93
Fortschr. Röntgenstr. 128, 1(1978) 93-94 © Georg Thieme Verlag, Stuttgart
Aorto-caval fistula as complication of abdominal aortic aneurysm A Case Report
By L. Ala-Ketola, P. Kärkölä and E. Koivisto 1 Figure University of Oulu, Department of Diagnostic Radiology )Dircctor and Department of Surgery (Director: Prof. Dr. T. Larmi)
'rof. 1) r. P. Vuoria)
Rupture of an abdominal aortic aneurysm usually occurs into the retroperitoneal space, while rupture into the inferior vena cava is very rare. Seventy-one cases of spontaneous rupture of abdominal aortic aneurysm into the vena cava have been reported (4). The first successful surgical repair was performed in 1954 (3).
The main symptoms are haemodynamic disorders due to a massive arteriovenous shunt. The correct clinical diagnosis is easy to the surgeon familiar with vascular diseases, but the symptoms of cardiac failure may be misleading. Operative treatment without delay is often necessary, hut aortography may be beneficial in obscure cases or in evaluating the state of the branches of the abdominal aorta. A report of a case with interesting clinical history and illustrative angiographie finding is presented.
and pulse rate 95 per minute. The heart was slightly enlarged and a systolic ejection murmur was heard on auscultation. ECG revealed a slight anterolateral íschemia, but no signs of myo-
cardial infarction. The abdomen was distended and a large pulsatile mass was palpated in the umbilical region. On the right border of the mass a systolic thrill radiating to the right inguinal
region was distinctly felt with hand. A "machinery murmur" was heard in the same area. Both lower extremities were edematous and the subcutaneous veins in the inguinal regions and thighs were distended. Laboratory findings revealed a hemoglobin of 116 g/l with a hematoermt of 33 vol%. The serum creatinine was 175 emol/1, sodium 130 mmol/l and potassium 6,1 mmol/l. The urine output was low. The diagnosis of abdominal aortic aneurysm was established and
an aorto-caval fistula with massive arteriovenous shunt was
Case report A 72 year-old male was admitted to the out-patient department of Oulu University Hospital on 9th May 1976, because of sudden severe angina and low back pain. He had a history of coronary disease. Since the angina subsided with nitroglycerin and nasal oxygen therapy, the patient was allowed to return home. After
a week he was readmitted because of continued severe low back pain and pain in the buttocks, angina, oliguria and desorientalion. He was grey and pale. Blood pressure was 120/60 mmHg 0340-1618/78
0132 - 0093 5 05.00 © 1978
suspected on the basis of clinical symptoms and signs. An immediate angiographie examination was performed with percutaneous transaxillary technique. Sixty cc of 60 percent Urografin® (Sche-
ring A.G.) was injected into the aortic arch. The abdominal aortic aneurysm was seen with a prompt and strong filling of the inferior vena cava and iliac veins (Fig. 1). The patient was prepared for emergency surgery. After midline
incision the aorta was clamped above the aneurysm and both common iliac arteries below the aneurysm. The aneurysm was entered and the fistula closed first with digital pressure, then
Georg Thieme Publishers
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
Fortschr. Röntgenstr. 128, 1
Schaukasten
94
Fortschr. Röntgensrr. 128, 1
Schaukasten
heart failure were the most common symptoms, while the most important signs in clinical examination were a palpable aneurysm, abdominal bruit and lower limb edema. The misleading symptoms of cardiac origin make a careful physical examination important
to attain the correct diagnosis and to avoid the typical delay as seen in the present case. Although the important hemodynamic changes produced by arteriovenous fistulas resulting in high
cardiac output failure have long been recognized, it may be
difficult to refer the symptoms to a fistula without palpating an abdominal mass and feeling a bruit. The lower limb edema is due to high cavai pressure (2), but the legs may be only mottled or bluish discolored if the history is short (1). Renal decompensation probably due to renal hypoperfusion (2, 1) is typical for this entity. Low urine output, increased serum ereatinine, lowered serum sodium and increased
serum potassium were observed on admission of the present patient after one week of initial attack. An immediate surgical therapy is essential in these critically ill patients. Aortography is not necessary (2), but may beneficial for patients with an obscure clinical picture (1). An arteriovenous
while according to Suzuki et al. (6) radiographic studies were diagnostic in the patients with aorto-left renal vein fisrulae. We believe that the aortogram was useful to us in confirming the diagnosis not made before in our clinic and may be important in revealing the state of the branches of the abdominal aorta especially in patients with history of hypertension or abdominal angina.
Fig. 1.
A
Aortographv. The contrast medium was injected into
the aorta (A). An aneurysm (AN.) is seen from which the contrast medium enters the inferior vena cava (V. C.) through a fistula (F).
with a Foley catheter. The balloon of the catheter was inflated within the vena cava at the level of the fisrula. After the fistula
Literatur
successful repair. (1955) 646
(i) Baker, \X. H., L. A. Sharzer, J. L. Ehrenhaft: Aottocaval fistula as a abdominal aornc aneurysms. Surgery 72 (1972) 933
compl ication
of
heaP, A. C., jr., iS. A. Cooley, G. C. Morris, (r., M. E. De Bakey: Perforation of arteriosclerotic aneurvsms I lito inferior vena cava. Arch. Surg. f16 (1963) 1109
bifurcated Dacron prorhesis.
The patient made an uneventful recovery and was discharged on the 9th postoperative day. At that time the urine output and serum creatinine values were normal. All symptoms of cardiac decompensation and mental disorders had subsided.
Discussion In a collected review of Reckless et al. (5) in patients with aortocavaI fistula, back pain and progressive symptoms of congestive
Surg.
147
venous listula from rupture of ab-
dominal aortic aneurysm. Arch. Surg. 110 (1975) 806 Reckless, J. P. D.,
i.
McColl,
G. W. Taylor: Aorto-caval fistulue: an uncommon complication uf abdominal aortic aneurysms. Brit. Surg. 59 (1972) 461
J.
Suzuki, M., G. M. Collins, G. T.
Dc Bakey, M. E., 1). A. Coolcy, G. C. Morris, jr., H. Collins Arterio-
renal vein fistula: An unusual corn-
venous fistula i nvo!x 111g the abdomin al Report of four cases with
plication of abdominal annie aneurysm. Ann. Surg. 184 (1976) 31
aorta:
Bassinger, R.
(diameter 30 miii) was closed with continous sutures, the balloon
was deflated and the catheter removed from the vena cava. Reconstruction of the abdominal aorta was performed with
Ann.
Mohr, L. L., L. L. Smith: Artetio-
Dr. L. Ala-Ketola,
Prof. Dr. med. Esklin Koivisto University of Oulu, Department of Diagnostic Radiology, SF 90220 Oulu 22, Finnland
Dr. P. Kärköla, University of Oulu, Department of Surgery, SF 90220 Oulu 22, Finnland
B.
Dilley:
Aurto-left
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
fistula was easiiy identified on the aortograms, but its exact location could not be determined in half of the cases of Mohr & Smith )4),
Fortschr. Röntgenstr. 128, 1(1978) 93-94 © Georg Thieme Verlag, Stuttgart
Aorto-caval fistula as complication of abdominal aortic aneurysm A Case Report
By L. Ala-Ketola, P. Kärkölä and E. Koivisto 1 Figure University of Oulu, Department of Diagnostic Radiology )Dircctor and Department of Surgery (Director: Prof. Dr. T. Larmi)
'rof. 1) r. P. Vuoria)
Rupture of an abdominal aortic aneurysm usually occurs into the retroperitoneal space, while rupture into the inferior vena cava is very rare. Seventy-one cases of spontaneous rupture of abdominal aortic aneurysm into the vena cava have been reported (4). The first successful surgical repair was performed in 1954 (3).
The main symptoms are haemodynamic disorders due to a massive arteriovenous shunt. The correct clinical diagnosis is easy to the surgeon familiar with vascular diseases, but the symptoms of cardiac failure may be misleading. Operative treatment without delay is often necessary, hut aortography may be beneficial in obscure cases or in evaluating the state of the branches of the abdominal aorta. A report of a case with interesting clinical history and illustrative angiographie finding is presented.
and pulse rate 95 per minute. The heart was slightly enlarged and a systolic ejection murmur was heard on auscultation. ECG revealed a slight anterolateral íschemia, but no signs of myo-
cardial infarction. The abdomen was distended and a large pulsatile mass was palpated in the umbilical region. On the right border of the mass a systolic thrill radiating to the right inguinal
region was distinctly felt with hand. A "machinery murmur" was heard in the same area. Both lower extremities were edematous and the subcutaneous veins in the inguinal regions and thighs were distended. Laboratory findings revealed a hemoglobin of 116 g/l with a hematoermt of 33 vol%. The serum creatinine was 175 emol/1, sodium 130 mmol/l and potassium 6,1 mmol/l. The urine output was low. The diagnosis of abdominal aortic aneurysm was established and
an aorto-caval fistula with massive arteriovenous shunt was
Case report A 72 year-old male was admitted to the out-patient department of Oulu University Hospital on 9th May 1976, because of sudden severe angina and low back pain. He had a history of coronary disease. Since the angina subsided with nitroglycerin and nasal oxygen therapy, the patient was allowed to return home. After
a week he was readmitted because of continued severe low back pain and pain in the buttocks, angina, oliguria and desorientalion. He was grey and pale. Blood pressure was 120/60 mmHg 0340-1618/78
0132 - 0093 5 05.00 © 1978
suspected on the basis of clinical symptoms and signs. An immediate angiographie examination was performed with percutaneous transaxillary technique. Sixty cc of 60 percent Urografin® (Sche-
ring A.G.) was injected into the aortic arch. The abdominal aortic aneurysm was seen with a prompt and strong filling of the inferior vena cava and iliac veins (Fig. 1). The patient was prepared for emergency surgery. After midline
incision the aorta was clamped above the aneurysm and both common iliac arteries below the aneurysm. The aneurysm was entered and the fistula closed first with digital pressure, then
Georg Thieme Publishers
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
Fortschr. Röntgenstr. 128, 1
Schaukasten
94
Fortschr. Röntgensrr. 128, 1
Schaukasten
heart failure were the most common symptoms, while the most important signs in clinical examination were a palpable aneurysm, abdominal bruit and lower limb edema. The misleading symptoms of cardiac origin make a careful physical examination important
to attain the correct diagnosis and to avoid the typical delay as seen in the present case. Although the important hemodynamic changes produced by arteriovenous fistulas resulting in high
cardiac output failure have long been recognized, it may be
difficult to refer the symptoms to a fistula without palpating an abdominal mass and feeling a bruit. The lower limb edema is due to high cavai pressure (2), but the legs may be only mottled or bluish discolored if the history is short (1). Renal decompensation probably due to renal hypoperfusion (2, 1) is typical for this entity. Low urine output, increased serum ereatinine, lowered serum sodium and increased
serum potassium were observed on admission of the present patient after one week of initial attack. An immediate surgical therapy is essential in these critically ill patients. Aortography is not necessary (2), but may beneficial for patients with an obscure clinical picture (1). An arteriovenous
while according to Suzuki et al. (6) radiographic studies were diagnostic in the patients with aorto-left renal vein fisrulae. We believe that the aortogram was useful to us in confirming the diagnosis not made before in our clinic and may be important in revealing the state of the branches of the abdominal aorta especially in patients with history of hypertension or abdominal angina.
Fig. 1.
A
Aortographv. The contrast medium was injected into
the aorta (A). An aneurysm (AN.) is seen from which the contrast medium enters the inferior vena cava (V. C.) through a fistula (F).
with a Foley catheter. The balloon of the catheter was inflated within the vena cava at the level of the fisrula. After the fistula
Literatur
successful repair. (1955) 646
(i) Baker, \X. H., L. A. Sharzer, J. L. Ehrenhaft: Aottocaval fistula as a abdominal aornc aneurysms. Surgery 72 (1972) 933
compl ication
of
heaP, A. C., jr., iS. A. Cooley, G. C. Morris, (r., M. E. De Bakey: Perforation of arteriosclerotic aneurvsms I lito inferior vena cava. Arch. Surg. f16 (1963) 1109
bifurcated Dacron prorhesis.
The patient made an uneventful recovery and was discharged on the 9th postoperative day. At that time the urine output and serum creatinine values were normal. All symptoms of cardiac decompensation and mental disorders had subsided.
Discussion In a collected review of Reckless et al. (5) in patients with aortocavaI fistula, back pain and progressive symptoms of congestive
Surg.
147
venous listula from rupture of ab-
dominal aortic aneurysm. Arch. Surg. 110 (1975) 806 Reckless, J. P. D.,
i.
McColl,
G. W. Taylor: Aorto-caval fistulue: an uncommon complication uf abdominal aortic aneurysms. Brit. Surg. 59 (1972) 461
J.
Suzuki, M., G. M. Collins, G. T.
Dc Bakey, M. E., 1). A. Coolcy, G. C. Morris, jr., H. Collins Arterio-
renal vein fistula: An unusual corn-
venous fistula i nvo!x 111g the abdomin al Report of four cases with
plication of abdominal annie aneurysm. Ann. Surg. 184 (1976) 31
aorta:
Bassinger, R.
(diameter 30 miii) was closed with continous sutures, the balloon
was deflated and the catheter removed from the vena cava. Reconstruction of the abdominal aorta was performed with
Ann.
Mohr, L. L., L. L. Smith: Artetio-
Dr. L. Ala-Ketola,
Prof. Dr. med. Esklin Koivisto University of Oulu, Department of Diagnostic Radiology, SF 90220 Oulu 22, Finnland
Dr. P. Kärköla, University of Oulu, Department of Surgery, SF 90220 Oulu 22, Finnland
B.
Dilley:
Aurto-left
Heruntergeladen von: NYU. Urheberrechtlich geschützt.
fistula was easiiy identified on the aortograms, but its exact location could not be determined in half of the cases of Mohr & Smith )4),
