Aortocaval fistula complicating abdominal aortic aneurysm: Case report and literature review

Aortocaval fistula is a rare complication of abdominal aortic aneurysm involving less than 1% of all abdominal aortic aneurysms. The diagnosis is difficult, and preoperative identification can be challenging. We describe an interesting case of a 72-year-old man presenting with acute-onset dyspnea who was found to have an aortocaval fistula secondary to a large abdominal aortic aneurysm. The clinical features that exemplify aortocaval fistula are discussed and the literature reviewed. © 1996 Wiley-Liss, Inc.     

Percutaneous closure of aortocaval fistula using the amplatzer muscular VSD occluder

Aortocaval fistula is an uncommon but often fatal complication of abdominal aortic aneurysm. Both open and endovascular repair of aortic aneurysm with aortocaval fistulae have been previously reported. We present the case of a patient with persistent aortocaval fistula after endovascular stent graft repair, which is closed using an Amplatzer muscular VSD occluder. Further studies using the Amplatzer muscular VSD occluder for closure of aortocaval fistulae are warranted.     

Transcatheter closure of aortocaval fistula with the amplatzer duct occluder.

PURPOSE: To report percutaneous closure of aortocaval fistulas with the Amplatzer Duct Occluder. CASE REPORTS: An aortocaval fistula was diagnosed after surgical repair of an abdominal aortic aneurysm in a 73-year-old man. A 3-year-old girl was treated for a congenital aortocaval fistula in another case. An 8 x 6-mm Amplatzer Duct Occluder was introduced via a 6-F introducer in each case, successfully occluding the fistulous track. Both patients are well and without any echocardiographic evidence of a shunt at 6 months. CONCLUSIONS: In selected patients, transcatheter closure of aortocaval fistula with the Amplatzer Duct Occluder could be an alternative to open surgery. Further evaluation is necessary.     

Acquired aortocaval fistulas

Collective experience at the Mayo Clinic with nine cases of acquired aortocaval fistula revealed a difference between the presenting features of patients with traumatic fistula and those of patients with spontaneous fistula. In addition, patients with spontaneous aortocaval fistula, rather than presenting with a single distinct clinical syndrome, present with at least three different clinical pictures: (1) the classic syndrome of high-output heart failure of recent onset with palpable aneurysm and continuous bruit, (2) hypotension and oliguria or anuria in the presence of an abdominal aortic aneurysm, which may not be tender and in which a characteristic bruit may be absent and (3) back pain or abdominal pain associated with a tender pulsatile mass, shock and retroperitoneal hemorrhage. (The fistula may not be suspected prior to surgery.)     

Unilateral Leg Oedema in Association with an Aortocaval Fistula

The study considers a case of a patient who presented with scrotal and unilateral leg oedema secondary to an aortocaval fistula (ACF) complicating an abdominal aortic aneurysm (AAA). During the operation, caval blood loss was controlled with digital pressure over the fistula, and direct closure performed using a 3/0 prolene suture. The aneurysm repair was carried out with a woven Dacron^® graft. The possibility of an ACF in the presence of AAAs should be considered when examining a patient with intractable unilateral leg oedema. The successful outcome depends on early preoperative recognition, prompt surgical repair and careful attention to intra-operative blood loss.     

A giant aortocaval fistula due to abdominal aortic aneurysm

Although very rare, the fistula development between vena cava inferior and an abdominal aortic aneurysm is a pathology which can deteriorate the clinical status of the patient rapidly. Today, this pathology can be diagnosed very easily with non-invasive tests, and invasive tests can also be used for diagnostic purposes when needed. Especially spiral computed tomography scan with contrast is usually sufficient to diagnose this pathology. A large-diameter aortocaval fistula case, which to our knowledge never presented in the literature before, and its diagnosis and treatment will be presented in this article.     

ENDOSCOPIC IMAGE OF SECONDARY AORTOENTERIC FISTULA

Surgical treatment of abdominal aortic aneurysms by resection of the aneurysm and graft replacement is now an accepted procedure, but this has led to various postoperative complications. One example of this is secondary aortoenteric fistula. The diagnosis of aortoenteric fistula is often difficult to establish. We report a case of aortoenteric fistula that occurred 1 year after resection of the aneurysm and graft replacement. A 69‐year‐old man was admitted to our hospital following a sudden episode of melena. He had undergone aorto‐bifemoral bypass surgery with a prosthetic graft 1 year previously for abdominal aortic aneurysm. Upper gastrointestinal endoscopy and computed tomography scan were performed and aortoenteric fistula as a result of aortic anastomotic pseudoaneurysm, was diagnosed. In the first stage operation, an extra‐anatomic bypass was implanted from the right axillary artery to both femoral arteries. Removal of the graft and aortic stump closure were carried out in the second stage. The patient recovered uneventfully. This case shows the use of endoscopy for early diagnosis of secondary aortoenteric fistula.     

Primary aortoenteric fistula: a rare cause of gastrointestinal bleeding in young adults

Aortoenteric fistula is defined as a communication between the native aorta and any portion of the gastrointestinal tract. Depending on previous aortic grafting it can be classified as primary, without previous grafting, or secondary. Primary aortoenteric fistula is less frequent and usually arises from an abdominal aortic aneurysm. Clinical presentation is usually gastrointestinal bleeding. The main diagnostic procedures are gastroscopy and computed tomography. We report the case of a 46-year-old man who presented to the emergency room with gastrointestinal bleeding and an abdominal pulsatile mass. Although complementary tests and clinical signs suggested a diagnosis of primary aortoenteric fistula, the communication was not observed on gastroscopy and was confirmed by exploratory laparotomy. Despite aggressive surgical treatment, the prognosis of this entity is poor.     

Aortopulmonary Fistula: A Rare Complication of an Aortic Aneurysm

In a patient with degenerative disease of the thoracic aorta, an aortopulmonary fistula with an aortic aneurysm after trauma is a rare occurrence. Few cases of successful surgical management have been reported. Aortopulmonary fistula should be suspected in a patient who has an aortic aneurysm and exhibits signs of congestive heart failure. Herein, we report the case of a 50-year-old man who underwent surgical repair of an ascending aortic aneurysm with fistula into the main pulmonary artery. Early diagnosis and prompt surgical intervention were crucial to the successful outcome.Key words: Aortic aneurysm, thoracic/complications/diagnosis; arterio-arterial fistula/etiology/surgery; fistula/surgery; pulmonary artery/abnormalities/pathology/surgery; vascular surgical proceduresThe natural course of thoracic aortic aneurysms usually involves acute aortic dissection or free rupture of the aneurysm rather than congestive heart failure. An aortic aneurysm with aortopulmonary fistula after trauma is unusual. Few cases of successful surgical management have been reported. Aortopulmonary fistula should be suspected in a patient who has an aortic aneurysm and shows signs of congestive cardiac failure. Early diagnosis and prompt surgical intervention are crucial to a successful outcome. Here, we report the case of a 50-year-old man with this combination of conditions.     

Angina pectoris as the initial manifestation of an aortocaval fistula

Spontaneous aortocaval fistula is an unusual disorder associated with abdominal aortic aneurysms and with the onset of high-output heart failure. A novel case of spontaneous aortocaval fistula formation that presented with angina is described. Increased myocardial oxygen demand due to elevated myocardial wall tension, inotropic state, and heart rate is the apparent contributing factor. Clinical evidence of ischemic heart disease and heart failure resolved with surgical correction of the shunt. Spontaneous aortocaval fistula formation can be a precipitating cause of new-onset angina.     

Fortuitous rupture of aortic aneurysm: A catastrophic event affording time for surgical cure

The rupture of an aortic aneurysm is generally a fatal event, but occasionally the rupture will occur into an adjacent vascular structure, thereby preventing exsanguination and affording temporary survival. Three cases are presented illustrating the fortuitous nature of the rupture of an aortic aneurysm into a vascular structure. The first patient had an atherosclerotic abdominal aortic aneurysm that ruptured into the inferior vena cava and was successfully repaired. The second case demonstrates the formation of a fistula from the aorta to the left pulmonary artery in a patient with a syphilitic thoracic aortic aneurysm. In the third patient a dissecting aneurysm of the aortic root that communicated with the right ventricle after coronary bypass surgery was successfully repaired. Rarely, aortic aneurysms will rupture fortuitously into vascular capacitance structures. These three cases emphasize the need for early accurate diagnosis and the institution of appropriate surgical measures.     

Aortoduodenal fistula as a cause of gastrointestinal bleeding--difficulties in endoscopic diagnosis

We report on three patients with severe gastrointestinal bleeding arising from aortoenteric fistula. Two patients presented with a secondary aortoduodenal fistula. In the first case bleeding occurred 8 months after aortobifemoral graft implantation. In the second patient aortobiliacal graft implantation was performed 22 years before. In the third case the aortoenteric fistula was primary and was caused by an abdominal aortic aneurysm without prior vascular intervention. In the first case diagnosis was made by urgent endoscopy visualizing ongoing bleeding from the duodenal fistula. In the two other patients urgent endoscopy and CT as well could not demonstrate the bleeding source. Aortoenteric fistula was diagnosed endoscopically during severe rebleeding some hours later. Two patients underwent surgery with implantation of an axillobifemoral bypass; the third patient declined further intervention and died. The course shows that aortoduodenal fistula can present with severe but intermittent gastrointestinal bleeding making the diagnosis in the non-bleeding interval difficult. In patients with severe gastrointestinal bleeding and a history of aortic disease (aneurysm, prior aortic graft repair or stenting) an aortoduodenal fistula should be suspected and the indication for surgical intervention should be considered early in spite of negative results of endoscopy and CT.     

Primary aortoduodenal fistula: Pitfalls and success in the endoscopic diagnosis

Primary aortoenteric fistula is a rare but catastrophic cause of gastrointestinal bleeding. The diagnosis of primary aortoenteric fistula is difficult to make and is usually accompanied by a very high level of clinical suspicion. It should be considered in any elderly patient presenting with upper gastrointestinal bleeding in the context of a known abdominal aortic aneurysm. Prompt surgical intervention is necessary. We present the case of a 78-year-old man with a history of atherosclerotic abdominal aortic aneurysm which is presented with massive upper gastrointestinal bleeding due to a primary aortoduodenal fistula. Initial misdiagnosis led to a delay in treatment and the patient succumbed to the illness.     

Enigma of primary aortoduodenal fistula

A diagnosis of primary aortoenteric fistula is difficult to make despite a high level of clinical suspicion. It should be considered in any elderly patient who presents with upper gastrointestinal bleeding in the context of a known abdominal aortic aneurysm. We present the case of young man with no history of abdominal aortic aneurysm who presented with massive upper gastrointestinal bleeding. Initial misdiagnosis led to a delay in treatment and the patient succumbing to the illness. This case is unique in that the fistula formed as a result of complex atherosclerotic disease of the abdominal aorta, and not from an aneurysm.     

Chronic contained rupture of an abdominal aortic aneurysm presenting as a lower extremity neuropathy

Rupture of an abdominal aortic aneurysm often presents with a pulsatile abdominal mass, abdominal pain, and hypotension. Recent clinical reports describe patients with less apparent clinical signs and symptoms who were found later in their evaluation to have a contained rupture of an abdominal aortic aneurysm. Even more unusual is a chronic contained rupture of an abdominal aortic aneurysm. Our patient had a chronic contained rupture of an abdominal aortic aneurysm that presented with erosion into the lumbar vertebral bodies and subsequent lumbar neuropathy. CT scan confirmed the contained rupture of the aortic aneurysm and the patient underwent successful repair of his aortic aneurysm. Our report discusses the significance of atypical presentations of abdominal aortic aneurysm rupture and the importance of prompt diagnosis and definitive repair.     

Refractory shock secondary to copper sulfate ingestion

Presented is the case of a 62-year-old man with refractory shock secondary to copper sulfate ingestion. The patient's history was complicated by the presence of peptic ulcer disease, myocardial disease, and a known abdominal aortic aneurysm. Despite the presence of such characteristic signs and symptoms as hemorrhagic gastroenteritis, hemolytic anemia, and refractory hypotension, the diagnosis of copper sulfate ingestion was delayed for several days after ingestion, when the family first volunteered that the patient had vomited blue-green material the day before his admission to the hospital. This delay contributed significantly to the patient's ultimate demise.     

Diagnosis of an aorto-caval fistula by echo 2D color Doppler flow imaging and echocardiographic probe

We describe a clinical case presenting two unusual features. The first was a spontaneous aorto-caval fistula which had developed from rupture of an atherosclerotic aortic aneurysm into the inferior vena cava. The second uncommon feature depended on the unusual method by which the diagnosis was performed. In fact, using an echo-Doppler color flow (HP 77020A ultrasound system) with a 2.5 MHz echocardiographic probe abdominal examination revealed an aneurysm of the abdominal aorta that communicated with a dilated inferior vena cava. Furthermore, flow study with pulsed color Doppler revealed a continuous turbolent, mixed (arterial and venous) blood flow into the vena cava.     

Aorto-Enteric Fistula Associated with Aortic Dissection

Primary aorto-enteric fistula (PAEF) is usually due to erosion by atherosclerotic aneurysm. We report a case of PAEF secondary to a previously unrecognised focal abdominal aortic dissection. A 66-year-old man was brought to the casualty department with shock and acute-on-chronic back pain. Following resuscitation, he deteriorated further secondary to frank haematemesis. A prompt contrast enhanced CT scan was performed, and aortic dissection with aorto-duodenal fistula was diagnosed and operated on. To our knowledge, there are no previous reports of penetrating, transmural PAEF secondary to abdominal aortic dissection.     

AORTO‐DUODENAL FISTULA: MULTIDETECTOR COMPUTED TOMOGRAPHY AND GASTRODUODENOSCOPY FINDINGS OF A RARE CAUSE OF UPPER GASTROINTESTINAL HEMORRHAGE

An aorto‐enteric fistula is a serious complication of abdominal aortic aneurysm. Acute upper gastrointestinal bleeding may be a life‐threatening condition that calls for immediate diagnosis and action. Morbidity and mortality remain high despite progress in diagnosis and therapeutic procedures. In the literature, the aorto‐enteric fistula diagnostic suspicion by multidetector computed tomography scan is assumed on the basis of the interruption of the aortic wall, with the presence of duodenal gas situated to tightened contact with the aorta. We report a patient with an aorto‐duodenal fistula associated with inflammatory abdominal aortic aneurysm detected by gastro‐duodenoscopy and multidetector computed tomography scan, with gas found in the lumen of the abdominal aorta, between the aneurysm wall and the thrombus.     

A complicated case of aortoduodenal fistula

Aortoduodenal fistula may occur primarily as a complication of abdominal aortic aneurysm or secondarily after reconstructive surgery of the abdominal aorta. The clinical presentation may be occult, with the classic triad of mass, pain, and bleeding inapparent or overshadowed by signs of infection. A high index of clinical suspicion combined with radiographic and endoscopic examinations will establish the diagnosis.