Anesthetic management of a patient with aortocaval fistula

Abstract

Aortocaval fistula is a rare complication of ruptured abdominal aortic aneurysm (AAA), and patients with an aortocaval fistula show multiple symptoms. We report an 87-year-old man who was diagnosed as having an AAA with aortocaval fistula and who developed refractory hypotension after induction of anesthesia. Following a phenylephrine injection for slight hypotension induced by anesthetic induction, he developed severe hypotension and bradycardia, and his skin became cyanotic. Vasopressor agents had no immediate effect on the hypotension, but blood pressure gradually increased in about 30 min with continuous infusion of dopamine and noradrenaline. Transesophageal echocardiography (TEE) showed right ventricle (RV) hypokinesis and massive tricuspid regurgitation (TR). Central venous pressure (CVP) showed a remarkably high value. After the repair of the aortocaval fistula, the hemodynamics became stable, RV motion was improved, TR was reduced, and CVP became normal. Anesthetic management of the repair of an aortocaval fistula is very difficult. The hemodynamics changed dramatically throughout anesthesia in our patient with this disorder, even though low-dose anesthetics were used. For the successful treatment of this disorder, preparation for the operation is required before the induction of anesthesia, and urgent closure of the fistula is necessary after the induction of anesthesia. TEE is a useful tool for monitoring hemodynamics in such patients.

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm

“…[530][531][532][533] EVAR is preferred, [534][535][536][537][538][539][540] with expected resolution of preoperative heart failure and other physiologic disturbances. [541][542][543][544] If open repair is required, venous bleeding should be anticipated and care taken to minimize the risk of pulmonary air embolism or embolism of thrombotic debris by placement of sponge sticks proximal and distal to the aortocaval fistula for control, followed by direct suture repair of the defect. 545,546 Since 2013, an additional 53 patients presenting with an aortocaval fistula have been added to the previously reported 250 cases.…”

Multimodales Vorgehen bei einem gedeckt rupturierten Bauchaortenaneurysma mit aortocavaler Fistel

“…Hierbei gilt es zunächst die vaskuläre Kontrolle über den aortalen Blutstrom herzustellen. Dann erfolgt nach Eröffnen des Aneurysmas die Unterbindung des Blutstroms in der Vena cava durch bimanuelle Kompression oder mittels zweier Fogartykatheter, die vor OP-Beginn über die V. femoralis proximal und distal der Fistel in der VCI platziert werden[9]. Anschließend kann der Operateur die Fistelöff-A) und B) Angiographie C) Angiocomputertomographie, arterielle Phase Dtsch Med Wochenschr 2010; 135: 2296-2299 • M. von Heesen et al, Multimodales Vorgehen bei … Autorenerklärung: Die Autoren erklären, dass sie keine finanziellen Verbindungen mit einer Firma haben, deren Produkt in dem Artikel eine wichtige Rolle spielt (oder mit einer Firma, die ein Konkurrenzprodukt vertreibt).…”