Anesthetic management of aortocaval fistula repair associated with aortic valve replacement, severe aortic regurgitation, and bacterial endocarditis

Abstract

We report a case of an adult male who had received a gunshot to the abdomen 12 years earlier. He presented with manifestations of high-output congestive heart failure (CHF), aortic regurgitation (AR), and pulmonary septic embolism. Further investigation revealed an aortocaval fistula (ACF). Following endovascular repair of the ACF, we observed an immediate rise in systemic vascular resistance (SVR), decrease in central venous pressure (CVP), increase in regurgitant flow across the aortic valve, and decrease in central mixed venous oxygenation. A combination of vasodilators and vasopressors was used to maintain hemodynamics. Milrinone infusion was necessary after cardiopulmonary bypass to maintain cardiac output. Even though local anesthesia and light sedation were used for ACF closure, the hemodynamics changed dramatically throughout the procedure. ACF closure under local anesthesia and sedation is preferred because the hemodynamics alterations under local anesthesia are less severe. The rise in SVR and regurgitant flow across aortic valve is less dramatic. As a result, hemodynamic management and separation from cardiopulmonary bypass are easier.

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.…”