PRIMARY AORTOCAVAL FISTULA IN RUPTURED ABDOMINAL AORTIC ANEURYSM — INSTITUTIONAL EXPERIENCE AND LITERATURE REVIEW
Introduction: Aortocaval Fistula is a rare clinical entity associated with Abdominal Aortic Aneurysm in less than 1% of cases. Main clinical features include acute heart failure, lower extremety edema, acute kidney injury and acute liver failure. Open surgical repair is associated with high mortality rates (16–66%)(1). On the other hand, endovascular treatment could represent a less morbid and equally efective treatment option. The authors aim to describe clinical presentation, surgical options and post-operative results of the treatment of abdominal aortic aneurysms associated with aortocaval fistula, comparing their results to literature.
Material and Methods: A retrospective review in a tertiary care center was designed. All patients treated for aortocaval fistula associated with AAA between January of 2014 and May of 2020 were included. Patient data were obtained by consulting the clinical record. Demographic, clinical, surgery and post-operative results and complications were obtained.
Results: During this period, four patients submitted to emergent surgery were identified. All patients were male with a mean age of 70 (±8) years and with tobacco use history (n=4). On admission, most frequent symptoms we're lumbar pain (n=4) and hipotension/tachycardia (n=4). Other frequent signs or symptoms we're abdominal pulsatile mass (n=3) and acute kidney injury with hematuria (n=2). In two patients, CT angiography revealed rAAA with retroperitoneal hematoma without aortocaval fistula, which was only diagnosed intraoperatively. Two patients were submitted to aorto-bi-iliac interposition graft and one to aorto-bi-femoral bypass, all with endoaneurysmal suture of the fistula. One patient was submitted to aorto-bi-iliac EVAR with a Gore Excluder C3® endoprosthesis. Most common post-operative complications were AKI (n=3), respiratory failure (n=2) and acute liver failure (n=2). The aorto-bi-iliac EVAR patient did not present any 30 day post-operative complication and was discharged at the 7th post-operative day. There was 1 secondary intervention within the first 30 days: left hemicolectomy for ischemic colitis. After 30 days we observed one reintervention: implantation of right iliac branch device due to an iliac aneurysm Two patients died in the early postoperative period (2nd and 3rd days). The remaining patients have a follow-up of 29 and 66 months.
Conclusions: ACF can occur with or without AAA with retroperitoneal hematoma. In the presence of retroperitoneal hematoma, the ACF could not be evident in CT angiography and only detected intraoperatively. Considering our experience and what is described in literature, we should have a high index of suspicion for this possible complication of rAAA in the presence of acute venous congestion with acute onset of organ failure (AKI, acute cardiac or liver failure), even if CT angiography only reveals retroperitoneal hematoma. Conventional surgery with endoaneurysmal suture of the fistula and interposition graft was the preferred technique, but if endovascular exclusion is feasible, it could be effective and associated with less morbimortality. In endovascular treatment, failure to close aortocaval communication does not appear to result in higher long-term morbidity and monitoring seems plausible in the presence of favorable evolution of the aneurysmal sac and in the absence of symptoms.
2. Sobrinho G, Ferreira ME, Albino JP, Gomes H, Capitão LM. Acute ischemic hepatitis in aortocaval fistula. Eur J Vasc Endovasc Surg. 2005;
3. Davidovic L, Dragas M, Cvetkovic S, Kostic D, Cinara I, Banzic I. Twenty years of experience in the treatment of spontaneous aorto-venous fistulas in a developing country. World J Surg. 2011;
4. Javerliat I, Coggia M, Di Centa I, Alfonsi P, Goëau-Brissonnière O. Undiagnosed aorto-caval fistula during total laparoscopic abdominal aortic aneurysm repair: A cause of conversion. Eur J Vasc Endovasc Surg. 2005;
5. Dauphine C, Kovar J, Donayre C, De Virgilio C. Abdominal aortic aneurysm with aortocaval fistula and a separate retroperitoneal rupture. Vascular. 2004;
6. Kotsikoris I, Papas TT, Papanas N, Maras D, Andrikopoulou M, Bessias N, et al. Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: A 12-year series. Vasc Endovascular Surg. 2012;
7. Maeda H, Umezawa H, Goshima M, Hattori T, Nakamura T, Nishii T, et al. Surgery for ruptured abdominal aortic aneurysm with an aortocaval and iliac vein fistula. Surgery Today. 2007.
8. Dhillon B, Morrow D, Lewis M, Ali T. Abdominal Aortic Aneurysm with Aortocaval Fistula–Staged Endovascular Management. J Vasc Interv Radiol. 2019;
9. Van De Luijtgaarden KM, Bastos Gonçalves F, Rouwet E V., Hendriks JM, Ten Raa S, Verhagen HJM. Conservative management of persistent aortocaval fistula after endovascular aortic repair. J Vasc Surg. 2013;
10. Burke C, Mauro MA. SIR 2003 film panel case 8: Aortocaval fistula supplied by a type II endoleak. J Vasc Interv Radiol. 2003;
11. Greenfield S, Martin G, Malina M, Theivacumar N. Aortocaval fistula, a potentially favourable complication of abdominal aortic aneurysm rupture in endovascular repair. Ann R Coll Surg Engl. 2020;
12. Shah TR, Parikh P, Borkon M, Mocharla R, Lonier J, Rosenzweig BP, et al. Endovascular repair of contained abdominal aortic aneurysm rupture with aortocaval fistula presenting with high-output heart failure. Vasc Endovascular Surg. 2013;
13. Leon LR, Arslan B, Ley E, Labropoulos N. Endovascular therapy of spontaneous aortocaval fistulae associated with abdominal aortic aneurysms. Vascular. 2007;
14. Umscheid T, Stelter WJ. Endovascular treatment of an aortic aneurysm ruptured into the inferior vena cava. J Endovasc Ther. 2000;
15. Vetrhus M, McWilliams R, Tan CK, Brennan J, Gilling-Smith G, Harris PL. Endovascular repair of abdominal aortic aneurysms with aortocaval fistula. Eur J Vasc Endovasc Surg. 2005;
16. Liu M, Wang H. Endovascular stent-graft repair of spontaneous aorto-caval fistula secondary to a ruptured abdominal aortic aneurysm: An emergency management of hostile anatomy. SAGE Open Med Case Reports. 2016;
17. Wang Y, Yu W, Li Y, Wang H. Emergent Endovascular Repair of Challenging Aortocaval Fistula with Hostile Anatomy. Vasc Endovascular Surg. 2017;
18. Madsen KR, Franz RW. Delayed Endovascular Aneurysm Repair for Aorto-caval Fistula with Correction of Physiologic and Metabolic Abnormalities: A Disease Process Review. Ann Vasc Surg. 2015;
19. Elkassaby M, Alawy M, Zaki M, Hynes N, Tawfick W, Sultan S. Total endovascular management of ruptured aortocaval fistula: Technical challenges and case report. Vascular. 2014;
20. Silveira PG, Cunha JRF, Barbosa Lima GB, Franklin RN, Bortoluzzi CT, Galego GDN. Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula based on aortic and inferior vena cava stent-graft placement. Ann Vasc Surg. 2014;
21. Janczak D, Chabowski M, Szydelko T, Garcarek J. Endovascular exclusion of a large spontaneous aortocaval fistula in a patient with a ruptured aortic aneurysm. Vascular. 2014;
22. Sultan S, Zaki M, Alawy M, Elkassaby M. Aortic and inferior vena cava bifurcated stent graft application in the endovascular management of a ruptured abdominal aortic aneurysm with an aortocaval fistula. J Vasc Surg. 2014;
23. De Almeida BL, Rossi FH, Rodrigues TO, Ahouagi LB, Cavalcante SFA, Beteli CB, et al. Tratamento endovascular de aneurisma de aorta abdominal com fístula aorto-cava utilizando oclusor vascular concomitante a endoprótese bifurcada: Relato de caso. J Vasc Bras. 2017;
24. Guzzardi G, Fossaceca R, Divenuto I, Musiani A, Brustia P, Carriero A. Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula. Cardiovasc Intervent Radiol. 2010;
25. Brightwell RE, Pegna V, Boyne N. Aortocaval fistula: Current management strategies. ANZ Journal of Surgery. 2013.
26. Nakad G, Abichedid G, Osman R. Endovascular treatment of major abdominal arteriovenous fistulas: A systematic review. Vascular and Endovascular Surgery. 2014.
27. Lee P, Sheehan BM, Gordon I, Maithel S, Putnam L, Khalsa B, et al. Novel Utility of Amplatzer Septal Occlusion Device to Treat Persistent Aortocaval Fistula following Ruptured Endovascular Aortic Aneurysm Repair (rEVAR). Ann Vasc Surg. 2020;
28. Melas N, Saratzis A, Saratzis N, Lazaridis I, Kiskinis D. Inferior vena cava stent-graft placement to treat endoleak associated with an aortocaval fistula. J Endovasc Ther. 2011;
29. Sveinsson M, Sonesson B, Resch TA, Dias N V., Holst J, Malina M. Aneurysm shrinkage is compatible with massive endoleak in the presence of an aortocaval fistula: Potential therapeutic implications for endoleaks and spinal cord ischemia. J Endovasc Ther. 2016;
30. Labarbera M, Nathanson D, Hui P. Percutaneous closure of aortocaval fistula using the amplatzer muscular VSD occluder. J Invasive Cardiol. 2011;
31. Sfyroeras GS, Moulakakis KG, Bessias N, Maras D, Tsanis A, Georgakis P, et al. Persistent endoleak after endovascular exclusion of an aortocaval fistula, producing renal insufficiency. Vasa - J Vasc Dis. 2010;