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.     

Successful endovascular repair of a ruptured abdominal aortic aneurysm in a patient with unfavorable anatomy

Endovascular repair of an abdominal aortic aneurysm (AAA) offers hope of improved outcomes in patients presenting with acute rupture. However, a high proportion of such patients have unfavorable proximal neck anatomy and are not suitable for treatment with conventional endografts. Fenestrated endografts overcome the problem of a short proximal neck, but at present their deployment is time consuming and therefore not easily applicable to a ruptured AAA. In this case report, the authors describe a hybrid device (a composite thoracic and infrarenal stent graft) that was able to overcome the problem of a short wide proximal neck in a patient with a ruptured AAA.     

Successful repair of a ruptured abdominal aortic aneurysm in a renal transplant recipient

A 53-year-old renal transplant recipient went into hypovolemic shock due to rupture of his abdominal aortic aneurysm. His successful perioperative and postoperative management are described. Fourteen cases of infrarenal aortic aneurysm repair in hemodynamically stable transplant recipients are reviewed with a discussion of management alternatives.     

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.     

Successful repair of an aortoesophageal fistula with aneurysm from esophageal diverticulum

Aortoesophageal fistula is a rare, frequently fatal, cause of upper gastrointestinal bleeding, and there are few reported survivors of it. We report a successful surgical case of aortoesophageal fistula associated with an infective thoracic aortic aneurysm. The patient had been diagnosed as having an esophageal diverticulum 8 months before admission. The aortoesophageal fistula was completely resected, followed by esophagojejunum anastomosis and patch closure for the entry of the aneurysm and omental coverage to the wall of the descending aorta in one stage. In this case, esophageal diverticulum was diagnosed before the development of an aortoesophageal fistula associated with an aneurysm.     

Hybrid open-endovascular repair of a contained suprarenal mycotic aneurysm using femoral vein

Mycotic aneurysms have a high mortality rate, predominantly driven by sepsis. We present a 61-year-old patient who was treated with a hybrid open-endovascular repair using autologous femoral vein as a single channel revascularization. This provided a practical and innovative approach to a high-risk situation.     

Superficial femoral vein graft interposition in situ repair for femoral mycotic aneurysm

Femoral mycotic aneurysms require surgical treatment to prevent progressive sepsis and hemorrhage. Some surgeons recommend simple debridement and ligation of the femoral artery, whereas others recommend reconstruction in selected cases or all cases due to concerns about high risk of limb loss. In situ reconstruction has been discouraged due to concerns about anastomotic or graft disruption by persistent infection. However, the superficial femoral vein has been used successfully as an in situ replacement after removal of infected aortic prostheses. We present two patients with femoral mycotic aneurysms, both of whom were treated successfully with in situ reconstruction using autogenous superficial femoral vein.     

Bronchoesophageal fistula after endovascular repair of ruptured aneurysm of the descending thoracic aorta

Aortoesophageal fistula secondary to thoracic aneurysm is rare and is usually fatal without prompt surgical intervention. A 79-year-old man with significant comorbidities and previous cancer surgery was admitted on an emergency basis because of the suspicion of a ruptured thoracic aortic aneurysm. Computed tomographic scan followed by angiography demonstrated a ruptured thoracic aneurysm with aortoesophageal fistula. An endovascular stent graft repair was performed with successful exclusion of both aneurysm and fistula. On postoperative day 6, dyspnea and an isolated episode of hemoptysis occurred. Endoscopy revealed the presence of a bronchoesophageal fistula, which necessitated double exclusion of the esophagus and feeding jejunostomy. At 6 months, clinical, bronchoscopic, and computed tomographic scan follow-up showed complete sealing of the aneurysm and resolution of the bronchoesophageal fistula. At 9 months, the patient was still alive but refused to undergo substernal gastric bypass in an attempt to restore oral feeding. Endovascular repair seems promising as an emergent and palliative treatment of aortoesophageal fistula. To the best of our knowledge, this is the first case in which a bronchoesophageal fistula developed after successful endovascular repair of aortoesophageal fistula. The pathogenesis of this complications remains unclear.     

Caval thrombectomy in a ruptured aortic aneurysm associated with aorto-caval fistula

Aorto-caval fistula is a rare but recognized complication of an aortic aneurysm. The association of pulmonary emboli has also been described and is attributed to paradoxical embolisation of the atheromatous contents of the aneurysm sac. This report describes a unique case of a fistula associated with a ruptured aneurysm in which a large intracaval thrombus was removed at the time of operation.     

Successful coil embolization of a ruptured gastroduodenal artery aneurysm

Aneurysms of the gastroduodenal artery are rare. Reported here is the case of a 60-year-old woman suffering from the covered rupturing of a twin aneurysm of the gastroduodenal artery. The patient presented herself in the surgical emergency unit with abdominal discomfort. Diagnostics showed free fluid in the abdominal cavity together with anemia of 9.9 g/dL. A computed tomography scan and an angiography revealed the covered rupturing of a twin aneurysm of the gastroduodenal artery, which was treated by endovascular coiling of the gastroduodenal and pancreaticoduodenal arteries. The patient's hemoglobin level remained stable after treatment, and she was released from the hospital after 18 days. Visceral artery aneurysms are rare. Although endovascular therapy is preferred in cases involving active bleeding, surgery remains the primary therapy in those cases in which bleeding becomes uncontrollable.     

Successful surgical treatment of a multiple ruptured true saphenous vein aneurysm after an anterior femoro-tibial bypass

Despite the fact, that we have been using the saphena magna as an autolog transplantatum for femoro-popliteal bypass since more than 50 years, the true aneurysma of the saphena graft is rare. Generally the aneurysma formations are detectable years after the primary operation, often in a life or limb threatening form. In our publication we report a successfully operated case of ruptured true saphena aneurysma. The multiplex aneurysma was operated on after a femoro-tibial anterior bypass operation, performed seven years earlier. The patient was normotensiv, without any laboratory sign of hyperlipidaemia. For the reconstruction we used autolog vein, from the upper limb.     

Successful treatment of a ruptured mycotic coronary artery aneurysm

Documented mycotic aneurysms of the coronary arteries are unusual, and antemortem identification of such an aneurysm is rare. We present the case of a patient who had successful management of a ruptured mycotic aneurysm of a coronary artery.     

Successful endovascular treatment of a ruptured internal iliac aneurysm

Internal iliac artery aneurysms (IIAs) are rare but can be the source of considerable morbidity when rupture occurs. IIAs have traditionally been treated with direct surgical exclusion or ligation. More recently, the advent of endovascular techniques have been adapted to treat isolated common and IIAs in lieu of elective surgical correction. This case report describes an 81-year-old patient with multiple medical problems and a symptomatic IIA, initially diagnosed with computed tomographic scan. Arteriography results showed extravasation of contrast from a left IIA. The aneurysm was treated with endovascular exclusion, with multiple coils in the IIA followed by placement of a covered stent within the common and external iliacs to exclude the orifice of the IIA. The patient tolerated the procedure well, and at 2 months after the procedure, no endoleak was present on follow-up computed tomographic scan results. At 12 months postprocedure, the patient has remained well. This case shows that endovascular therapies may offer a good treatment option in symptomatic or ruptured IIA, particularly in a patient who is at poor operative risk.     

Saphenous vein spiral graft: successful emergency repair of a mycotic aneurysm with aortoduodenal fistula.

Mycotic aneurysms leading to aortoduodenal fistula (ADF) are associated with high morbidity and mortality. We report a patient with a mycotic aneurysm and ADF who required emergency laparotomy. After excision of the aneurysm, vascular reconstruction was performed using an autologous graft. The left long saphenous vein was harvested and constructed into a spiral graft. The graft was inserted using a standard inlay technique. After 12 months the patient is in good health. No inflammation or dilation of the saphenous vein spiral graft has been noted. We suggest that in the emergency treatment of mycotic abdominal aneurysm, aortic reconstruction with saphenous vein spiral graft is a valuable option.