Ann Vasc Dis Vol. 6, No. 4; 2013; pp 741–744 ©2013 Annals of Vascular Diseases
Online November 15, 2013 doi:10.3400/avd.cr.13-00078
Case Report
Endovascular Aortic Stenting in Patients with Chronic Traumatic Aortocaval Fistula Tanop Srisuwan, MD,1 Rungsrit Kanjanavanit, MD,2 and Kittipan Rerkasem, MD, PhD3,4
This study aimed to present the treatment of a case of delay presenting of traumatic aortocaval fistula (ACF) and its effect on hemodynamic problem. A 59-year-old man was admitted to our hospital with heart failure due to a 41-year-old traumatic ACF. ACF closure was performed by endovascular aortic stenting. His hospital course after procedure was complicated by severe bradycardia and torsades de pointes and excessive diuresis. We concluded the endovascular technique provided an attractive alternative to open surgical methods for repair of chronic ACF. However, in chronic cases, complications such as severe bradycardia (Nicoladoni-Branham sign) and excessive diuresis must be anticipated. Keywords: aortocaval fistula, trauma, heart failure
Introduction
Case Report
C
A 59-year-old male came to hospital with progressive dyspnea and peripheral edema, which began 7 years before. He had a recent history of frequent hospital readmission with chest discomfort and congestive heart failure (CHF). Physical examination revealed severe tricuspid regurgitation and atrial fibrillation. Ill-defined pulsatile mass in the right paraumbilical area with continuous abdominal bruit was also detected. Both legs were swelling. His oxygen saturation was 90% at room air. Chest radiograph showed cardiomegaly with increased pulmonary blood flow and pulmonary arterial hypertension compatible with chronic long-standing left to right shunting. Volume load right ventricle, severe tricuspid regurgitation (TR) and pulmonary hypertension and patent foramen ovale (PFO) with right to left shunting was noted with echocardiogram. Left ventricular (LV) was mildly dilated with normal systolic function (LVEF 70.3%) but right ventricular (RV) systolic function was severely impaired (RV fractional area change 24.1%). Also, thrombocytopenia (92000 cells/cu.mm3) and renal insufficiency (plasma creatinine 3.2 mg/dl) were detected. He had a stab wound at right lower quadrant 41 years ago. He was taken to the operating room, where an exploratory laparotomy was performed to repair the bowel laceration. Computed tomography (CT) scanning was performed and showed mildly atherosclerotic aorta with aortocaval
hronic aortocaval fistula (ACF) is a rare complication of trauma and causes major hemodynamic and structural changes.1) Previously, chronic ACF was mainly reported as a complication of ruptured abdominal aortic aneurysm (80%–90%).1–4) In the past 20 years, three cases of traumatic ACF were treated with endovascular stenting, but to our knowledge, no previous study has reported the application of endovascular aortic stenting in any patients with a 40 year ACF history.5) This report aimed to present and review the treatment of a rare case of delay presenting of traumatic ACF by using an endovascular approach and its effect on the hemodynamic problem. 1Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 3Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 4Center for Applied Science, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
Received: August 14, 2013; Accepted: September 14, 2013 Corresponding author: Kittipan Rerlasem, MD, PhD. Department of Surgery, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., Tambon Sriphum, Chiang Mai 50200, Thailand Tel: +66-53-945532, Fax: +66-53-946139 E-mail: [email protected]
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
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(A)
(B)
(C)
Fig. 1 A ortocaval fistula with a huge inferior vena cava (IVC) aneurysm. (A) volume rendering (VR) CT angiographic image showed connection between infrarenal aorta (Ao) and IVC through the calcified false aneurysm (*). (B) Conventional angiography before stent graft placement demonstrated aortocaval fistula through the false aneurysm. (C) After deployed abdominal tube stent graft, minimal type I endoleak (**) was shown.
fistula in the infrarenal part (Fig. 1), with a huge inferior vena cava (IVC) aneurysm. The diameter of the IVC and renal veins were 10 cm and 2 cm, respectively. The infrarenal aorta above the fistula was 20 mm in diameter and its length below the left renal artery, which was the lowest one was 20 mm. The aorta below the fistula was 20 mm in diameter. There was neither aortic stenosis nor arterial obstructive lesion. Bilateral iliac arteries were not severely tortuous. Endovascular closure of the ACF was conducted. After systemic heparinisation with 5000-units of heparin, a 23 × 70 mm abdominal tube stent graft (Endurant) was inserted under fluoroscopic guidance and deployed to cover the fistula via surgically exposed right common femoral artery. Immediately after stent graft placement, bradycardia and hypotension were found, and the pre-operatively prepared transcutaneous cardiac pacemaker was turned on and good hemodynamic condition was restored. Angiography revealed type Ia endoleak passing through the fistula. Balloon dilatation of the proximal and distal landing zones was carefully performed to adequate sealing. However, minimal endoleak persisted, and we decided to retain the endoleak because of slow flow in the IVC aneurysm. Consequently, that reduced the chance of IVC thrombus formation. Postoperatively, the patient was returned to the critical care unit, where his hospital course was complicated by severe bradycardia and torsades de pointes, and excessive diuresis. A temporary pacemaker was put in place. To facilitate venous return from the IVC aneurysm, the patient lay in the Trendelenburg position. This was confirmed
742
11 CR_13-00078 Rerkasem.indd
by bedside ultrasonography. In the first week after intervention, the cardiac, renal, and thrombocytopenic problems were improved (plasma creatinine 0.7 mg/dL and platelet count 116000 cells/cu.mm3). Post operative echocardiogram showed decompression of RV with significant improvement in RV systolic function and severity of TR. With a decrease in venous pressure, PFO was spontaneously closed with normalized systemic oxygen saturation. On follow up the second week, the CT angiography showed no connection between the aorta and IVC, with slow stagnant contrast filling in false aneurysm, which represented partial thrombosis of the fistula. There was no thrombosis in the IVC aneurysm. His blood had been anticoagulated with warfarin together with heparinization overlapping. He developed a hematoma at the right groin wound, which needed drainage Day 16 after the operation. Otherwise, he recovered uneventfully. The 6th week after the operation, the CT angiography no longer showed contrast from aorta connect to either false aneurysm or IVC (Fig. 2). His legs were not edematous.
Discussion Chronic ACF is rare and can give hemodynamically variable pictures, and is often misdiagnosed.6) In our patient with a long standing history of heart failure, it was not suspected until a continuous abdominal bruit and thrill was detected. Chronic left to right shunt via the ACF gives rise to right ventricular volume overload, increased pulmonary
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
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Chronic Traumatic Aortocaval Fistula
dynamic status, therefore, to provide some flow into IVC aneurysm, we decided upon endoleak. Trendelenburg position was useful for providing more venous return from the IVC aneurysm to the heart, and was observed by bedside ultrasonography, which demonstrated the changing of stagnate multilayer-like echoic blood into a more lamina flow. Anticoagulant was also given to prevent a disastrous embolism from the IVC thrombosis.
Conclusion (A)
(B)
Fig. 2 C omputed tomography (CT) angiographic image 6 weeks following endovascular stenting. (A) Volume rendering (VR) CT image showed disappearance of arteriovenous shunt. (B) Coronal maximum intensity projection (MIP) image demonstrated completely excluded false aneurysm with thrombosis of the false aneurysmal sac.
blood flow with subsequent pulmonary hypertension, and right sided heart failure. The clinical pictures, including chest X-ray and echocardiogram, are not much different from those of atrial septal defect, which was initially suspected in this patient. A clinical picture of high output failure similar to that of aortic regurgitation (wide pulse pressure, Water Hammer sign) was also presented. This was due to aortic runoff in ACF. The high pressure of the “arterialized” vein gave rise to various interesting findings in our patient, including (1) impaired renal function due to renal vein congestion, (2) thrombocytopenia from congestive hypersplenism, and (3) PFO and systemic desaturation as a result of high RA pressure, all of which were resolved after repair. Endovascular therapy is an emerging field providing a variety of treatments via small skin incision with less invasiveness, decreased hospital stay, and fewer post operative complications.7) Arteriovenous fistula can be endovascular treated by occlusion of the fistula by a variety of embolic materials such as glue, coil, vascular plug, or an occluder device, depending on flow and anatomical vascular architecture.8–11) Another endovascular treatment option is stent graft placement to exclude the fistula and preserve the parent artery. This method has been applied to aortocaval fistula from ruptured aneurysm with satisfactory results.11) However, our patient, who had longstanding-ACF, also had a huge IVC aneurysm which may have become thrombosed after fistula obliteration. The primary aim for this patient was to reduce flow through the fistula as much as possible in order to stabilise hemo-
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
11 CR_13-00078 Rerkasem.indd
743
The endovascular technique provides an attractive alternative to open surgical methods for repair of chronic ACF. However, in chronic cases, complications such as severe reflex bradycardia (Nicoladoni-Branham sign) from abrupt increase in peripheral vascular resistance, after load, and excessive diuresis must be anticipated and readily addressed after ACF closure.
Disclosure Statement The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References 1) Spencer TA, Smyth SH, Wittich G, et al. Delayed presentation of traumatic aortocaval fistula: a report of two cases and a review of the associated compensatory hemodynamic and structural changes. J Vasc Surg 2006; 43: 836-40. 2) Kotsikoris I, Papas TT, Papanas N, et al. Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: a 12-year series. Vasc Endovascular Surg 2012; 46: 26-9. 3) Arruche Herrero M, Ruiz García V, Castillo Escudero AI, et al. Acute renal failure as a presentation of an aortocaval fistula associated with abdominal aortic aneurism. Nefrologia 2011; 31: 124-6. 4) Fedakar A, Fındık O, Kalender M, et al. Unusual emergent presentations of abdominal aortic aneurysm: can simple blood tests predict the state of emergency? Ulus Travma Acil Cerrahi Derg 2011; 17: 525-32. 5) Waldrop JL, Dart BW, Barker DE. Endovascular stent graft treatment of a traumatic aortocaval fistula. Ann Vasc Surg 2005; 19: 562-5. 6) Unosawa S, Kimura H, Niino T. Surgical repair of ruptured abdominal aortic aneurysm with non-bleeding aortocaval fistula. Ann Vasc Dis 2013; 6: 209-11. 7) Brightwell RE, Pegna V, Boyne N. Aortocaval fistula:
743
2013/12/11
13:22:23
Srisuwan T, et al.
current management strategies. ANZ J Surg 2013; 83: 31-5. 8) Cekirge S, Oguzkurt L, Saatçi I, et al. Embolization of a high-output postnephrectomy aortocaval fistula with Gianturco coils and cyanoacrylate. Cardiovasc Intervent Radiol 1996; 19: 56-8. 9) Godart F, Haulon S, Houmany M, et al. Transcatheter closure of aortocaval fistula with the amplatzer duct
744
11 CR_13-00078 Rerkasem.indd
occluder. J Endovasc Ther 2005; 12: 134-7. 10) Antunes A, Marinho A, Rodrigues D, et al. Percutaneous embolization of a congenital aortocaval fistula—clinical case. Rev Port Cardiol 2003; 22: 1101-6. 11) Rapacciuolo A, De Angelis MC, di Pietro E, et al. Percutaneous treatment of a aorto-caval fistula in a old high risk patient. BMC Surg 2012; 12 Suppl 1: S32.
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
744
2013/12/11
13:22:24
Online November 15, 2013 doi:10.3400/avd.cr.13-00078
Case Report
Endovascular Aortic Stenting in Patients with Chronic Traumatic Aortocaval Fistula Tanop Srisuwan, MD,1 Rungsrit Kanjanavanit, MD,2 and Kittipan Rerkasem, MD, PhD3,4
This study aimed to present the treatment of a case of delay presenting of traumatic aortocaval fistula (ACF) and its effect on hemodynamic problem. A 59-year-old man was admitted to our hospital with heart failure due to a 41-year-old traumatic ACF. ACF closure was performed by endovascular aortic stenting. His hospital course after procedure was complicated by severe bradycardia and torsades de pointes and excessive diuresis. We concluded the endovascular technique provided an attractive alternative to open surgical methods for repair of chronic ACF. However, in chronic cases, complications such as severe bradycardia (Nicoladoni-Branham sign) and excessive diuresis must be anticipated. Keywords: aortocaval fistula, trauma, heart failure
Introduction
Case Report
C
A 59-year-old male came to hospital with progressive dyspnea and peripheral edema, which began 7 years before. He had a recent history of frequent hospital readmission with chest discomfort and congestive heart failure (CHF). Physical examination revealed severe tricuspid regurgitation and atrial fibrillation. Ill-defined pulsatile mass in the right paraumbilical area with continuous abdominal bruit was also detected. Both legs were swelling. His oxygen saturation was 90% at room air. Chest radiograph showed cardiomegaly with increased pulmonary blood flow and pulmonary arterial hypertension compatible with chronic long-standing left to right shunting. Volume load right ventricle, severe tricuspid regurgitation (TR) and pulmonary hypertension and patent foramen ovale (PFO) with right to left shunting was noted with echocardiogram. Left ventricular (LV) was mildly dilated with normal systolic function (LVEF 70.3%) but right ventricular (RV) systolic function was severely impaired (RV fractional area change 24.1%). Also, thrombocytopenia (92000 cells/cu.mm3) and renal insufficiency (plasma creatinine 3.2 mg/dl) were detected. He had a stab wound at right lower quadrant 41 years ago. He was taken to the operating room, where an exploratory laparotomy was performed to repair the bowel laceration. Computed tomography (CT) scanning was performed and showed mildly atherosclerotic aorta with aortocaval
hronic aortocaval fistula (ACF) is a rare complication of trauma and causes major hemodynamic and structural changes.1) Previously, chronic ACF was mainly reported as a complication of ruptured abdominal aortic aneurysm (80%–90%).1–4) In the past 20 years, three cases of traumatic ACF were treated with endovascular stenting, but to our knowledge, no previous study has reported the application of endovascular aortic stenting in any patients with a 40 year ACF history.5) This report aimed to present and review the treatment of a rare case of delay presenting of traumatic ACF by using an endovascular approach and its effect on the hemodynamic problem. 1Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 2Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 3Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 4Center for Applied Science, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
Received: August 14, 2013; Accepted: September 14, 2013 Corresponding author: Kittipan Rerlasem, MD, PhD. Department of Surgery, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., Tambon Sriphum, Chiang Mai 50200, Thailand Tel: +66-53-945532, Fax: +66-53-946139 E-mail: [email protected]
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
11 CR_13-00078 Rerkasem.indd
741
741
2013/12/11
13:22:22
Srisuwan T, et al.
(A)
(B)
(C)
Fig. 1 A ortocaval fistula with a huge inferior vena cava (IVC) aneurysm. (A) volume rendering (VR) CT angiographic image showed connection between infrarenal aorta (Ao) and IVC through the calcified false aneurysm (*). (B) Conventional angiography before stent graft placement demonstrated aortocaval fistula through the false aneurysm. (C) After deployed abdominal tube stent graft, minimal type I endoleak (**) was shown.
fistula in the infrarenal part (Fig. 1), with a huge inferior vena cava (IVC) aneurysm. The diameter of the IVC and renal veins were 10 cm and 2 cm, respectively. The infrarenal aorta above the fistula was 20 mm in diameter and its length below the left renal artery, which was the lowest one was 20 mm. The aorta below the fistula was 20 mm in diameter. There was neither aortic stenosis nor arterial obstructive lesion. Bilateral iliac arteries were not severely tortuous. Endovascular closure of the ACF was conducted. After systemic heparinisation with 5000-units of heparin, a 23 × 70 mm abdominal tube stent graft (Endurant) was inserted under fluoroscopic guidance and deployed to cover the fistula via surgically exposed right common femoral artery. Immediately after stent graft placement, bradycardia and hypotension were found, and the pre-operatively prepared transcutaneous cardiac pacemaker was turned on and good hemodynamic condition was restored. Angiography revealed type Ia endoleak passing through the fistula. Balloon dilatation of the proximal and distal landing zones was carefully performed to adequate sealing. However, minimal endoleak persisted, and we decided to retain the endoleak because of slow flow in the IVC aneurysm. Consequently, that reduced the chance of IVC thrombus formation. Postoperatively, the patient was returned to the critical care unit, where his hospital course was complicated by severe bradycardia and torsades de pointes, and excessive diuresis. A temporary pacemaker was put in place. To facilitate venous return from the IVC aneurysm, the patient lay in the Trendelenburg position. This was confirmed
742
11 CR_13-00078 Rerkasem.indd
by bedside ultrasonography. In the first week after intervention, the cardiac, renal, and thrombocytopenic problems were improved (plasma creatinine 0.7 mg/dL and platelet count 116000 cells/cu.mm3). Post operative echocardiogram showed decompression of RV with significant improvement in RV systolic function and severity of TR. With a decrease in venous pressure, PFO was spontaneously closed with normalized systemic oxygen saturation. On follow up the second week, the CT angiography showed no connection between the aorta and IVC, with slow stagnant contrast filling in false aneurysm, which represented partial thrombosis of the fistula. There was no thrombosis in the IVC aneurysm. His blood had been anticoagulated with warfarin together with heparinization overlapping. He developed a hematoma at the right groin wound, which needed drainage Day 16 after the operation. Otherwise, he recovered uneventfully. The 6th week after the operation, the CT angiography no longer showed contrast from aorta connect to either false aneurysm or IVC (Fig. 2). His legs were not edematous.
Discussion Chronic ACF is rare and can give hemodynamically variable pictures, and is often misdiagnosed.6) In our patient with a long standing history of heart failure, it was not suspected until a continuous abdominal bruit and thrill was detected. Chronic left to right shunt via the ACF gives rise to right ventricular volume overload, increased pulmonary
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
742
2013/12/11
13:22:23
Chronic Traumatic Aortocaval Fistula
dynamic status, therefore, to provide some flow into IVC aneurysm, we decided upon endoleak. Trendelenburg position was useful for providing more venous return from the IVC aneurysm to the heart, and was observed by bedside ultrasonography, which demonstrated the changing of stagnate multilayer-like echoic blood into a more lamina flow. Anticoagulant was also given to prevent a disastrous embolism from the IVC thrombosis.
Conclusion (A)
(B)
Fig. 2 C omputed tomography (CT) angiographic image 6 weeks following endovascular stenting. (A) Volume rendering (VR) CT image showed disappearance of arteriovenous shunt. (B) Coronal maximum intensity projection (MIP) image demonstrated completely excluded false aneurysm with thrombosis of the false aneurysmal sac.
blood flow with subsequent pulmonary hypertension, and right sided heart failure. The clinical pictures, including chest X-ray and echocardiogram, are not much different from those of atrial septal defect, which was initially suspected in this patient. A clinical picture of high output failure similar to that of aortic regurgitation (wide pulse pressure, Water Hammer sign) was also presented. This was due to aortic runoff in ACF. The high pressure of the “arterialized” vein gave rise to various interesting findings in our patient, including (1) impaired renal function due to renal vein congestion, (2) thrombocytopenia from congestive hypersplenism, and (3) PFO and systemic desaturation as a result of high RA pressure, all of which were resolved after repair. Endovascular therapy is an emerging field providing a variety of treatments via small skin incision with less invasiveness, decreased hospital stay, and fewer post operative complications.7) Arteriovenous fistula can be endovascular treated by occlusion of the fistula by a variety of embolic materials such as glue, coil, vascular plug, or an occluder device, depending on flow and anatomical vascular architecture.8–11) Another endovascular treatment option is stent graft placement to exclude the fistula and preserve the parent artery. This method has been applied to aortocaval fistula from ruptured aneurysm with satisfactory results.11) However, our patient, who had longstanding-ACF, also had a huge IVC aneurysm which may have become thrombosed after fistula obliteration. The primary aim for this patient was to reduce flow through the fistula as much as possible in order to stabilise hemo-
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
11 CR_13-00078 Rerkasem.indd
743
The endovascular technique provides an attractive alternative to open surgical methods for repair of chronic ACF. However, in chronic cases, complications such as severe reflex bradycardia (Nicoladoni-Branham sign) from abrupt increase in peripheral vascular resistance, after load, and excessive diuresis must be anticipated and readily addressed after ACF closure.
Disclosure Statement The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References 1) Spencer TA, Smyth SH, Wittich G, et al. Delayed presentation of traumatic aortocaval fistula: a report of two cases and a review of the associated compensatory hemodynamic and structural changes. J Vasc Surg 2006; 43: 836-40. 2) Kotsikoris I, Papas TT, Papanas N, et al. Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: a 12-year series. Vasc Endovascular Surg 2012; 46: 26-9. 3) Arruche Herrero M, Ruiz García V, Castillo Escudero AI, et al. Acute renal failure as a presentation of an aortocaval fistula associated with abdominal aortic aneurism. Nefrologia 2011; 31: 124-6. 4) Fedakar A, Fındık O, Kalender M, et al. Unusual emergent presentations of abdominal aortic aneurysm: can simple blood tests predict the state of emergency? Ulus Travma Acil Cerrahi Derg 2011; 17: 525-32. 5) Waldrop JL, Dart BW, Barker DE. Endovascular stent graft treatment of a traumatic aortocaval fistula. Ann Vasc Surg 2005; 19: 562-5. 6) Unosawa S, Kimura H, Niino T. Surgical repair of ruptured abdominal aortic aneurysm with non-bleeding aortocaval fistula. Ann Vasc Dis 2013; 6: 209-11. 7) Brightwell RE, Pegna V, Boyne N. Aortocaval fistula:
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2013/12/11
13:22:23
Srisuwan T, et al.
current management strategies. ANZ J Surg 2013; 83: 31-5. 8) Cekirge S, Oguzkurt L, Saatçi I, et al. Embolization of a high-output postnephrectomy aortocaval fistula with Gianturco coils and cyanoacrylate. Cardiovasc Intervent Radiol 1996; 19: 56-8. 9) Godart F, Haulon S, Houmany M, et al. Transcatheter closure of aortocaval fistula with the amplatzer duct
744
11 CR_13-00078 Rerkasem.indd
occluder. J Endovasc Ther 2005; 12: 134-7. 10) Antunes A, Marinho A, Rodrigues D, et al. Percutaneous embolization of a congenital aortocaval fistula—clinical case. Rev Port Cardiol 2003; 22: 1101-6. 11) Rapacciuolo A, De Angelis MC, di Pietro E, et al. Percutaneous treatment of a aorto-caval fistula in a old high risk patient. BMC Surg 2012; 12 Suppl 1: S32.
Annals of Vascular Diseases Vol. 6, No. 4 (2013)
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2013/12/11
13:22:24
