Abstract
Aortocaval fistula is a rare but life-threatening complication of abdominal aortic aneurysm. We report the case of a 63-year-old man who was found to have hyperdynamic heart failure caused by a large infrarenal abdominal aortic aneurysm fistulized to the inferior vena cava. An urgent endovascular approach was performed using an aortomonoiliac endoprosthesis with femorofemoral bypass and adjunctive iliac stenting. Despite initial clinical improvement, follow-up imaging revealed a persistent endoleak maintaining patency of the fistula. A secondary endovascular procedure was successfully performed, including hypogastric artery embolization and placement of a cava endoprosthesis to exclude the fistulous communication. Follow-up computed tomography angiography at 6 months confirmed complete exclusion of the aneurysm and resolution of the aortocaval fistula without endoleaks.
A 63-year-old man with no relevant medical history presented to the emergency department after an episode of syncope and dyspnea. He was normotensive with a sinus tachycardia of 130 bpm. A pulsatile abdominal mass was noticed and echocardiogram showed signs of hyperdynamic heart failure. Computed tomography (CT) angiography revealed an infrarenal aortic aneurysm of 98 mm in diameter, with a neck of 32 mm, and right and left iliac arteries of 25 mm and 23 mm, respectively. The aneurysm was fistulized to the inferior vena cava, which showed early filling in the arterial phase (A).
Urgent surgical treatment was indicated owing to heart failure.1 Despite the patient's age, open repair was considered high risk because of the potential for massive bleeding inherent to aortocaval fistula (ACF) repair. Therefore, an endovascular strategy was selected.2,3 Right side aortomonoiliac endoprosthesis placement with cross-over bypass and retrograde stent to the left hypogastric was planned. Bilateral open inguinal access was performed, and aortography confirmed a large ACF (B). An Endurant II aortomonoiliac endoprosthesis (36 mm) was implanted at infrarenal level, needing a proximal Excluder cuff. The right axis was completed with Excluder extensions and a Viabahn stent in the external iliac artery. A Viabahn stent was placed from the left external iliac artery to the hypogastric, extending with a Viabahn VBX stent. Finally, a femorofemoral bypass with an 8 mm polytetrafluorethylene graft was performed.
During the procedure, the patient exhibited a progressive deterioration of hemodynamic status; however, rapid stabilization was achieved after deployment of the main endoprosthesis.
The immediate postoperative period was uneventful, with heart function improvement and <24 hours in the intensive care unit. A follow-up CT angiography performed 48 hours later revealed an endoleak, likely from retrograde flow from the right hypogastric, draining through the ACF and keeping it patent (C). A stenosis of the right renal artery was also detected.
A new intervention was planned. A Viabahn VBX stent was placed in the right renal artery, followed by embolization of the right hypogastric using a Ruby Coil. A 28 × 100 mm Excluder C-TAG endoprosthesis was placed in the inferior vena cava, covering the communication between it and the aneurysmal sac. The final aortography showed correct exclusion of the aneurysm and the ACF with no early endoleaks. A 6-month control CT angiography confirmed the resolution of the ACF with no endoleaks. The cava prosthesis is notably separated from the aorta owing to the large size of the aneurysmal sac (D/Cover). The patient's consent was obtained to publish this case.
Funding
None.
Disclosures
None.
Footnotes
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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Appendix
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Appendix (online only)
Cover image.
References
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