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Resumo
As fístulas aorto-cava são entidades raras e de etiologia variada, estando frequentemente associadas a significativa morbimortalidade. Acredita-se que o aumento da tensão da parede nos grandes aneurismas resulte em reação inflamatória e aderência à veia adjacente, culminando na erosão das camadas aderidas e na formação da fístula. O tratamen...
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Context 1
... color Doppler ultrasonography indicated an abdominal aortic aneurysm with a diameter of 9.7 cm, with mural thrombus and mobile thrombi in the lumen (Figure 1). High velocity flow was observed at the right posterolateral wall, suggestive of an arteriovenous fistula with a diameter of 5 mm, communicating between the aneurysm and the inferior vena cava. ...
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Citations
... Aortocaval fistula (ACF) are a rare complication of abdominal aortic aneurysm (AAA) that often result from erosion or rupture of an abdominal aortic aneurysm into the inferior vena cava [1]. Abdominal pain, abdominal machinery bruit, and a pulsating abdominal mass are the triad of clinical findings. ...
... Conventional surgical intervention has high mortality rates, whereas endoleaks and paradoxical pulmonary embolism are the main concerning complications of endovascular treatment. However, a combination of a bifurcated endograft and a vascular occluder can be a good option for the treatment of aortocaval fistula complicating abdominal aortic aneurysm [1]. The authors present here a case of spontaneous aortocaval fistula presented with an acute renal failure in a 70-year-old male with an abdominal aortic aneurysm, successfully managed with EVAR. ...
... A primary/spontaneous ACF occurs in 1% of AAA cases and 6% of ruptured AAA cases, being thus responsible for 80% of all ACF cases [6]. It is believed that increased tension in the walls of large aneurysms can cause an inflammatory reaction resulting in adhesion to the adjacent vein and culminating in erosion of the adherent layers and fistula formation [1]. Other causes include penetrating abdominal trauma, iatrogenic trauma at lumbar disc surgery and connective tissue disorders [7]. ...
Introduction
Aortocaval fistulas (ACFs) are a rare complication of abdominal aortic aneurysm (AAA), associated with high morbidity and mortality. It is thought that increased tension in the walls of large aneurysms can cause an inflammatory reaction resulting in adhesion to the adjacent vein and culminating in necrosis of the adherent layers and fistula formation.
Presentation of case
A 70-year-old male was referred from a local state center to the emergency department of our hospital, complaining of weakness and oliguria for two days. The laboratory analysis yielded high urea and creatinine levels, indicating an acute renal failure. Computed tomography images showed an aortocaval fistula complicating infrarenal abdominal aortic aneurysm. The patient was successfully managed by endovascular intervention.
Discussion
Aortocaval fistulas generally affect elderly men with an average age of 65 years. The diagnosis is often delayed because of the variable clinical manifestations, which increases the difficulties in treatment. Conventional surgical intervention has high mortality rates, whereas endoleaks and paradoxical pulmonary embolism are the main concerning complications of endovascular treatment.
Conclusion
Spontaneous aortocaval fistulas are a rare, but potentially life-threatening complication of abdominal aortic aneurysm with myriad clinical manifestations. Early diagnosis and management can directly affect the prognosis and outcome. Modern non-invasive diagnostic imaging can help timely diagnosis and provide a road map for the treatment plan. Endovascular repair is the first choice of treatment. However, a high incidence and persistence of endoleak with the endovascular approach requires caution and a close long time follow up.
Aortocaval fistulas (ACFs) are rare complications of abdominal aortic aneurysms (AAA), with an incidence of 0.22% to 6.04%, associated with a significant increase in mortality rate because of both their direct clinical repercussion and the technical difficulty involved in their treatment. Owing to technical limitations related to the open treatment of AAA with ACFs, as well as their associated morbidity and mortality rates, endovascular treatment is an important option to consider.
However, under such clinical situations, the morphology of the aneurysm and the possibility of endoleak may present as limitations to an endovascular approach, as the endoleak is seen as the most frequent complication in the treatments of AAAs.
Herein, we report the case of a patient who underwent endovascular treatment with an endoprosthesis for an infrarenal abdominal aortic aneurysm fistulized to the inferior vena cava, associated with a type III endoleak correction.
The hemodynamic behavior of the fistula described in this case resembled that of a high-output fistula. ACF diagnosis is preferably made by contrast computed tomography, where early presence of contrast in the venous system and loss of space or abnormal communication is detected between the two vessels involved; in this case, the abdominal aorta and inferior vena cava (IVC). The treatment is surgery through ACF and aneurysm repair. We report the case of a patient who underwent endovascular correction of AAA with ACF, and presented, after 4 months, with the need for reintervention due to a type III endoleak. This case shows two complications in the same patient, a rare situation in the medical literature.
