Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula Based on Aortic and Inferior Vena Cava Stent-Graft Placement Pierre Galvagni Silveira,1 Josue Rafael Ferreira Cunha,2 Guilherme Baumgardt Barbosa Lima,1 Rafael Narciso Franklin,2 Cristiano Torres Bortoluzzi,2 and Gilberto do Nascimento Galego,1 Florianopolis, Santa Catarina, Brazil
A ruptured abdominal aortic aneurysm (RAAA), complicated by an aortocaval fistula (ACF), is usually associated with high morbidity and mortality during open operative repair. We report a case of endovascular treatment of an RAAA with ACF. After accessing both common femoral arteries, a bifurcated aortic stent graft was placed. Subsequently, we accessed the fistula from the right femoral vein and a cava vein angiography showed a persistent massive flow from the cava to the excluded aneurysm sac. We proceeded by covering the fistula with an Excluder aortic stent-graft cuff to prevent pressurization of the aneurysm sac and secondary endoleaks. This procedure is feasible and may reduce the chances of posterior endoleaks.
Aortocaval fistula (ACF) is a rare complication reported in 3e6% of all ruptured abdominal aortic aneurysms (RAAA).1 ACF can be present with or without retroperitoneal rupture. If ACF is without retroperitoneal rupture, the clinical presentation can be suggestive of congestive heart failure, delaying diagnosis and treatment of a rupture. Its high early mortality (22e51%) is a result of a high blood flow through the fistula usually resulting in refractory congestive heart failure.1e4 Successful endovascular repair of RAAA associated with ACF has been reported in literature, most of which were treated by exclusive aorta 1
Department of Vascular Service and Surgery, Universidade Federal de Santa Catarina, Florianopolis, Santa Catarina, Brazil. 2 Department of Vascular Surgery, Coris Medicina Avanc¸ ada, Florianopolis, Santa Catarina, Brazil. Correspondence to: Guilherme Baumgardt Barbosa Lima, MD, Universidade Federal de Santa Catarina, Rua das Castanheiras, 122, Lagoa da Conceic¸ ~ ao 88062-284, Florianopolis, Santa Catarina, Brazil; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1933.e1e1933.e5 http://dx.doi.org/10.1016/j.avsg.2014.06.073 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: January 4, 2014; manuscript accepted: June 19, 2014; published online: July 11, 2014.
endografting.5 However, in these cases, there may be persistent communication between the aortic sac and the inferior vena cava.4 The presence of this communication could result in a high-flow type II endoleak and in persistent high cardiac output.6 We report a case in which an RAAA with ACF was successfully managed by aortic and vena cava endografting to avoid posterior interventions.
CASE REPORT A 69-year-old male with a history of hypertension, morbid obesity, hyperlipidemia, and tobacco abuse presented to us with acute abdominal pain. On admission, his physical examination revealed blood pressure of 140/ 60 mm Hg, heart rate of 100 beats/min, jugular distension, and absence of distal inferior limb pulses. Abdominal examination revealed a pulsatile mass and a continuous audible bruit with systolic accentuation over the abdomen on auscultation, suggesting an ACF. No shortness of breath was noticed. Venous central pressure on initial assessment was 22 mm Hg. Laboratory findings showed azotemia with a serum creatinine level of 5.0 mg/dL and anemia with a hemoglobin of 9 g/L. 1933.e1
1933.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Axial (A) and coronal (B) section CT scan with intravenous contrast demonstrates aortic abdominal aneurysm ruptured into the vena cava. Black arrow shows a large defect in the vena cava communicating with the aneurysm sac.
Fig. 2. (A) Intraoperative angiography after aortic stent-graft implantation indicates an endoleak from cava vein into the aneurysm sac. (B) Control angiography after cava vein stent-graft implantation without signs of endoleaks.
Computed tomography (CT) angiography revealed a ruptured infrarenal aortic aneurysm with a maximum diameter of 12 cm. During the arterial phase, there was a rapid contrast filling of the inferior vena cava vein indicating the presence of a large ACF (Fig. 1). Therefore, due to the ruptured aneurysm and considerable size of the ACF, the patient was offered and elected to undergo endovascular repair. The procedure was done under standard heparinization as the patient was hemodynamically stable. A bifurcated stent graft Excluder, 23 14 180 mm (W.L. Gore & Associates, Flagstaff, AZ) was successfully deployed by accessing bilateral common femoral arteries. At this time, central venous pressure dropped from 22 to
8 mm Hg. Subsequently, we accessed the fistula from the surgically exposed right femoral vein and performed a cava vein angiography, which showed a persistent massive flow from the cava to the excluded aneurysm sac (Fig. 2). We proceeded by covering the fistula with a Excluder aortic stent-graft cuff, 23 30 mm (W.L. Gore & Associates, Flagstaff, AZ), to prevent pressurization of the aneurysm sac and secondary endoleaks. Finally, a control angiography revealed a complete exclusion of the fistula without endoleak in the excluded aneurysm sac. At the end of the procedure protamin was administered. Dual antiplatelet therapy was prescribed to prevent venous thrombosis. The patient had no postoperative complications and was discharged 6 days later,
Vol. 28, No. 8, November 2014
Case reports 1933.e3
Fig. 3. Axial and 3D reconstruction of 30-day postoperative follow-up CT scan with no evidence of endoleaks or any residual perfusion in the aneurysm sack.
Fig. 4. Angio CT at 24 months follow-up with shrinkage of aneurysm sac with its complete exclusion and caval patency. asymptomatic and with normal creatinine levels. The CT scan at the 1 month follow-up confirmed complete exclusion of the aneurysm and ACF with no evidence of flow. (Fig. 3). The CT scan at 2 years follow-up revealed complete exclusion and shrinkage of aneurysm sac and caval patency (Fig. 4).
DISCUSSION The clinical course of a patient with a spontaneous ACF fistula is characterized by a high cardiac output with progressive cardiac decompensation and gradual onset of intractable ventricular failure.1e3,7
Several management strategies have been published and are summarized in Table I. Open surgical repair of RAAA with ACF consists of rapid suturing of the fistula from within the aneurysmal sac.8 It is associated with high mortality and morbidity.1,2,8,9 Miani et al. presented a 36-patient series with ACF, surgically treated with an overall mortality rate of 21%.2 To reduce the morbidity and avoid the risks of open surgery caused by the technically challenging dissection and bleeding, hybrid, and endovascular approach have been described in literature.1,8,10 Hybrid strategy with initial covering of the caval entry using a conventional stent graft and subsequent open surgery for the aortic aneurysm were reported.10 The method was successful, but the surgical approach to aortic aneurysm even without caval bleeding risk still seems to us as an aggressive surgical alternative. Another interventional treatment of this entity has been achieved using aortic stent grafts alone.4,9e11 We believe this approach is an incomplete treatment because it does not occlude ACF, maintaining both the communication from cava to the excluded aneurysm sac and a high risk of type II endoleak usually treated with a secondary interventional procedure.9,13,14 Successfully endovascular caval stentgrafting and embolization procedures have been described in the treatment of late endoleak type II after aortic endovascular repair of RAAA with ACF.12,14 Nevertheless, Jeuri€ens-van de Ven et al.13 suggested that in the presence of a type II endoleak, the fistula serves as an outflow pathway that inhibits spontaneous closure of the fistula. Therefore,
1933.e4 Case reports
Annals of Vascular Surgery
Table I. Main management strategies for RAAA with ACF Author (reference)
Cases
Approach
Outcomes
Calligaro et al. Siepe et al.10 Antoniou et al.11
159 1 23
Open Surgery Hybrid approach Endovascular aortic repair
Elkassaby et al.16
2
72% survived surgery The patient had a good outcome Technical success 96%. No 30-day mortality. Type II endoleak in 22% Both patients had good outcomes
17
Endovascular simultaneously venous and aortic repair
embolization procedures to decrease the inflow of the fistula should not interfere with the pressure gradient between the aneurysm sac and the venous system, promoting new collateral routes, maintaining the endoleak.13 On the other hand, a conservative management of these type II endoleaks was proposed by Luijtgaarden et al.15 Theoretically, this type II endoleak probably would not cause aneurysm sac growth owing to its low-pressure nature due to the connection with the venous system. The author observed aneurysm sac shrinkage at 1 year after conservative management. Despite that, we believe aneurysm sac pressurization is a possibility even in the presence of ACF. Depending on the size of the fistula orifice, a significant endoleak inflow in the aneurysm sac can be higher than the outflow to cava vein leading to an aneurysm sac pressurization. Moreover, the presence of the ACF may lead to significant consequences, such as in this case report, where the pulseless and the renal manifestations presumably were a consequence of low renal and limb perfusion due to a high-flow arteriovenous shunt. Thus, an immediate simultaneously aortic and caval endovascular repair seems to be an effective option in the treatment of RAAA with ACF as described so far only by ElKassaby et al.16 Despite the fact that the experience with venous stentgrafting is still limited to a few reports,12,14,16 it seems to be a safe and uncomplicated alternative procedure that guarantees the occlusion of arteriovenous communication. The absence of type II endoleaks may prevent secondary interventions, reduce the chances of embolization with aneurysm sac debris to the venous system, avoiding increased cardiac output from arteriovenous fistulas and aneurysm sac pressurization. Baring in mind that there are no endovascular devices specifically designed for vena cava, off label approach remains a safe alternative to treat these lesions. We believe that, in the near future, with the improvement on the devices and further experience, endovascular repair will become the standard treatment of ACF.
We described a case of endovascular treatment of an RAAA with ACF based on aortic and caval stentgrafting. This report shows that simultaneous aortic and vena cava stentgrafting is feasible and may be more effective than exclusive endovascular aortic repair. Nevertheless, despite our 2 year follow-up, more data is required to prove superiority of this procedure.
REFERENCES 1. Iriz E, Ozdogan ME, Erer D, et al. A giant aortocaval fistula due to abdominal aortic aneurysm. Int J Cardiol 2006;112: 78e80. 2. Miani S, Giorgetti PL, Arpesani A, et al. Spontaneous aortocaval fistulas from ruptured abdominal aortic aneurysms. Eur J Vasc Surg 1994;8:36e40. 3. Petetin L, Pelouze GA, Mercier V, et al. Rupture of abdominal aortic aneurysm into the inferior vena cava: a study of seven cases. Ann Vasc Surg 1987;1:572e7. 4. Sebastian AJ, Choksy SA. Endovascular treatment of aortocaval fistula. EJVES Extra 2011;22:65e6. 5. Pevec WC, Lee ES, Lamba R. Symptomatic, acute aortocaval fistula complicating an infrarenal aortic aneurysm. J Vasc Surg 2010;51:475. 6. Vetrhus M, McWilliams R, Tan CK, et al. Endovascular repair of abdominal aortic aneurysms with aortocaval fistula. Eur J Vasc Endovasc Surg 2005;30:640e3. 7. Gabrielli R, Rosati MS, Irace L, et al. Rupture of abdominal aortic aneurysm into retro-aortic left renal vein: a case report. EJVES Extra 2009;18:21e3. 8. Laxdal E, Søvik K, Pedersen G, et al. Inflammatory infrarenal aortic aneurysm with aortocaval fistula. Ann Vasc Surg 2007;21:633e6. 9. Kopp R, Weidenhagen R, Hoffmann R, et al. Immediate endovascular treatment of an aortoiliac aneurysm ruptured into the inferior vena cava. Ann Vasc Surg 2006;20:525e8. 10. Siepe M, Koeppe S, Euringer, et al. Aorto-caval fistula from acute rupture of an abdominal aortic aneurysm treated with a hybrid approach. J Vasc Surg 2009;49:1574e6. 11. Antoniou GA, Koutsias S, Karathanos C, et al. Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review. J Endovasc Ther 2009;16:514e23. 12. Mitchell ME, McDaniel HB, Rushton FW. Endovascular repair of a chronic aortocaval fistula using a thoracic aortic endoprosthesis. Ann Vasc Surg 2009;23:150e2. 13. Jeuri€ens-van de Ven SA, Schouten van der Velden AP, Schultze Kool LJ. Persisting iliaco-caval fistula after EVAR maintained by a type II endoleak. Ann Vasc Surg 2011;25: 1142e7.
Vol. 28, No. 8, November 2014
14. Melas N, Saratzis A, Saratzis N, et al. Inferior vena cava stent-graft placement to treat endoleak associated with an aortocaval fistula. J Endovasc Ther 2011;18:250e4. 15. Luijtgaarden MK, Gonc¸alves FB, Rouwet EV, et al. Conservative management of persistent aortocaval fistula after endovascular aortic repair. J Vasc Surg 2013;58:1080e3.
Case reports 1933.e5
16. ElKassaby M, Alawy M, Zaki M, et al. Total endovascular management of ruptured aortocaval fistula: technical challenges and case report. Vascular 2014;22:306e9. 17. Calligaro KD, Savarese RP, DeLaurentis DA. Unusual aspects of aortovenous fistulas associated with ruptured abdominal aortic aneurysms. J Vasc Surg 1990;12:586e90.
A ruptured abdominal aortic aneurysm (RAAA), complicated by an aortocaval fistula (ACF), is usually associated with high morbidity and mortality during open operative repair. We report a case of endovascular treatment of an RAAA with ACF. After accessing both common femoral arteries, a bifurcated aortic stent graft was placed. Subsequently, we accessed the fistula from the right femoral vein and a cava vein angiography showed a persistent massive flow from the cava to the excluded aneurysm sac. We proceeded by covering the fistula with an Excluder aortic stent-graft cuff to prevent pressurization of the aneurysm sac and secondary endoleaks. This procedure is feasible and may reduce the chances of posterior endoleaks.
Aortocaval fistula (ACF) is a rare complication reported in 3e6% of all ruptured abdominal aortic aneurysms (RAAA).1 ACF can be present with or without retroperitoneal rupture. If ACF is without retroperitoneal rupture, the clinical presentation can be suggestive of congestive heart failure, delaying diagnosis and treatment of a rupture. Its high early mortality (22e51%) is a result of a high blood flow through the fistula usually resulting in refractory congestive heart failure.1e4 Successful endovascular repair of RAAA associated with ACF has been reported in literature, most of which were treated by exclusive aorta 1
Department of Vascular Service and Surgery, Universidade Federal de Santa Catarina, Florianopolis, Santa Catarina, Brazil. 2 Department of Vascular Surgery, Coris Medicina Avanc¸ ada, Florianopolis, Santa Catarina, Brazil. Correspondence to: Guilherme Baumgardt Barbosa Lima, MD, Universidade Federal de Santa Catarina, Rua das Castanheiras, 122, Lagoa da Conceic¸ ~ ao 88062-284, Florianopolis, Santa Catarina, Brazil; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1933.e1e1933.e5 http://dx.doi.org/10.1016/j.avsg.2014.06.073 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: January 4, 2014; manuscript accepted: June 19, 2014; published online: July 11, 2014.
endografting.5 However, in these cases, there may be persistent communication between the aortic sac and the inferior vena cava.4 The presence of this communication could result in a high-flow type II endoleak and in persistent high cardiac output.6 We report a case in which an RAAA with ACF was successfully managed by aortic and vena cava endografting to avoid posterior interventions.
CASE REPORT A 69-year-old male with a history of hypertension, morbid obesity, hyperlipidemia, and tobacco abuse presented to us with acute abdominal pain. On admission, his physical examination revealed blood pressure of 140/ 60 mm Hg, heart rate of 100 beats/min, jugular distension, and absence of distal inferior limb pulses. Abdominal examination revealed a pulsatile mass and a continuous audible bruit with systolic accentuation over the abdomen on auscultation, suggesting an ACF. No shortness of breath was noticed. Venous central pressure on initial assessment was 22 mm Hg. Laboratory findings showed azotemia with a serum creatinine level of 5.0 mg/dL and anemia with a hemoglobin of 9 g/L. 1933.e1
1933.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Axial (A) and coronal (B) section CT scan with intravenous contrast demonstrates aortic abdominal aneurysm ruptured into the vena cava. Black arrow shows a large defect in the vena cava communicating with the aneurysm sac.
Fig. 2. (A) Intraoperative angiography after aortic stent-graft implantation indicates an endoleak from cava vein into the aneurysm sac. (B) Control angiography after cava vein stent-graft implantation without signs of endoleaks.
Computed tomography (CT) angiography revealed a ruptured infrarenal aortic aneurysm with a maximum diameter of 12 cm. During the arterial phase, there was a rapid contrast filling of the inferior vena cava vein indicating the presence of a large ACF (Fig. 1). Therefore, due to the ruptured aneurysm and considerable size of the ACF, the patient was offered and elected to undergo endovascular repair. The procedure was done under standard heparinization as the patient was hemodynamically stable. A bifurcated stent graft Excluder, 23 14 180 mm (W.L. Gore & Associates, Flagstaff, AZ) was successfully deployed by accessing bilateral common femoral arteries. At this time, central venous pressure dropped from 22 to
8 mm Hg. Subsequently, we accessed the fistula from the surgically exposed right femoral vein and performed a cava vein angiography, which showed a persistent massive flow from the cava to the excluded aneurysm sac (Fig. 2). We proceeded by covering the fistula with a Excluder aortic stent-graft cuff, 23 30 mm (W.L. Gore & Associates, Flagstaff, AZ), to prevent pressurization of the aneurysm sac and secondary endoleaks. Finally, a control angiography revealed a complete exclusion of the fistula without endoleak in the excluded aneurysm sac. At the end of the procedure protamin was administered. Dual antiplatelet therapy was prescribed to prevent venous thrombosis. The patient had no postoperative complications and was discharged 6 days later,
Vol. 28, No. 8, November 2014
Case reports 1933.e3
Fig. 3. Axial and 3D reconstruction of 30-day postoperative follow-up CT scan with no evidence of endoleaks or any residual perfusion in the aneurysm sack.
Fig. 4. Angio CT at 24 months follow-up with shrinkage of aneurysm sac with its complete exclusion and caval patency. asymptomatic and with normal creatinine levels. The CT scan at the 1 month follow-up confirmed complete exclusion of the aneurysm and ACF with no evidence of flow. (Fig. 3). The CT scan at 2 years follow-up revealed complete exclusion and shrinkage of aneurysm sac and caval patency (Fig. 4).
DISCUSSION The clinical course of a patient with a spontaneous ACF fistula is characterized by a high cardiac output with progressive cardiac decompensation and gradual onset of intractable ventricular failure.1e3,7
Several management strategies have been published and are summarized in Table I. Open surgical repair of RAAA with ACF consists of rapid suturing of the fistula from within the aneurysmal sac.8 It is associated with high mortality and morbidity.1,2,8,9 Miani et al. presented a 36-patient series with ACF, surgically treated with an overall mortality rate of 21%.2 To reduce the morbidity and avoid the risks of open surgery caused by the technically challenging dissection and bleeding, hybrid, and endovascular approach have been described in literature.1,8,10 Hybrid strategy with initial covering of the caval entry using a conventional stent graft and subsequent open surgery for the aortic aneurysm were reported.10 The method was successful, but the surgical approach to aortic aneurysm even without caval bleeding risk still seems to us as an aggressive surgical alternative. Another interventional treatment of this entity has been achieved using aortic stent grafts alone.4,9e11 We believe this approach is an incomplete treatment because it does not occlude ACF, maintaining both the communication from cava to the excluded aneurysm sac and a high risk of type II endoleak usually treated with a secondary interventional procedure.9,13,14 Successfully endovascular caval stentgrafting and embolization procedures have been described in the treatment of late endoleak type II after aortic endovascular repair of RAAA with ACF.12,14 Nevertheless, Jeuri€ens-van de Ven et al.13 suggested that in the presence of a type II endoleak, the fistula serves as an outflow pathway that inhibits spontaneous closure of the fistula. Therefore,
1933.e4 Case reports
Annals of Vascular Surgery
Table I. Main management strategies for RAAA with ACF Author (reference)
Cases
Approach
Outcomes
Calligaro et al. Siepe et al.10 Antoniou et al.11
159 1 23
Open Surgery Hybrid approach Endovascular aortic repair
Elkassaby et al.16
2
72% survived surgery The patient had a good outcome Technical success 96%. No 30-day mortality. Type II endoleak in 22% Both patients had good outcomes
17
Endovascular simultaneously venous and aortic repair
embolization procedures to decrease the inflow of the fistula should not interfere with the pressure gradient between the aneurysm sac and the venous system, promoting new collateral routes, maintaining the endoleak.13 On the other hand, a conservative management of these type II endoleaks was proposed by Luijtgaarden et al.15 Theoretically, this type II endoleak probably would not cause aneurysm sac growth owing to its low-pressure nature due to the connection with the venous system. The author observed aneurysm sac shrinkage at 1 year after conservative management. Despite that, we believe aneurysm sac pressurization is a possibility even in the presence of ACF. Depending on the size of the fistula orifice, a significant endoleak inflow in the aneurysm sac can be higher than the outflow to cava vein leading to an aneurysm sac pressurization. Moreover, the presence of the ACF may lead to significant consequences, such as in this case report, where the pulseless and the renal manifestations presumably were a consequence of low renal and limb perfusion due to a high-flow arteriovenous shunt. Thus, an immediate simultaneously aortic and caval endovascular repair seems to be an effective option in the treatment of RAAA with ACF as described so far only by ElKassaby et al.16 Despite the fact that the experience with venous stentgrafting is still limited to a few reports,12,14,16 it seems to be a safe and uncomplicated alternative procedure that guarantees the occlusion of arteriovenous communication. The absence of type II endoleaks may prevent secondary interventions, reduce the chances of embolization with aneurysm sac debris to the venous system, avoiding increased cardiac output from arteriovenous fistulas and aneurysm sac pressurization. Baring in mind that there are no endovascular devices specifically designed for vena cava, off label approach remains a safe alternative to treat these lesions. We believe that, in the near future, with the improvement on the devices and further experience, endovascular repair will become the standard treatment of ACF.
We described a case of endovascular treatment of an RAAA with ACF based on aortic and caval stentgrafting. This report shows that simultaneous aortic and vena cava stentgrafting is feasible and may be more effective than exclusive endovascular aortic repair. Nevertheless, despite our 2 year follow-up, more data is required to prove superiority of this procedure.
REFERENCES 1. Iriz E, Ozdogan ME, Erer D, et al. A giant aortocaval fistula due to abdominal aortic aneurysm. Int J Cardiol 2006;112: 78e80. 2. Miani S, Giorgetti PL, Arpesani A, et al. Spontaneous aortocaval fistulas from ruptured abdominal aortic aneurysms. Eur J Vasc Surg 1994;8:36e40. 3. Petetin L, Pelouze GA, Mercier V, et al. Rupture of abdominal aortic aneurysm into the inferior vena cava: a study of seven cases. Ann Vasc Surg 1987;1:572e7. 4. Sebastian AJ, Choksy SA. Endovascular treatment of aortocaval fistula. EJVES Extra 2011;22:65e6. 5. Pevec WC, Lee ES, Lamba R. Symptomatic, acute aortocaval fistula complicating an infrarenal aortic aneurysm. J Vasc Surg 2010;51:475. 6. Vetrhus M, McWilliams R, Tan CK, et al. Endovascular repair of abdominal aortic aneurysms with aortocaval fistula. Eur J Vasc Endovasc Surg 2005;30:640e3. 7. Gabrielli R, Rosati MS, Irace L, et al. Rupture of abdominal aortic aneurysm into retro-aortic left renal vein: a case report. EJVES Extra 2009;18:21e3. 8. Laxdal E, Søvik K, Pedersen G, et al. Inflammatory infrarenal aortic aneurysm with aortocaval fistula. Ann Vasc Surg 2007;21:633e6. 9. Kopp R, Weidenhagen R, Hoffmann R, et al. Immediate endovascular treatment of an aortoiliac aneurysm ruptured into the inferior vena cava. Ann Vasc Surg 2006;20:525e8. 10. Siepe M, Koeppe S, Euringer, et al. Aorto-caval fistula from acute rupture of an abdominal aortic aneurysm treated with a hybrid approach. J Vasc Surg 2009;49:1574e6. 11. Antoniou GA, Koutsias S, Karathanos C, et al. Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review. J Endovasc Ther 2009;16:514e23. 12. Mitchell ME, McDaniel HB, Rushton FW. Endovascular repair of a chronic aortocaval fistula using a thoracic aortic endoprosthesis. Ann Vasc Surg 2009;23:150e2. 13. Jeuri€ens-van de Ven SA, Schouten van der Velden AP, Schultze Kool LJ. Persisting iliaco-caval fistula after EVAR maintained by a type II endoleak. Ann Vasc Surg 2011;25: 1142e7.
Vol. 28, No. 8, November 2014
14. Melas N, Saratzis A, Saratzis N, et al. Inferior vena cava stent-graft placement to treat endoleak associated with an aortocaval fistula. J Endovasc Ther 2011;18:250e4. 15. Luijtgaarden MK, Gonc¸alves FB, Rouwet EV, et al. Conservative management of persistent aortocaval fistula after endovascular aortic repair. J Vasc Surg 2013;58:1080e3.
Case reports 1933.e5
16. ElKassaby M, Alawy M, Zaki M, et al. Total endovascular management of ruptured aortocaval fistula: technical challenges and case report. Vascular 2014;22:306e9. 17. Calligaro KD, Savarese RP, DeLaurentis DA. Unusual aspects of aortovenous fistulas associated with ruptured abdominal aortic aneurysms. J Vasc Surg 1990;12:586e90.
