Large external iliac vein aneurysm in a patient with a post-traumatic femoral arteriovenous fistula

We report about a young patient with a large aneurysm of the left external iliac vein associated with a traumatic arteriovenous fistula between the left superficial femoral artery and the femoral vein after a stab wound 20 years ago. The patient presented with swelling of the left leg, which developed during the past years and worsened after saphenectomy 12 months before hospital admission. The chronically hyperperfused common iliac artery proximal to the arteriovenous fistula was compressing the common iliac vein. The venous outflow obstruction and subsequent venous hypertension render a possible explanation for the formation of the iliac vein aneurysm. Surgical repair of the venous aneurysm by interposition grafting and closure of the arteriovenous fistula was successful. A postoperative computed tomography scan showed a 50% size reduction of the feeding artery, underlining the ability of the arterial system to normalize arterial diameter in response to flow reduction, even after a high flow situation had existed for probably >20 years.     

Secondary rupture of an iliac artery aneurysm after exclusion-bypass

We report a case of secondary rupture of a common iliac artery aneurysm into the common iliac vein. Exclusion of the iliac aneurysm had been performed 2 years earlier in association with reconstruction of an aortic aneurysm that had ruptured into the inferior vena cava. After closure of the aortocaval fistula by the endoaneurysmal route, aortobifemoral bypass grafting had been performed and a caval clip had been placed. The common iliac arteries had been sutured by the endoaneurysmal route and the right common iliac artery had been excluded by ligation of the right iliac artery. Occlusion of the inferior vena cava distal to the caval clip resulted in increased peripheral venous hypertension causing the secondary arteriovenous fistula (rupture of scrotal varices and edema of lower extremities) but prevented right cardiac insufficiency. This observation confirms the possibility of secondary rupture after treatment of an aneurysm by exclusion. Thus the inclusion-graft technique is more reliable.     

Abdominal arteriovenous fistula due to rupture of aorto-iliac aneurysm with multivarious clinical manifestations. Report of a case with successful repair

We present a 63-year old man with the arteriovenous fistula caused by the rupture of the aneurysm which extended from the abdominal aorta to the bilateral internal iliac arteries. The clinical manifestations included edema of the left lower extremity, pulmonary embolism, high-output congestive heart failure, origulia, azotemia, liver dysfunction and unstable angina. Because of the variety of the clinical symptoms and the lack of the awareness of this rare complication (arteriovenous fistula), we missed the prompt detection of the entity of the abdominal arteriovenous fistula. We finally succeeded the surgical closure of the fistula and the aortic reconstruction with a woven Dacron bifarcation graft. Problems of diagnosis and operative management are discussed.     

The syndrome of spontaneous iliac arteriovenous fistula: a distinct clinical and pathophysiologic entity

While the development of a spontaneous iliac arteriovenous fistula is an uncommon complication of arteriosclerotic aneurysmal disease, its association with a distinct clinical syndrome allows timely operative intervention for this potentially life-threatening event. A review of cases reported in the literature reveals a triad of symptoms consistently associated with the presence of a spontaneous iliac arteriovenous fistula: high-output cardiac failure of precipitous onset, a pulsatile abdominal mass accompanied by a thrill and bruit, and unilateral lower-extremity ischemia or venous engorgement. Survival may be anticipated if an aggressive diagnostic and operative approach is employed.     

Successful surgical repair of an ilio-iliac arteriovenous fistula associated with a ruptured common iliac artery aneurysm

IntroductionWe describe the case of an 86-year-old man with an ilio-iliac arteriovenous fistula (AVF) resulting from a ruptured aneurysm. This condition rarely occurs, has a high mortality rate, and was successfully treated via surgery.Presentation of caseThe patient presented with a temporary loss of consciousness and left leg edema. A pulsatile abdominal mass with vascular murmur and thrill was detected. Enhanced computed tomography showed abdominal aortic and iliac aneurysms with left common iliac vein occlusion, and the left external iliac vein was easily seen through the AVF. We directly sutured the AVF and performed aneurysmectomy and prosthetic graft replacement. During surgery, placement of occlusive balloon catheters through the AVF minimized intraoperative bleeding. The patient recovered uneventfully, and swelling of the left leg was immediately reduced after surgery.DiscussionAlthough rare, AVFs can be life-threatening, and urgent treatment and intensive care are occasionally needed. Surgical management of AVF requires a definitive preoperative diagnosis and control of venous bleeding during surgery. Fulfilling these major requirements can potentially reduce morbidity and mortality in patients with AVFs. Interestingly, there was no sign of high-output heart failure throughout the treatment course due to compression of the aneurysm and consequent blood flow failure to the left iliac vein.ConclusionUsing the balloon occlusion technique, we were able to minimize blood loss during open repair. Use of multiple imaging modalities facilitates correct preoperative diagnosis and consequently improves surgical outcome.     

Spontaneous iliac arteriovenous fistula

The formation of an iliac arteriovenous fistula caused by rupture of an atherosclerotic iliac artery aneurysm is unusual. We describe a case and review the previously reported 18 cases of spontaneous iliac arteriovenous fistula. The presence of a palpable abdominal mass associated with a thrill or bruit and unilateral leg symptoms of venous engorgement or arterial insufficiency, with or without acute onset of congestive heart failure, should result in a high index of suspicion of this entity. Prompt recognition and surgical closure of the iliac fistula are most important in successful management.     

Iliac Arteriovenous Fistula Secondary to Iliac Aneurysm Rupture Associated with Pulmonary Embolism and Anuria

We present a case of iliac aneurysm rupture that started with high-output cardiac failure and anuria and later presented as a pulmonary embolism that needed a preoperatory filter for the cava vein.     

Intravenous rupture of abdominal aneurysms: diagnostic and pathological considerations

Seven cases of abdominal arteriovenous fistula secondary to aneurysm are reported. There were five aortocaval fistulae, one aortolumbar vein fistula, and one iliac artery to vein fistula. Three of five aortocaval fistulae were diagnosed pre-operatively. One in-hospital death occurred, and one post-hospital death. An analysis of the diagnostic patterns is made in an attempt to increase pre-operative diagnosis.     

Traumatic superior mesenteric arteriovenous fistula. A case report

In a case of traumatic superior mesenteric arteriovenous fistula resulting from a stab wound in the abdomen clinical signs of high-output cardiac failure or portal hypertension were absent. Selective angiography was useful in confirming and locating the fistula. The patient made a good recovery after resection of the aneurysm and fistula and insertion of a prosthetic graft.     

High-Output Heart Failure Caused by a Huge Renal Arteriovenous Fistula After Nephrectomy: Report of a Case

Postnephrectomy renal arteriovenous fistula (AVF) with an aneurysmal lesion is a rare clinical entity that may cause high-output heart failure. In this report, we describe the case of a 68-year-old man who had undergone nephrectomy for renal tuberculosis 43 years previously, in whom an acquired large renal AVF presenting as an aneurysm caused congestive cardiac failure. We also discuss the hemodynamic, hormonogenic (human arterial natriuretic polypeptide; hANP), and radiographic findings before and after surgery for the AVF. The AVF with an aneurysmal lesion was clearly visualized by three-dimensional-computerized tomographic (CT) scanning, and proximal ligation of the renal artery was followed by an uneventful recovery. This procedure can produce good results when a fistula is too large to allow safe embolization and when excision would be hazardous due to inflammation surrounding the fistula. Received: March 1, 2000 / Accepted: November 20, 2000     

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目的 评价腔内人造血管内支撑术在治疗血管外科疾病中的早期临床疗效。方法 ９例病人接受腔内人造血管内支撑术治疗。其中腹主动脉瘤６例，左锁骨下动脉瘤１例，左髂总动静脉瘘１例，左髂股动脉重度硬化性狭窄１例。术前均行Ｄｒｐｌｅｘ彩超、四肢节段性测压（ＰＶＬ）和ＤＳＡ造影，６例动脉瘤病人术前行三维重建螺ＣＴ。结果 术后即刻ＤＳＡ造影显示，７例动脉瘤消失，近远端人造血管与宿主动脉结合外均未见渗漏；１例左髂动静     

Spontaneous common iliac arteriovenous fistula manifested by acute renal failure: a case report

Arteriovenous fistulas between the common iliac vessels resulting from spontaneous rupture of aneurysms are rare, with only 31 cases having been reported since 1971. Clinical diagnosis is possible when a unique set of findings is present, namely high-output cardiac failure, a pulsatile abdominal mass associated with a bruit or thrill, and unilateral arterial insufficiency or venous engorgement. Recently, with advancements in diagnostic techniques, the number of cases in which an arteriovenous fistula is found between the common iliac vessels has increased. Diagnosis can be difficult, however, as in the case of one of our patients in whom the predominant sign was acute renal failure. Other reports of renal failure or impairment in the presence of a common iliac fistula have also appeared. Awareness of this phenomenon can help the physician to establish the diagnosis when one or more of the classic signs are absent. Prompt diagnosis and surgical management have contributed to the high incidence of survival in patients with arteriovenous fistulas between the common iliac vessels.     

General anesthesia in a patient with Parkes Weber syndrome with high-output cardiac failure due to multiple arteriovenous fistulas complicated by severe aortic regurgitation

Parkes Weber syndrome is a rare disease characterized by overgrowth of an extremity linked to the presence of an arteriovenous malformation with multiple arteriovenous fistulas (AVFs). We report a patient with Parkes Weber syndrome with high-output cardiac failure due to multiple AVFs complicated by severe aortic regurgitation (AR) who required surgical treatment for AVFs. Division of the left deep femoral artery and banding of the left superficial femoral artery were performed. Such procedures can cause aggravation of AR and left ventricular failure due to the sudden increase in cardiac afterload. Pulmonary artery pressure, mixed venous oxygen saturation and cardiac index monitored by a thermodilution catheter, and a transesophageal echocardiography were useful in evaluating the effect of the surgical procedure and resultant acute increase in cardiac afterload on cardiac output and left ventricular function.     

Primary arteriovenous fistulas of the abdomen. Their occurrence secondary to aneurysmal disease of the aorta and iliac arteries

We present three cases of arteriovenous fistula secondary to aneurysmal disease. The first patient, a 75-year-old man, presented with abdominal pain, a large pulsatile mass, and renal failure. He underwent repair of his aortocaval fistula; his renal failure resolved and the remainder of his course was uneventful. The second patient, a 77-year-old man, presented with a several-day history of nausea, lower abdominal pain, and a pulsatile mass. He underwent repair of his aortocaval fistula but died on the 21st postoperative day of progressive pulmonary failure. The third patient, a 76-year-old man, presented with an episode of syncope and subsequent rapid development of left lower extremity edema. He was subsequently found to have a right iliac artery to left iliac vein fistula, which was repaired. He did well postoperatively with gradual resolution of his lower extremity edema.     

Diagnosis by computed tomography of arteriovenous fistula complicating ruptured iliac artery aneurysm

Isolated iliac artery aneurysms comprise less than 1% of all arteriosclerotic aneurysms. Spontaneous iliac arteriovenous fistula is a rare complication of these aneurysms with only 16 cases previously described. The diagnosis depends on a strong clinical suspicion and usually requires angiography for confirmation. We report a case in which CT with contrast medium showed clear findings of a spontaneous iliac arteriovenous fistula complicating rupture of an isolated iliac artery aneurysm. CT findings included: (1) iliac artery aneurysm, (2) vena caval dilatation, (3) rapid flow of contrast medium from the arterial side into the dilated inferior vena cava on dynamic scanning, (4) increased density of the inferior vena cava similar to that of the aorta caused by entry through the fistula of blood with a high concentration of iodinated contrast medium, and (5) the actual fistula connecting the two vessels.     

A case of ruptured aneurysm of the middle cerebral artery associated with dural arteriovenous fistula in the anterior cranial fossa

A 66-year-old man suffered from subarachnoid hemorrhage due to the rupture of a right middle cerebral artery aneurysm that was detected by 3D-CTA. He underwent an emergent clipping operation. Incidentally, postoperative DSA demonstrated dural arteriovenous fistula in the left anterior cranial fossa, which was fed by the left anterior ethmoidal artery and drained into the superior sagittal sinus via the cortical vein of the left frontal lobe. We performed electrocoagulation and division of the fistula at the second surgery. Subsequently, he underwent a ventriculo-peritoneal shunt and was discharged without any neurological deficits. We reviewed reported cases of rare association of ruptured cerebral aneurysm and dural arteriovenous fistula in the left anterior cranial fossa.     

Venous reconstruction of the inferior vena cava bifurcation for retroperitoneal rhabdomyosarcoma in a child. Case report

Retroperitoneal tumors, as well as traumatic lesions and occlusions of the bifurcation of the inferior vena cava (IVC) and the common iliac veins may require venous vascular reconstruction. We present a method for inferior vena caval bifurcation reconstruction which employs the advantages of a large size straight expanded polytetrafluorethylene (ePTFE) graft in this position after a new IVC bifurcation has been created by uniting the stumps of both common iliac veins, and construction of an arteriovenous (A-V) fistula with controlled flow to decrease the rethrombosis rate of the graft, and still not cause heart failure. This method was used in a case of recurrent rhabdomyosarcoma in an 8 year old child encroaching upon the bifurcation of the IVC as well as on both common iliac veins. The situation was managed by radical resection of the tumor and by creating a new caval bifurcation of the common iliac veins, followed by interposition of a straight ePTFE graft. An A-V fistula was created between the left femoral vein and left femoral artery using the left greater saphenous vein in controlled fashion. The arterial defect of the right common iliac artery was reconstructed by interposition of a PTFE graft end-to-end.     

Transposed Basilic Vein-Brachial Arteriovenous Fistula: An Alternative Vascular Access for Hemodialysis

Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated one-year patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachial-basilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels.     

Traumatic arteriovenous fistula. Case report

A young man with a fistula between the right femoral artery and vein due to bullet wound presented 6 years later with exertional dyspnea and palpitations and venous insufficency of the right leg. Angiography showed a wide (greater than 20 mm) arteriovenous fistula. Moderate cardiac hypertrophy and cardiac output 14.8 l/min were found. During division and closure of the fistula, 8 l/min flow was measured in the right external iliac artery. The cardiac symptoms disappeared immediately and the venous insufficiency gradually.     

Giant iliac vein aneurysm secondary to long standing traumatic popliteal arteriovenous fistula

A 48-year-old man presented with a traumatic arteriovenous fistula (AVF) in the left popliteal space, due to a bullet injury 20 years back. A computed tomographic (CT) angiography revealed an AVF in the left popliteal space with an associated large iliac vein aneurysm (9.2 x 9.0 cms). Primary repair of the AVF was done. A Doppler scan showed marked reduction in the size of the aneurysm, 4 months after surgery. Cases associated with a venous aneurysm distant from the site of AVF are rare and there are only 7 cases reported in the international literature.