Aorto-Left Renal Vein Fistula: An Unusual Complication of Abdominal Aortic Aneurysm MERTON SUZUKI, M.D., GEOFFREY M. COLLINS, M.D., GERALD T. BASSINGER, M.D., RALPH B. DILLEY, M.D.
A patient with an abdominal aortic aneurysm with a preaortic left renal vein fistula is presented. Review of the 7 reported cases of aorto-left renal vein fistulae demonstrates many similarities in the clinical presentation with aorto-caval fistulae. However, in addition to the triad of pain, pulsatile abdominal mass and bruit, commonly found in aorto-caval fistulae, the presence of hematuria, proteinuria, and azotemia suggests a renal vein fistula. Radiographic studies often demonstrate a large non-functional left kidney. Operative management of the fistula may be performed by a variety of maneuvers. All 7 patients survived. When repair was undertaken without delay, function in the left kidney returned to normal within two months postoperatively.
TrHE CHALLENGE in the diagnosis and management of complications of aneurysms of the aorta secondary to atherosclerotic degenerative disease is well recognized. In a cumulated autopsy series of greater than 1100 patients collected by Gore and Hurst,1 atherosclerotic abdominal aortic aneurysms ruptured in 28% of patients during their lifetime. The clinical picture depends upon the direction in which the aneurysm ruptures. The most frequently encountered form is retroperitoneal rupture, with varying degrees of tamponade. Free intraperitoneal rupture is marked by severe and often fatal hemorrhagic shock, and in rare instances, gastrointestinal bleeding indicates an aortoduodenal fistula secondary to the aneurysm. Perhaps the most unusual and diagnostically challenging complication of aneurysm rupture is perforation into an adjacent major venous channel. Through 1971, 71 cases of aorto-caval Submitted for publication September 8, 1975. All correspondence: Ralph B. Dilley, M. D., Department of Surgery, University Hospital, 225 W. Dickinson Street, San Diego, Ca. 92103.
31
From The Department of Surgery, University of California Medical Center, La Jolla, California 92037
fistulae had been recorded ,2 and even fewer cases of aortoleft renal vein fistulae. We are aware of 6 such reports and in each instance the perforation was into a retroaortic left renal vein. Recent experience with this complication in which the fistula involved an anterior left renal vein prompts this report. Case Report E.L., a 57-year-old man, was first admitted to San Diego Veterans Administration Hospital in November, 1973, with bleeding gastritis. A pulsatile abdominal mass was discovered and ultrasound examination demonstrated a 4.5 cm abdominal aneurysm. Ten months later, the aneurysm had enlarged to 5.5 cm, and even though it remained asymptomatic, resection was advised. On 10/14/74, two weeks before his scheduled admission, the patient came into the Emergency Room with a 3-hour history of severe, constant, aching left flank and back pain which radiated to the left inguinal region. There was no previous history of renal stones. Physical examination revealed a moderately obese man in severe distress. He was afebrile with a blood pressure of 130/80 and a pulse of 88/minute. Positive findings included bibasilar rales and a soft systolic ejection mujrmur. Exquisite tenderness was present in the left upper quadrant and left flank, and a pulsatile epigastric abdominal mass was present. Bowel sounds were hypoactive and no bruit was noted. Peripheral pulses were normal and there was no lower extremity edema. Hematocrit, hemoglobin, and white cell count were normal. Blood urea nitrogen and creatinine were 18 and 1.5 mg% respectively. His urine initially showed 3+ proteinuria and microscopic hematuria with progression to gross hematuria while the patient was being evaluated in the Emergency Room. An abdominal x-ray demonstrated a small area of calcification in the lower pole of
SUZUKI AND OTHERS
32
Ann.
Surg. * July 1976
border of the aneurysm (Fig. 2). Since there was no intraor retroperitoneal bleeding, a diagnosis of aorto-left renal vein fistula was made. With the aorta and iliac vessels clamped,
upper
opentoneal
bleeding from
t ; _ _3- _i
opened
the
aneurysm
relentless
was
until
the
left
renal vein was ligated on either side of the fistula. The aneurysm was partially excised and arterial continuity was re-established with Dacron bifurcation
a
Postoperatively hematuria
graft.
the
resolved
patient
rapidly,
had and
an
the
uneventful blood
urea
course.
The
nitrogen
and
creatinine levels remained normal. Ten days postoperatively, intravenous
A
pyelogram
retrograde
revealed
pyelogram
an
slight function in the left kidney.
demonstrated
normal
a
left
collecting
postoperatively, 99Tc-DTPA and 1311 hippuran renal scans showed persistent impairment of left renal perfusion and function. An IVP, repeated two months postoperatively, showed system.
One month
return of normal renal function
(Fig. 3).
Discussion
Aorto-venous
fistulization
abdominal aortic aneurysm
as
was
a
complication
first reported in
of 1831
by Syme,3 who described a 22-year-old man with a leutic aneurysm who died 31/2 months after the onset of his symptoms. The first attempt at surgical correction, although unsuccessful, was made in 1935 by Lehman.4 In 1954, DeBakey and Cooley were the first to success-
fully repair an abdominal aortic aneurysm with an aorto-caval fistula. In their series of 1400 patients with FIG. 1. Admission intravenous pyelogram. Dotted lines indicated enlarged non-functioning left kidney. Arrow indicates a functioning right kidney. an
the left kidney, and apparent enlargement of the aneurysm to 8.5 An emergency intravenous pyelogram demonstrated an enlarged
cm.
non-functioning
left
At laparotomy,
kidney (Fig. 1).
a
prominent thrill
left renal vein which
was
s"3X_
was
noted in the
located anterior to the
FIG. 2. Diagram indicating site of perforation into renal vein.
area
aorta
an
of the
and at the
anterior left
FIG. 3. Intravenous pyelogram two months postoperatively indicating normal function bilaterally.
AORTO-LEFT RENAL VEIN FISTULA
Vol. 184 e No. I
33
TABLE 1. Clinical Findings in Patients with Aorto-left Renal Vein Fistulae and Aorto-caval Fistulae
Lord 1964 Age and sex
62 M
Pain Pulsatile
+
abdominal mass Abdominal bruit Blood pressure Cardiac failure Leg edema Hematuria Proteinuria Blood urea nitrogen/ creatinine Intravenous pyelogram (left kidney) Aortogram Left renal vein position
+ +
*
Graham 1971
Yashar 1969
Horan 1967
Scetbon 1973
Mohr 1975
Suzuki 1975
60 M 0
55 M
58 M
75 M
70 M
57 M
+
+
+
+
+
+ +
+
125/60
0 + 160/60
0
+
145/40 0
+
0
+
Microscopic
Microscopic 0
+
+
0
0 90/60 0 0 Gross +
28/1.5
49/2.1
27/-
71/4.8
-
Nonfunction Nonfunction Fistula Fistula
Retroaortic
Retroaortic
Retroaortic
0 +
+ +
120/80 0 0
0
Microscopic
Gross
Ccr37*
30/-
Nonfunction Fistula
Nonfunction Nonfunction Fistula
130/70
+
Retroaortic Retroaortic
+
0 130/80 0 0 Gross
Reckless 1972 41 Patients with Aorto-caval Fistulae 61 (95% M) 88% 90% 83% 37% 56% 17%
+
Retroaortic
18/1.5
Preaortic
Cc,r-creatinine clearance.
abdominal aortic aneurysm reported in 1963,6 130 presented with rupture and three with aorto-caval fistulae, an incidence of 2.3% of all patients with a ruptured aneurysm. Recently Reckless surveyed the world literature and found 71 reported cases of aorto-caval fistula.2 Of these, 41 were operated upon with a mortality of 25%. The first reported case of successful correction of an aorto-left renal vein fistula was reported by Lord7 in 1964, and since then 5 additional cases have been reported.8-'2 Table 1 lists the symptoms, signs and pertinent laboratory findings in the 7 patients (including the patient in this report) with aorto-left renal fistulae and compares these with 40 patients operated on for aorto-caval fistulae as reported by Reckless.2 In patients with aortocaval fistulae, the most frequent clinical findings include abdominal, back, or flank pain, a pulsatile abdominal mass and an abdominal bruit. Although abdominal bruits may occur in up to 20% of patients with an abdominal aortic aneurysm,'3 they are present in 83% of patients in whom the aneurysm perforates into the vena cava. Patients with aorto-left renal vein fistulae have a clinical picture very similar to that of aorto-caval fistulae. In contrast, the pain is generally localized to the left flank and lumbar region and often radiates to the groin, closely mimicking ureteral colic. Shock, a widened pulse pressure, high cardiac output failure, and leg edema are found infrequently, probably reflecting the fact that flow through an aorto-left renal vein fistula is less than through an aorto-caval fistula. The only patient who presented with shock had a large
hematoma associated with retroperitoneal rupture,'0 in addition to the aorto-left renal vein fistula. The most important clinical features which differentiate patients with aorto-left renal vein fistulae from patients with ruptured aneurysms or aorto-caval fistulae are the presence of hematuria, proteinuria, and azotemia. Although 10% of patients with aortic aneurysms may present with symptomatology initially suggesting a urologic disorder, hematuria is not a prominent feature.'4 Hematuria has been reported in 17% of patients with aorto-caval fistulae, and in contrast, all but one of the patients with aorto-left renal vein fistulae had hematuria. In three gross hematuria was present. A mild degree of azotemia was present in all 7 cases of aorto-left renal vein fistulae, and proteinuria was present in 6. Excluding the patient who was hypotensive,10 the blood urea nitrogen ranged from 18-49 mg% and the serum creatinine from 1.5 to 2.1 mg%. Azotemia and proteinuria is present in a 14-54% of patients with abdominal aortic aneurysms'13"4; however, a likely predisposing cause, such as renal disease, is usually evident. Less obvious causes include renal failure due to an aneurysm which involves the renal arteries, or rarely, obstruction of the ureters by the enlarging aneurysm. Radiographic studies were diagnostic in the patients with aorto-left renal vein fistulae. Non-visualization of the left kidney was uniformly found, and in two patients the left kidney was enlarged.8'0"2 The severe renal venous hypertension produced by the fistula is responsible for the left renal malfunction and enlargement,
SUZUKI AND OTHERS
34
and this also explains the high incidence of proteinuria and hematuria in comparison with other complications of abdominal aortic aneurysms. Aortograms were performed in 4 of the cases reported and successfully demonstrated the aorto-venous fistula in each instance. 8,9,11,12
Should the diagnosis not be made preoperatively, the intraoperative findings of a prominent thrill in the pre-aortic region should alert the surgeon to the possible presence of an aorto-left renal vein fistula. The operative plan should include an attempt to isolate the left renal vein on either side of the fistula prior to opening the aneurysms. Isolation of the left renal vein is an easy maneuver when it is located anteriorly, but may be treacherous if it is posterior to the aneurysm. In such cases, the aneurysm should be opened and back bleeding from the fistula controlled from within.7'9'12 A retroaortic left renal vein, which occurs in 3% of the population,15 was present in all previously reported cases, and may be a predisposing cause since aneurysms perforate posteriorly in most instances. Caution should also be exercised to prevent embolization of atheromatous material. Two such cases have been documented, one of which was fatal.16'17
References 1. Gore, I. and Hurst, A. E., Jr.: Arteriosclerotic Aneurysms of the Abdominal Aorta. Prog. Cardiovasc. Dis., 16:113, 1973. 2. Reckless, J. P. D., McColl, I. and Taylor, G. W.: AortoCaval Fistulae: An Uncommon Complication of Abdominal Aortic Aneurysms. Br. J. Surg., 59:461, 1972.
Ann. Surg. * July 1976
3. Syme, J.: Case of Spontaneous Varicose Aneurysm. Edin. Med. Surg. J., 36:104, 1931. 4. Lehman, E. P.: Spontaneous Arteriovenous Fistula Between the Abdominal Aorta and the Inferior Vena Cava. Ann. Surg., 108:694, 1938. 5. DeBakey, M. E., Cooley, D. A., Morris, G. C., Jr. and Collins, H.: Arteriovenous Fistula Involving the Abdominal Aorta: Report of Four Cases with Successful Repair. Ann. Surg., 147:646, 1958. 6. Beall, A. C., Cooley, D. A., Morris, G. C., Jr. and DeBakey, M. E.: Perforation of Arteriosclerotic Aneurysms Into Inferior Vena Cava. Arch. Surg., 86:809, 1963. 7. Lord, J. W., Vigorita, J. and Florio, J.: Fistula Between Abdominal Aortic Aneurysm and Anomalous Renal Vein, JAMA, 187:535, 1964. 8. Horan, D. P. and Sharp, J. H.: Spontaneous Fistula Between the Aorta and Left Renal Vein. Am. J. Surg., 113:802, 1967. 9. Yashar, James J., Hallman, G. L. and Cooley, D. A.: Fistula Between Aneurysm of Aorta and Left Renal Vein. Arch. Surg., 99:546, 1969. 10. Grahame, J. W. and Downs, A. R.: Ruptured Abdominal Aortic Aneurysm Presenting with Gross Hematuria. J. Urol., 106:628, 1971. 11. Scetbon, V., Helenon, C. and Helenon, P.: Aneurysme de l'aorte Abdominale Fistulise dans la Veine Renale Gauche. Nouve. Presse Med., 2:2101, 1973. 12. Mohr, L. L. and Smith, L. L.: Arteriovenous Fistula from Rupture of Abdominal Aortic Aneurysm. Arch. Surg., 110:806, 1975. 13. Wright, I. S., Urdaneta, E. and Wright, B.: Problems in the Diagnosis and Treatment of Abdominal Aortic Aneurysms. Am. J. Surg., 123:698, 1972. 14. Culp, 0. S. and Bernatz, P. E.: Urologic Aspects of Lesions in the Abdominal Aorta. J. Urol., 86:189. 1961. 15. Brener, B. M., Darling, R. C., Frederich, P. L. and Linton, R. R.: Major Venous Anomalies Complicating Abdominal Aortic Surgery. Arch. Surg., 108:159, 1974. 16. Hufnagel, C. A. and Conrad, P.: Abdominal Arteriovenous Fistulas. Surg. Gynecol. Obstet., 114:470, 1962. 17. Baker, W. H., Sharzer, L. A. and Ehrenhaft, J. L.: Aortocaval Fistula as a Complication of Abdominal Aortic Aneurysms. Surgery, 72:933, 1972.