Abdominal Aortic Aneurysm with Rupture into the Inferior Vena Cava

Abstract

A patient is presented with an arteriosclerotic abdominal aneurysm that ruptured into the inferior vena cava. Clinically, the picture was that of a peripheral arteriovenous communication with heart failure of the "high-output" type. Intestinal bleeding occurred as a result of venous engorgement and hemorrhagic colitis.ANEURYSM of the abdominal aorta is a rare finding. abdominal tenderness to deep palpation with some abdominal distention, and was expelling large amounts of gas both by mouth and by rectum. At this time it was thought that the patient had diverticulitis with partial intestinal obstruction. He was hospitalized and x-ray studies were made. These revealed numerous distended loops of small bowel. There was a moderate amount of gas within the colon, with a distended loop in the left upper quadrant. There was a rounded area of calcified density in the right upper quadrant which suggested a gallstone. No fluid level was seen. No other masses or soft tissue shadows were visible. X-ray findings were thought to be compatible with intestinal obstruction. He was treated with penicillin, streptomycin, and sulfathalidine. He improved on this regime but continued to have some lower abdominal cramping. On the third hospital day he was discovered to have an abdominal mass about the size of an orange. This was situated a little more to the right of the midline than to the left. During the next few hours the mass increased in size and a continuous murmur over it was noted. The next morning an associated continuous thrill was found over the mass. It was thought at this time that the mass represented aneurysmal dilatation with an arteriovenous communication, most likely between the aorta and the inferior vena cava. The blood pressure was 140/40 and there was a typical Corrigan pulse.Four days later bleeding from the rectum occurred but this promptly subsided following the administration of morphine. During the remaining six weeks of his life there was constant severe anorexia, and, after taking food, nausea would become evident. In addition, he developed progressive right-sided heart failure which responded poorly to digitalis and mercury. All the typical signs of a high cardiac output were present during this time. The loud continuous murmur and the pronounced thrill continued to be present over the abdominal mass. He became progressively more edematous in spite of therapy, and it finally became necessary to make puncture holes in his legs to allow the fluid to drain. This procedure was associated with a 30 pound weight loss. However, he continued to lose strength as the result of starvation.

Aortocaval and iliac arteriovenous fistulas: Recognition and treatment

“…Similarly, rupture of distended superficial colorectal mucosal veins may cause rectal bleeding. 13,33 Renal insufficiency manifested by oliguria or anuria and azotemia, as seen in four of our patients, may also cause diagnostic confusion or inappropriate delay in operative treatment. It is thought such renal failure is caused in part by markedly elevated renal venous pressure and decreased mean arterial pressure, leading to reduced renal blood flow.…”

Aorto-Caval Fistulas

“…Result of that is diversion of most shunted blood toward the pelvis and extremities with regional venous hypertension [5]. Regional venous hypertension produces swelling of the lower extremities, hematuria, renal insufficiency, scrotal edema and rectal bleeding due to superficial colorectal mucosal veins rupture [19,29,[34][35][36]. We found leg swelling in five (31.25%) of our cases.…”

Surgical Repair of a 13-cm Infrarenal Abdominal Aortic Aneurysm with Aortocaval Fistula in a 63-Year-Old Tuba Player

“…Syme is credited as being the first to describe ACF (in 1831), 8 and Viar and Lombardo reported the first detailed modern case (1952). 9 In 1955, in response to Javid and colleagues' case series, 10 Cooley noted his own case 11 of a poor surgical candidate who recovered after an operation to correct a ruptured AAA with ACFapparently the first successful repair.…”