Traumatic Juxtarenal Aortocaval Fistula and Pseudoaneurysm K.V. K r i s h n a s a s t r y , M D , Steven G. F r i e d m a n , M D , S t e p h e n L. D e c k o f f , M D , W i l l i a m D o s c h e r , M D , Great Neck, N e w York
We discuss the treatment of a fistula located between the aorta and inferior vena cava which was caused by trauma. Fewer than 30 such cases have been reported in the English literature. A juxtarenal pseudoaneurysm and aortocaval fistula resulting from a gunshot wound, unrecognized upon the initial presentation of the patient, is reported herein. (Ann Vasc Surg 1990;4:378-380). KEY WORDS: Aortocaval fistula; trauma; pseudoaneurysm; juxtarenat.
A fistula b e t w e e n t h e a o r t a a n d the i n f e r i o r v e n a c a v a is a r a r e e n t i t y , o c c u r r i n g m o s t o f t e n f o l l o w i n g e r o s i o n o f an a b d o m i n a l a o r t i c a n e u r y s m into the inferior vena cava. Traumatic injury accounts for a p p r o x i m a t e l y 15% o f t h e s e fistulas, w h i l e 3 - 4 % a r e i a t r o g e n i c [1]. F e w e r t h a n 30 c a s e s o f t r a u m a t i c a o r t o c a v a l fistulas h a v e b e e n r e p o r t e d in the English l i t e r a t u r e to d a t e ; t h e i r t y p i c a l l o c a t i o n is distal to the r e n a l a r t e r i e s . W e r e c e n t l y t r e a t e d an indiv i d u a l with an a o r t o c a v a l fistula at t h e level o f the r e n a l a r t e r i e s , w i t h an a s s o c i a t e d p s e u d o a n e u r y s m . A d e s c r i p t i o n o f this c a s e a n d r e v i e w o f the literat u r e f o r m s t h e b a s i s o f this r e p o r t .
CASE REPORT A 53-year-old man was admitted to Booth Memorial Medical Center after sustaining a gunshot wound to the chest. The entrance wound appeared at the bisection of the left nipple line and the anterior axillary line: no exit wound was noted. The patient's blood pressure upon admission was 80/60 mm Hg; the pulse was 120. Bilateral chest tubes were placed and the patient was taken to the operating room for suspected intraabdominal bleeding. An initial thoracotomy was performed, with clamping of the aorta, for severe hypotension and shock. At laparot-
From the Booth Memorial Medical Center, Department of Surgery, Flushing, New York. Reprint requests: Steven G. Friedman, MD, 560 Northern Boulevard, Suite 209, Great Neck, New York 11021. 378
omy. a cholecystectomy and common bile duct repair, with T-tube drainage, was performed for injuries to these organs. A gastroduodenat artery laceration was treated by ligation. Lateral venography of the inferior vena cava was performed following mobilization of the right colon. The remainder of the abdominal exploration was negative. The patient initially did well; however, one week following surgery he developed a sinus tachycardia. The following day a bruit was noted on physical examination of the abdomen. A computed tomographic (CT) scan of the abdomen revealed a pseudoaneurysm of the aorta at the level of the renal arteries (Fig. 1). A pulmonary arterial catheter revealed a cardiac output of 9.5 L. An aortogram obtained several days later revealed the pseudoaneurysm and an aortocaval fistula (Fig. 2). The right kidney was smaller then the left: perfusion of both was normal. There were two right renal arteries. The following day the patient was explored through a thoracoabdominal, retroperitoneal approach; the aorta was exposed from just above the diaphragm to the inferior mesenteric artery. Individual control of the celiac axis, superior mesenteric artery and renal arteries was obtained. During the dissection a 4 cm pseudoaneurysm involving the posterior pararenal aortic wall was noted. The aorta was clamped above the superior mesenteric artery and below the renal arteries, and the pseudoaneurysm was excised. A patch of aorta bearing the two right renal arteries and single left renal artery was preserved and implanted into a 14 mm woven dacron graft which was used to restore aortic continuity. At this time a moderate amount of clot was noted in the aortocaval fistula which was thrombosed. The renal arteries were intermittently perfused with cold Ringer's lactate solution during the forty-minute aortic clamp time. The initial
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Fig. 1. Preoperative CT demonstrating pseudoaneurysm (arrow) between aorta and inferior vena cava.
postoperative cardiac output decreased to 5 L. Renal function remained within normal limits and a postoperative renal scan demonstrated excellent blood supply to both kidneys. A repeat aortogram three weeks after the second procedure revealed excellent perfusion of both renal arteries with no evidence of the aortocaval fistula (Fig. 3). The patient was doing well three months after his hospital discharge.
DISCUSSION J. Syme is generally credited for the first report of an aortocaval fistula in 1831 [2]. His patient was a 22-year-old man with a syphilitic aneurysm. The first traumatic aortocaval fistula was reported by Bigger in 1944 [3] and during the ensuing forty years, only 16 additional cases have been described. These were recently reviewed by Machiedo and associates [1]. The largest series of combined injuries to the aorta and inferior vena cava is that of Mattox and his colleagues, who described 29 such cases [4]. Among these were 10 aortocaval fistulas. However, the authors did not offer specific details regarding the location and management of these cases. A review of the 26 aortocaval fistulas described in the above reports reveals that the vast majority were caused by gunshot wounds. At iaparotomy, a retroperitoneal hematoma with an associated thrill is highly suggestive of an aortic injury and possible fistula. If the patient is hemodynamically stable and other associated injuries have been addressed, arteriography should be considered for precise localization of the fistula and other possible vascular injuries, which can then be surgically repaired.
Fig. 2. Preoperative arteriogram reveals extent of pseudoaneurysm (arrows) about the aorta (a) and fistula (arrowheads) to inferior vena cava (v).
Most of the previously reported traumatic aortocaval fistulas were repaired following significant time intervals ranging from several days to twelve years in one case [5]. In our case the patient was operated on two weeks after the initial injury. The
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wounds [7]. Difficulty in gaining adequate exposure and controlling hemorrhage caused the majority of deaths. There were no recurrent arteriovenous fistulas among patients successfully treated. Although the survival rate among patients undergoing repair of chronic fistulas is significantly higher than in those who develop them as a result of trauma, this is likely a reflection of less severe initial injuries in the former group. It should not be used as justification for any form of delayed repair. The most important aspects of acute management of traumatic aortocaval fistulas are early operation, and, at the time of surgery, wide exposure. Several reports have extolled the value of the thoracoabdominal, retroperitoneal approach for cases of upper abdominal injuries [6,7]. In our case this approach, with mobilization of the left colon and spleen to the midline, allowed complete visualization of the injured site as well as access to all neighboring vessels. Repair could then proceed in an unhurried and controlled manner. Combined injuries to the abdominal aorta and inferior vena cava will continue to challenge the trauma and vascular surgeon. Only with early exploration through adequate incisions can the often fatal hemorrhage which results from these injuries be prevented. In cases where the vascular injury is initially overlooked, repair of a chronic aortocaval fistula should be performed as soon as the patient's condition permits.
Fig. 3. Postoperative arteriogram demonstrating three renal arteries (arrows) originating from prosthetic interposition graft. long interval between injury and repair is usually due to failure to diagnose the vascular injury when the patient is first treated. Although many of the delayed repairs were successful, as ours was, repair immediately after injury remains the treatment of choice. This is due to the unpredictable nature of vascular injuries and the constant risks of delayed massive hemorrhage, or pseudoaneurysm formation with its risk of rupture. Penetrating injuries of the aorta and inferior vena cava together are usually fatal unless repaired immediately. Only 27% of the patients in Mattox's series survived these combined
mmm
REFERENCES 1. MACH1EDO GW, JAIN KM, SWAN KG, et al. Traumatic aorto-caval fistula. J Trauma 1983;23:243-247. 2. SYMES JM, EADIE DGA, M A C L E A N ADW. Traumatic aorto-caval fistula associated with a horseshoe kidney. J Trauma 1974;14:402-408. 3. BIGGER IA. Treatment of traumatic aneurysms and arteriovenous fistulas. Arch Surg 1944;49:170-179. 4. MATTOX KL, W H I S E N N A N D HH, ESPADA R, BEALL AC Jr. Management of acute combined injuries of the aorta and inferior vena cava. Am J Surg 1975;130:720-724. 5. D E C K E R P. Traitement operatoire d'une fistule aorto-cave abdominale haute. Mem Acad Chir 1950;76:453-456. 6. LIM RC Jr, T R U N K E Y DD, B L A I S D E L L FW. Acute abdominal aortic injury: an analysis of operative and postoperative management. Arch Surg 1974;109:706-711. 7. MATTOX KL, M C C O L L U M WM, JORDON GL Jr, et al. Management of upper abdominal vascular trauma. Am J Surg 1974;128:823-828.
We discuss the treatment of a fistula located between the aorta and inferior vena cava which was caused by trauma. Fewer than 30 such cases have been reported in the English literature. A juxtarenal pseudoaneurysm and aortocaval fistula resulting from a gunshot wound, unrecognized upon the initial presentation of the patient, is reported herein. (Ann Vasc Surg 1990;4:378-380). KEY WORDS: Aortocaval fistula; trauma; pseudoaneurysm; juxtarenat.
A fistula b e t w e e n t h e a o r t a a n d the i n f e r i o r v e n a c a v a is a r a r e e n t i t y , o c c u r r i n g m o s t o f t e n f o l l o w i n g e r o s i o n o f an a b d o m i n a l a o r t i c a n e u r y s m into the inferior vena cava. Traumatic injury accounts for a p p r o x i m a t e l y 15% o f t h e s e fistulas, w h i l e 3 - 4 % a r e i a t r o g e n i c [1]. F e w e r t h a n 30 c a s e s o f t r a u m a t i c a o r t o c a v a l fistulas h a v e b e e n r e p o r t e d in the English l i t e r a t u r e to d a t e ; t h e i r t y p i c a l l o c a t i o n is distal to the r e n a l a r t e r i e s . W e r e c e n t l y t r e a t e d an indiv i d u a l with an a o r t o c a v a l fistula at t h e level o f the r e n a l a r t e r i e s , w i t h an a s s o c i a t e d p s e u d o a n e u r y s m . A d e s c r i p t i o n o f this c a s e a n d r e v i e w o f the literat u r e f o r m s t h e b a s i s o f this r e p o r t .
CASE REPORT A 53-year-old man was admitted to Booth Memorial Medical Center after sustaining a gunshot wound to the chest. The entrance wound appeared at the bisection of the left nipple line and the anterior axillary line: no exit wound was noted. The patient's blood pressure upon admission was 80/60 mm Hg; the pulse was 120. Bilateral chest tubes were placed and the patient was taken to the operating room for suspected intraabdominal bleeding. An initial thoracotomy was performed, with clamping of the aorta, for severe hypotension and shock. At laparot-
From the Booth Memorial Medical Center, Department of Surgery, Flushing, New York. Reprint requests: Steven G. Friedman, MD, 560 Northern Boulevard, Suite 209, Great Neck, New York 11021. 378
omy. a cholecystectomy and common bile duct repair, with T-tube drainage, was performed for injuries to these organs. A gastroduodenat artery laceration was treated by ligation. Lateral venography of the inferior vena cava was performed following mobilization of the right colon. The remainder of the abdominal exploration was negative. The patient initially did well; however, one week following surgery he developed a sinus tachycardia. The following day a bruit was noted on physical examination of the abdomen. A computed tomographic (CT) scan of the abdomen revealed a pseudoaneurysm of the aorta at the level of the renal arteries (Fig. 1). A pulmonary arterial catheter revealed a cardiac output of 9.5 L. An aortogram obtained several days later revealed the pseudoaneurysm and an aortocaval fistula (Fig. 2). The right kidney was smaller then the left: perfusion of both was normal. There were two right renal arteries. The following day the patient was explored through a thoracoabdominal, retroperitoneal approach; the aorta was exposed from just above the diaphragm to the inferior mesenteric artery. Individual control of the celiac axis, superior mesenteric artery and renal arteries was obtained. During the dissection a 4 cm pseudoaneurysm involving the posterior pararenal aortic wall was noted. The aorta was clamped above the superior mesenteric artery and below the renal arteries, and the pseudoaneurysm was excised. A patch of aorta bearing the two right renal arteries and single left renal artery was preserved and implanted into a 14 mm woven dacron graft which was used to restore aortic continuity. At this time a moderate amount of clot was noted in the aortocaval fistula which was thrombosed. The renal arteries were intermittently perfused with cold Ringer's lactate solution during the forty-minute aortic clamp time. The initial
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Fig. 1. Preoperative CT demonstrating pseudoaneurysm (arrow) between aorta and inferior vena cava.
postoperative cardiac output decreased to 5 L. Renal function remained within normal limits and a postoperative renal scan demonstrated excellent blood supply to both kidneys. A repeat aortogram three weeks after the second procedure revealed excellent perfusion of both renal arteries with no evidence of the aortocaval fistula (Fig. 3). The patient was doing well three months after his hospital discharge.
DISCUSSION J. Syme is generally credited for the first report of an aortocaval fistula in 1831 [2]. His patient was a 22-year-old man with a syphilitic aneurysm. The first traumatic aortocaval fistula was reported by Bigger in 1944 [3] and during the ensuing forty years, only 16 additional cases have been described. These were recently reviewed by Machiedo and associates [1]. The largest series of combined injuries to the aorta and inferior vena cava is that of Mattox and his colleagues, who described 29 such cases [4]. Among these were 10 aortocaval fistulas. However, the authors did not offer specific details regarding the location and management of these cases. A review of the 26 aortocaval fistulas described in the above reports reveals that the vast majority were caused by gunshot wounds. At iaparotomy, a retroperitoneal hematoma with an associated thrill is highly suggestive of an aortic injury and possible fistula. If the patient is hemodynamically stable and other associated injuries have been addressed, arteriography should be considered for precise localization of the fistula and other possible vascular injuries, which can then be surgically repaired.
Fig. 2. Preoperative arteriogram reveals extent of pseudoaneurysm (arrows) about the aorta (a) and fistula (arrowheads) to inferior vena cava (v).
Most of the previously reported traumatic aortocaval fistulas were repaired following significant time intervals ranging from several days to twelve years in one case [5]. In our case the patient was operated on two weeks after the initial injury. The
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wounds [7]. Difficulty in gaining adequate exposure and controlling hemorrhage caused the majority of deaths. There were no recurrent arteriovenous fistulas among patients successfully treated. Although the survival rate among patients undergoing repair of chronic fistulas is significantly higher than in those who develop them as a result of trauma, this is likely a reflection of less severe initial injuries in the former group. It should not be used as justification for any form of delayed repair. The most important aspects of acute management of traumatic aortocaval fistulas are early operation, and, at the time of surgery, wide exposure. Several reports have extolled the value of the thoracoabdominal, retroperitoneal approach for cases of upper abdominal injuries [6,7]. In our case this approach, with mobilization of the left colon and spleen to the midline, allowed complete visualization of the injured site as well as access to all neighboring vessels. Repair could then proceed in an unhurried and controlled manner. Combined injuries to the abdominal aorta and inferior vena cava will continue to challenge the trauma and vascular surgeon. Only with early exploration through adequate incisions can the often fatal hemorrhage which results from these injuries be prevented. In cases where the vascular injury is initially overlooked, repair of a chronic aortocaval fistula should be performed as soon as the patient's condition permits.
Fig. 3. Postoperative arteriogram demonstrating three renal arteries (arrows) originating from prosthetic interposition graft. long interval between injury and repair is usually due to failure to diagnose the vascular injury when the patient is first treated. Although many of the delayed repairs were successful, as ours was, repair immediately after injury remains the treatment of choice. This is due to the unpredictable nature of vascular injuries and the constant risks of delayed massive hemorrhage, or pseudoaneurysm formation with its risk of rupture. Penetrating injuries of the aorta and inferior vena cava together are usually fatal unless repaired immediately. Only 27% of the patients in Mattox's series survived these combined
mmm
REFERENCES 1. MACH1EDO GW, JAIN KM, SWAN KG, et al. Traumatic aorto-caval fistula. J Trauma 1983;23:243-247. 2. SYMES JM, EADIE DGA, M A C L E A N ADW. Traumatic aorto-caval fistula associated with a horseshoe kidney. J Trauma 1974;14:402-408. 3. BIGGER IA. Treatment of traumatic aneurysms and arteriovenous fistulas. Arch Surg 1944;49:170-179. 4. MATTOX KL, W H I S E N N A N D HH, ESPADA R, BEALL AC Jr. Management of acute combined injuries of the aorta and inferior vena cava. Am J Surg 1975;130:720-724. 5. D E C K E R P. Traitement operatoire d'une fistule aorto-cave abdominale haute. Mem Acad Chir 1950;76:453-456. 6. LIM RC Jr, T R U N K E Y DD, B L A I S D E L L FW. Acute abdominal aortic injury: an analysis of operative and postoperative management. Arch Surg 1974;109:706-711. 7. MATTOX KL, M C C O L L U M WM, JORDON GL Jr, et al. Management of upper abdominal vascular trauma. Am J Surg 1974;128:823-828.
