Sudden Cardiac Arrest Immediately after Stent Graft Deployment during Treatment of Iliac Aneurysm with Iliocaval Fistula Daijirou Akamatsu, Akira Sato, Hitoshi Goto, Hideki Ohta, Munetaka Hashimoto, Takuya Shimizu, Ken Tsuchida, and Noriaki Ohuchi, Sendai, Japan
An 84-year-old woman with heaviness of the right lower extremity had an iliocaval fistula related to a right internal iliac aneurysm. Immediately after deployment of an endovascular device, cardiac arrest occurred because of severely decreased sympathetic activity. After surgery, the patient recovered well and has been followed up with exclusion of the arteriovenous fistula and resolution of the type II endoleak. Endovascular treatment for large arteriovenous fistulas induces rapid closure of the fistula together with restoration of blood supply to the lower extremity. Markedly deactivated sympathetic nerve traffic could result in a critical hemodynamic status in association with endograft deployment.
An iliocaval fistula is a rare clinical entity that is associated with high perioperative mortality and morbidity.1,2 Recently, some cases of successful endovascular repair have been reported.3e6 Acute arteriovenous fistula (AVF) occlusion has been shown to induce a decrease in sympathetic activity known as the NicoladonieBranham sign.7 We describe the first case of cardiac arrest assumed to be caused by decreased sympathetic activity during endovascular aneurysm repair for treatment of an iliocaval fistula.
CASE REPORT An 84-year-old woman with a history of open appendectomy and cholecystectomy had been admitted to another hospital under the care of physicians 3 days before an Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan. Correspondence to: Daijirou Akamatsu, MD, PhD, Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku Sendai, 9808574 Japan; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1031.e11–1031.e13 http://dx.doi.org/10.1016/j.avsg.2013.05.020 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 15, 2013; manuscript accepted: May 8, 2013; published online: November 1, 2013.
operation in our department because of heaviness of her right back and lower extremity. She had no symptoms of heart failure. She had a heart rate of 98 beats/min, blood pressure of 94/50 mm Hg, and an oxygen saturation of 98%. The clinical examination revealed a palpable, nontender right lower abdominal mass, machinery-like bruit, and right lower limb edema. Blood biochemical findings revealed renal dysfunction (urea: 61 mg/dL; creatinine: 2.2 mg/dL) without oliguria. She was transferred to our department for close investigation and treatment. A contrast-enhanced computed tomography scan revealed a 7.5-cm right internal iliac aneurysm beginning from its orifice and a fistula between the aneurysm and inferior vena cava (IVC). The IVC was enhanced in the arterial phase. Her aorta was normal in caliber, measuring 17 mm at the infrarenal aortic level and 25 mm at the aortic bifurcation. The diameter of the right common iliac artery was 21 mm and that of the right external iliac artery was 10 mm. An echocardiographic examination revealed a dilated diastolic right ventricular diameter (45 mm), although the left ventricular wall motion was normal and the left ventricular ejection fraction was 75%. A preoperative electrocardiogram revealed a sinus rhythm and no findings of myocardial ischemia. Preoperative discussions focused on a treatment strategy to resolve the problem. We selected endovascular treatment because open surgery raised concerns about risks of major bleeding and abdominal adhesion because of multiple previous abdominal surgeries. The use of an isolated iliac covered stent was impossible because no
1031.e11
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proximal common iliac sealing zone existed; therefore, we planned to use an aortobi-iliac graft. The operation was performed under general anesthesia, and aortography revealed a right internal iliac aneurysm and early filling of the caval vein (Fig. 1). The common trunk of the superior and inferior gluteal artery was embolized. Through left common femoral access, an aortobi-iliac device (Gore Excluder; W.L. Gore and Associates, Flagstaff, AZ) was deployed from below the left renal artery to the left common iliac artery. Immediately after sealing the left common iliac artery, the patient suffered cardiac arrest without bradycardia or arrhythmia (Fig. 2). Electrocardiography revealed no QRS wave; only P waves were present. After several seconds of cardiac massage, spontaneous circulation returned. Transesophageal echocardiography revealed no findings of deteriorated right heart overload and showed normal left ventricular wall motion. Her central venous pressure had been decreased from 20 mm Hg at the start of the operation to 9 mm Hg. A temporary pacemaker was implanted because cardiac arrest recurred a total of 8 times during the operation. From right side access, a 0.035-in guidewire was passed through the contralateral gate, although narrowing of the contralateral gate made it difficult to pass the guidewire because both limbs opened at the infrarenal aorta, which was about 17 mm in diameter (Fig. 3). After extending the endograft to the right external iliac artery, completion angiography confirmed exclusion of the iliocaval AVF, although a type II endoleak via the lumbar artery was present. The total operative hemorrhage volume was 540 mL, and the duration of the procedure was 5 hrs and 56 min. On postoperative day 4, the temporary pacemaker was removed because no cardiac event had occurred, electrocardiography consistently revealed a regular sinus rhythm, and echocardiography revealed normal left ventricular function and a normal diastolic right ventricular diameter (30 mm). Her biochemical parameters improved (urea: 20 mg/dL; creatinine: 0.9 mg/dL), and a computed tomography scan on postoperative day 8 revealed a closed AVF, patent endograft, resolved type II endoleak, and no findings of pulmonary embolism. At an outpatient clinic 6 months later, duplex ultrasonography confirmed exclusion of the AVF without an endoleak or sac enlargement.
DISCUSSION In the presence of a large AVF, cardiac output increases by an augmented preload and heart rate; however, arterial blood pressure decreases.7,8 The decreased renal pressure and increased venous pressure lead to decreased renal perfusion and activation of the renin-angiotensin system.8 The sympathetic nervous system is also stimulated and contributes to vasoconstriction.9 Atrial natriuretic peptide is concurrently released in association with the increased preload and contributes to vasodilation and compensatory action. These conflicting balances
Annals of Vascular Surgery
Fig. 1. A perioperative aortography revealed the right internal iliac aneurysm (A) and early filling of the inferior vena cava (V).
Fig. 2. Immediately after endograft deployment, the intra-arterial monitor revealed flat (A) and electrocardiography revealed the loss of QRS waves (B).
reflect the clinical hemodynamic status in patients with a large AVF.10 When the fistula is occluded, the blood pressure arises, especially the diastolic pressure.7 The increase in blood pressure activates the arterial baroreflex and induces a decrease in heart rate and marked peripheral sympathetic inhibition.9 The heart rate response associated with opening and closing of the AVF is known as the NicoladonieBranham sign. In the present case, an endograft (Gore Excluder) was first deployed from the aorta below the level of the left renal artery to the left common iliac artery through left common femoral access. At this stage, shunt flow from the right internal iliac aneurysm to the IVC would have been supplied via the right limb of the aortobi-iliac graft. However, the shunt flow had almost disappeared because both limbs were opened at the aorta, which had a diameter of about 17 mm and the right limb was compressed
Vol. 28, No. 4, May 2014
Case reports 1031.e13
performance and cardiac electrical activity were normal except during cardiac arrest. However, during the operation and immediately after exclusion of the AVF, cardiac arrest occurred with complete atrioventricular block as noted during electrocardiography. It would be preferable to implant a temporal pacemaker before closing the fistula or prepare for its immediate use when treating a large fistula. In conclusion, open surgical repair of aortoiliocaval fistulas is associated with high morbidity and mortality and an increased risk of significant blood loss. Endovascular stent-graft treatment for this clinical entity is a less invasive and more attractive alternative, but careful management and preparation is necessary. REFERENCES
Fig. 3. A 0.035-in guidewire was passed through the narrowing contralateral gate (arrow) by leading the guidewire from the right side to the gateway of the contralateral leg and pushing the catheter into the endograft body with the wire-shaped knuckle (dotted line).
by the left endograft limb, which had a diameter of 16 mm. In addition, the blood flow via the lumbar arteries and inferior mesenteric artery was weak in this patient because of atherosclerotic change. Unlike clamping at the proximal aorta during open surgery, endograft deployment causes closure of the AVF together with restoration of blood supply to the lower extremity. Dramatic hemodynamic changes markedly deactivate peripheral and central sympathetic nerve traffic in such cases and were thought to be the cause of sudden cardiac arrest in this patient. Although we cannot rule out the possibility of the involvement of other mechanisms because we did not measure sympathetic nerve activity, various test results confirmed that the perioperative circulating blood volume was under proper control and that the ventricular systolic
1. Brewster DC, Cambria RP, Moncure AC, et al. Aortocaval and iliac arteriovenous fistulas: recognition and treatment. J Vasc Surg 1991;13:253e64. 2. Lin PH, Bush RL, Lumsden AB. Aortocaval fistula. J Vasc Surg 2004;39:266. 3. Akwei S, Altaf N, Tennant W, et al. Emergency endovascular repair of aortocaval fistulada single center experience. Vasc Endovasc Surg 2011;45:442e6. 4. 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. 5. Shah TR, Parikh P, Borkon M, et al. Endovascular repair of contained abdominal aortic aneurysm rupture with aortocaval fistula presenting with high-output heart failure. Vasc Endovasc Surg 2013;47:51e6. 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. Epstein FH, Shadle OW, Ferguson TB, et al. Cardiac output and intracardiac pressures in patients with arteriovenous fistulas. J Clin Invest 1953;32:543e7. 8. Brunkwall J, Lanne T, Bergentz SE. Acute renal impairment due to a primary aortocaval fistula is normalised after a successful operation. Eur J Vasc Endovasc Surg 1999;17:191e6. 9. Velez-Roa S, Neubauer J, Wissing M, et al. Acute arteriovenous fistula occlusion decreases sympathetic activity and improves baroreflex control in kidney transplanted patients. Nephrol Dial Transplant 2004;19:1606e12. 10. Abassi ZA, Winaver J, Hoffman A. Large A-V fistula: pathophysiological consequences and therapeutic perspectives. Curr Vasc Pharmacol 2003;1:347e54.
An 84-year-old woman with heaviness of the right lower extremity had an iliocaval fistula related to a right internal iliac aneurysm. Immediately after deployment of an endovascular device, cardiac arrest occurred because of severely decreased sympathetic activity. After surgery, the patient recovered well and has been followed up with exclusion of the arteriovenous fistula and resolution of the type II endoleak. Endovascular treatment for large arteriovenous fistulas induces rapid closure of the fistula together with restoration of blood supply to the lower extremity. Markedly deactivated sympathetic nerve traffic could result in a critical hemodynamic status in association with endograft deployment.
An iliocaval fistula is a rare clinical entity that is associated with high perioperative mortality and morbidity.1,2 Recently, some cases of successful endovascular repair have been reported.3e6 Acute arteriovenous fistula (AVF) occlusion has been shown to induce a decrease in sympathetic activity known as the NicoladonieBranham sign.7 We describe the first case of cardiac arrest assumed to be caused by decreased sympathetic activity during endovascular aneurysm repair for treatment of an iliocaval fistula.
CASE REPORT An 84-year-old woman with a history of open appendectomy and cholecystectomy had been admitted to another hospital under the care of physicians 3 days before an Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan. Correspondence to: Daijirou Akamatsu, MD, PhD, Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku Sendai, 9808574 Japan; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1031.e11–1031.e13 http://dx.doi.org/10.1016/j.avsg.2013.05.020 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 15, 2013; manuscript accepted: May 8, 2013; published online: November 1, 2013.
operation in our department because of heaviness of her right back and lower extremity. She had no symptoms of heart failure. She had a heart rate of 98 beats/min, blood pressure of 94/50 mm Hg, and an oxygen saturation of 98%. The clinical examination revealed a palpable, nontender right lower abdominal mass, machinery-like bruit, and right lower limb edema. Blood biochemical findings revealed renal dysfunction (urea: 61 mg/dL; creatinine: 2.2 mg/dL) without oliguria. She was transferred to our department for close investigation and treatment. A contrast-enhanced computed tomography scan revealed a 7.5-cm right internal iliac aneurysm beginning from its orifice and a fistula between the aneurysm and inferior vena cava (IVC). The IVC was enhanced in the arterial phase. Her aorta was normal in caliber, measuring 17 mm at the infrarenal aortic level and 25 mm at the aortic bifurcation. The diameter of the right common iliac artery was 21 mm and that of the right external iliac artery was 10 mm. An echocardiographic examination revealed a dilated diastolic right ventricular diameter (45 mm), although the left ventricular wall motion was normal and the left ventricular ejection fraction was 75%. A preoperative electrocardiogram revealed a sinus rhythm and no findings of myocardial ischemia. Preoperative discussions focused on a treatment strategy to resolve the problem. We selected endovascular treatment because open surgery raised concerns about risks of major bleeding and abdominal adhesion because of multiple previous abdominal surgeries. The use of an isolated iliac covered stent was impossible because no
1031.e11
1031.e12 Case reports
proximal common iliac sealing zone existed; therefore, we planned to use an aortobi-iliac graft. The operation was performed under general anesthesia, and aortography revealed a right internal iliac aneurysm and early filling of the caval vein (Fig. 1). The common trunk of the superior and inferior gluteal artery was embolized. Through left common femoral access, an aortobi-iliac device (Gore Excluder; W.L. Gore and Associates, Flagstaff, AZ) was deployed from below the left renal artery to the left common iliac artery. Immediately after sealing the left common iliac artery, the patient suffered cardiac arrest without bradycardia or arrhythmia (Fig. 2). Electrocardiography revealed no QRS wave; only P waves were present. After several seconds of cardiac massage, spontaneous circulation returned. Transesophageal echocardiography revealed no findings of deteriorated right heart overload and showed normal left ventricular wall motion. Her central venous pressure had been decreased from 20 mm Hg at the start of the operation to 9 mm Hg. A temporary pacemaker was implanted because cardiac arrest recurred a total of 8 times during the operation. From right side access, a 0.035-in guidewire was passed through the contralateral gate, although narrowing of the contralateral gate made it difficult to pass the guidewire because both limbs opened at the infrarenal aorta, which was about 17 mm in diameter (Fig. 3). After extending the endograft to the right external iliac artery, completion angiography confirmed exclusion of the iliocaval AVF, although a type II endoleak via the lumbar artery was present. The total operative hemorrhage volume was 540 mL, and the duration of the procedure was 5 hrs and 56 min. On postoperative day 4, the temporary pacemaker was removed because no cardiac event had occurred, electrocardiography consistently revealed a regular sinus rhythm, and echocardiography revealed normal left ventricular function and a normal diastolic right ventricular diameter (30 mm). Her biochemical parameters improved (urea: 20 mg/dL; creatinine: 0.9 mg/dL), and a computed tomography scan on postoperative day 8 revealed a closed AVF, patent endograft, resolved type II endoleak, and no findings of pulmonary embolism. At an outpatient clinic 6 months later, duplex ultrasonography confirmed exclusion of the AVF without an endoleak or sac enlargement.
DISCUSSION In the presence of a large AVF, cardiac output increases by an augmented preload and heart rate; however, arterial blood pressure decreases.7,8 The decreased renal pressure and increased venous pressure lead to decreased renal perfusion and activation of the renin-angiotensin system.8 The sympathetic nervous system is also stimulated and contributes to vasoconstriction.9 Atrial natriuretic peptide is concurrently released in association with the increased preload and contributes to vasodilation and compensatory action. These conflicting balances
Annals of Vascular Surgery
Fig. 1. A perioperative aortography revealed the right internal iliac aneurysm (A) and early filling of the inferior vena cava (V).
Fig. 2. Immediately after endograft deployment, the intra-arterial monitor revealed flat (A) and electrocardiography revealed the loss of QRS waves (B).
reflect the clinical hemodynamic status in patients with a large AVF.10 When the fistula is occluded, the blood pressure arises, especially the diastolic pressure.7 The increase in blood pressure activates the arterial baroreflex and induces a decrease in heart rate and marked peripheral sympathetic inhibition.9 The heart rate response associated with opening and closing of the AVF is known as the NicoladonieBranham sign. In the present case, an endograft (Gore Excluder) was first deployed from the aorta below the level of the left renal artery to the left common iliac artery through left common femoral access. At this stage, shunt flow from the right internal iliac aneurysm to the IVC would have been supplied via the right limb of the aortobi-iliac graft. However, the shunt flow had almost disappeared because both limbs were opened at the aorta, which had a diameter of about 17 mm and the right limb was compressed
Vol. 28, No. 4, May 2014
Case reports 1031.e13
performance and cardiac electrical activity were normal except during cardiac arrest. However, during the operation and immediately after exclusion of the AVF, cardiac arrest occurred with complete atrioventricular block as noted during electrocardiography. It would be preferable to implant a temporal pacemaker before closing the fistula or prepare for its immediate use when treating a large fistula. In conclusion, open surgical repair of aortoiliocaval fistulas is associated with high morbidity and mortality and an increased risk of significant blood loss. Endovascular stent-graft treatment for this clinical entity is a less invasive and more attractive alternative, but careful management and preparation is necessary. REFERENCES
Fig. 3. A 0.035-in guidewire was passed through the narrowing contralateral gate (arrow) by leading the guidewire from the right side to the gateway of the contralateral leg and pushing the catheter into the endograft body with the wire-shaped knuckle (dotted line).
by the left endograft limb, which had a diameter of 16 mm. In addition, the blood flow via the lumbar arteries and inferior mesenteric artery was weak in this patient because of atherosclerotic change. Unlike clamping at the proximal aorta during open surgery, endograft deployment causes closure of the AVF together with restoration of blood supply to the lower extremity. Dramatic hemodynamic changes markedly deactivate peripheral and central sympathetic nerve traffic in such cases and were thought to be the cause of sudden cardiac arrest in this patient. Although we cannot rule out the possibility of the involvement of other mechanisms because we did not measure sympathetic nerve activity, various test results confirmed that the perioperative circulating blood volume was under proper control and that the ventricular systolic
1. Brewster DC, Cambria RP, Moncure AC, et al. Aortocaval and iliac arteriovenous fistulas: recognition and treatment. J Vasc Surg 1991;13:253e64. 2. Lin PH, Bush RL, Lumsden AB. Aortocaval fistula. J Vasc Surg 2004;39:266. 3. Akwei S, Altaf N, Tennant W, et al. Emergency endovascular repair of aortocaval fistulada single center experience. Vasc Endovasc Surg 2011;45:442e6. 4. 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. 5. Shah TR, Parikh P, Borkon M, et al. Endovascular repair of contained abdominal aortic aneurysm rupture with aortocaval fistula presenting with high-output heart failure. Vasc Endovasc Surg 2013;47:51e6. 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. Epstein FH, Shadle OW, Ferguson TB, et al. Cardiac output and intracardiac pressures in patients with arteriovenous fistulas. J Clin Invest 1953;32:543e7. 8. Brunkwall J, Lanne T, Bergentz SE. Acute renal impairment due to a primary aortocaval fistula is normalised after a successful operation. Eur J Vasc Endovasc Surg 1999;17:191e6. 9. Velez-Roa S, Neubauer J, Wissing M, et al. Acute arteriovenous fistula occlusion decreases sympathetic activity and improves baroreflex control in kidney transplanted patients. Nephrol Dial Transplant 2004;19:1606e12. 10. Abassi ZA, Winaver J, Hoffman A. Large A-V fistula: pathophysiological consequences and therapeutic perspectives. Curr Vasc Pharmacol 2003;1:347e54.
![[Utero-iliac fistula - successful therapy with stent graft implantation].](/assets/img/hold.png)
