British Journal of Radiology (2006) 79, e62-e63
© 2006 British Institute of Radiology
doi: 10.1259/bjr/27172509
Endovascular repair of a recurrent aortocaval fistula and anastamotic false aneurysm
S Pathak, MBBS, MRCSEd
1
S W Yusuf, DM, FRCS
2
T N Doyle, FRCR
1
I A Francis, FRCS, FRCR
1
P A E Hurst, MS, FRCS
2 and
C Davidson, MB BChir, , FRCP, FESC
3
Departments of 1Radiology 2Vascular Surgery and 3Cardiology, Brighton and Sussex University Hospitals NHS Trust, The Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK
Correspondence: S W Yusuf, Consultant Vascular Surgeon, The Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK
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Abstract
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Aortocaval fistula (ACF) and false aneurysm are a recognized complication of open abdominal aortic aneurysm (AAA) repair. Untreated they are often fatal. However, open surgical repair of this complication is associated with a high operative mortality and a significant complication rate. Endovascular management using a stent-graft to exclude the false aneurysm and fistula is a technically feasible alternative and confers many advantages over open repair by virtue of its minimally invasive nature. We report the endovascular management of this rare but serious complication of open AAA repair.
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Introduction
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Aortocaval fistula (ACF) and false aneurysm are an uncommon complication of open abdominal aortic aneurysm (AAA) repair. Most occur as a complication of aortic graft infection and their prevalence is estimated at less than 1% [1]. Untreated they are often fatal. Most patients are elderly with decreased physiological reserve and multiple co-morbidities, this is reflected in the high complication rate of open repair with a perioperative mortality of up to 90% [2]. Endovascular repair using a stent-graft is able to exclude both the false aneurysm and the abnormal fistula in a single procedure. Endovascular repair of anastomotic aneurysms following open surgery has been reported [3]. We describe the endovascular management of a recurrent ACF with false aneurysm.
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Materials and methods
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A 75-year-old man with a previous history of AAA repair presented with an abdominal mass, fluid retention and shortness of breath. Clinical examination revealed cardiac failure and a pulsatile mass in the abdomen with a "machinery-like" murmur. All peripheral pulses were present. Multidetector CT scan showed a 14 cm false aneurysm adjacent to the proximal graft anastamosis and a fistula between the false aneurysm and the inferior vena cava (IVC) (Figure 1
). A transaxillary arteriogram showed contrast extravasating from the posterior aspect of the proximal graft anastamosis into the false aneurysm. A repair was undertaken using an endovascular custom made stent-graft (William Cook, Bjaeverskov, Denmark) to exclude both the false aneurysm and the ACF. The original graft was an aorto-bifemoral graft with a short body. The stent-graft was designed to cover the segment from immediately below the renal arteries to the graft bifurcation. Intra-arterial access was obtained via the left limb of the aorto-bifemoral graft. A 7 F angiocatheter was introduced via the right brachial artery. The endovascular stent delivery system was introduced over a 0.35'' Lunderquist wire and deployed at the site of the false aneurysm and ACF, with its covered segment below the origin of the renal arteries. Completion angiogram showed no further communication of the aorta with the IVC or escape of contrast into the false aneurysm.
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Results
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The immediate post-procedure period was complicated by clinical signs of consumption coagulopathy, with a falling platelet count and abnormal clotting tests. The patient spent 9 days in ITU but made a satisfactory recovery. A CT scan was performed before discharge which showed no evidence of contrast extravasation and a successful exclusion of the false aneurysm and ACF. The patient was discharged on day 24 on long-term antibiotics. 6 months later, the patient required an axillo-femoral bypass graft to deal with a false aneurysm which had developed at the distal anastamosis of the original graft at the right groin; this graft thrombosed at 3 months leading to an above knee amputation. Subsequent CT scan at 18 months demonstrated satisfactory appearances of the stent-graft with continuing exclusion and shrinkage of the false aneurysm (Figure 2). At the same time, a whole body white cell scan did not show any increased uptake of tracer around the stent-graft.
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Discussion
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The endovascular management of the complications of open AAA is fast gaining recognition as a viable alternative to surgical repair. The use of endovascular stents to exclude anastomotic false aneurysms [3] and aortoenteric fistulae is well documented [4], but to our knowledge there is only one report which describes the emergency endovascular management of recurrent ACF [5]. ACF and false aneurysms are a rare complication of aortic bypass and are commonly caused by aortic graft anastomotic breakdown as a result of mechanical stresses and infection. Traditionally, treatment has been by open surgical repair involving graft removal with in situ replacement with femoral veins or extra-anatomical bypass. However, most of these patients are elderly with multiple co-morbidities. This is reflected in the poor outcome and high complication rate of open repair which is associated with an operative mortality rate of 25–90% [2]. The minimally invasive nature of an endovascular approach places less demand on the patients' physiological reserve and achieves successful exclusion of the false aneurysm and fistula in a single procedure. Care must be taken, because of the introduction of a synthetic graft into a potentially infected area and suppression of infection is of the utmost importance in maintaining the long term viability of the new graft. Nevertheless, endovascular repair of this condition provides a less invasive alternative to open surgical management.
Received for publication September 3, 2004.
Revision received April 26, 2005.
Accepted for publication September 2, 2005.
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References
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Abstract
Introduction
