal aortic aneurysm rupture—a case report. Indian J Radiol Imaging 16:453–456
Alexander JJ, Imbembo AL (1989) Aorto-vena cava fistula. Surgery 105:1–12
Cinara IS, Davidovic LB, Kostic DM et al (2005) Aorto-caval fistulas: a review of eighteen years experience. Acta Chir Belg 105:616–620
Beveridge CJ, Pleass HC, Chamberlain J et al (1998) Aortoiliac aneurysm with arteriocaval fistula treated by a bifurcated endovascular stent-graft. Cardiovasc Intervent Radiol 21:244–246
Umscheid T, Stelter WJ (2000) Endovascular treatment of an aortic aneurysm ruptured into the inferior vena cava. J Endovasc Ther 7:31–35
Lau LL, O’Reilly MJ, Johnston LC et al (2001) Endovascular stent-graft repair of primary aortocaval fistula with an abdominal aortoiliac aneurysm. J Vasc Surg 33:425–428
Gandini R, Ippoliti A, Pampana E et al (2002) Emergency endograft placement for recurrent aortocaval fistula after conventional AAA repair. J Endovasc Ther 9:208–211
Vetrhus M, McWilliams R, Tan CK et al (2005) Endovascular repair of abdominal aortic aneurysms with aortocaval fistula. Eur J Vasc Endovasc Surg 30:640–643
Waldorp JL Jr, Dart BW 4th, Barker DE (2005) Endovascular stent graft treatment of a traumatic aortocaval fistula. Ann Vasc Surg 19:562–565
Kopp R, Weidenhagen R, Hoffmann R et al (2006) Immediate endovascular treatment of an aortoiliac aneurysm ruptured into the inferior vena cava. Ann Vasc Surg 20:525–528
Pathak S, Yusuf SW, Doyle TN et al (2006) Endovascular repair of a recurrent aortocaval fistula and anastamotic false aneurysm. Br J Radiol 79:62–63
Fukuda I, Minakawa M, Fukui K et al (2007) Management of an aorto-caval fistula from a ruptured aortic false aneurysm using a covered stent graft. Interact CardioVasc Thorac Surg 6:682–684
Hetzel G, Gabriel P, Rompel O et al (2006) Aortocaval fistula after stent-graft repair. J Endovasc Ther 13:117–120
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Davidovic, L., Dragas, M., Cvetkovic, S. et al. Twenty Years of Experience in the Treatment of Spontaneous Aorto-venous Fistulas in a Developing Country. World J Surg 35, 1829–1834 (2011). https://doi.org/10.1007/s00268-011-1128-1
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DOI: https://doi.org/10.1007/s00268-011-1128-1