Aorto-Caval Fistulas

Abstract

The surgical repair of 16 aorto-caval (A-C) fistulas (15 male and one female patient; average age of 61.3 years) is reviewed. Fourteen fistulas were caused by aneurysm's erosion, one by iatrogenic injury, while one followed abdominal blunt trauma. The interval from presumed occurrence to diagnosis ranged from 6 h to 2 years. The presence of an abdominal bruit (87.5%) was the most reliable physical finding. Congestive heart failure was prominent in three (18.7%) cases, while severe lower extremity edema in five (31.2%). Two patients (12.5%) had hematuria, two (12.5%) renal insufficiency, while four (25%) scrotal edema. The diagnosis was not recognized before the surgery in five (31.2%) cases. In all 16 cases after transaortic suture of the fistula, aortic reconstructions were performed. Four operative deaths (25%) occurred, in patients who were not correctly diagnosed before surgery. In one case the cause of death was massive bleeding, and in three MOFS. All other patients were followed from 1 to 17 years (mean 4 years and 2 months). All grafts are patent, and there is no lower extremity venous insufficiency or pelvic venous hypertension. Surgical repair of A-C fistulas is mandatory to prevent serious complications.

Twenty Years of Experience in the Treatment of Spontaneous Aorto‐venous Fistulas in a Developing Country

“…The importance of adequate preoperative diagnosis of AVF has been emphasized [19]. Computerized tomography (CT) when available is often the initial and optimal imaging method, but angiography, duplex ultrasonography, and magnetic resonance angiography (MRA) can also be useful diagnostic tools [6, 7, 10, 11, 16, 22, 23, 26, 27]. The use of angiography and MRA, however, are restricted to hemodynamically stable patients.…”

“…The most important issue during ACF repair is control of venous bleeding from the fistula. Bleeding control from the IVC can be achieved by direct digital compression above and below the fistula [13] (45 of our cases), or by preoperative proximal and distal insertion of balloon occlusive catheters into the IVC via femoral veins [5, 7, 11, 28, 29] (5 of our cases). If bleeding control from the fistula is unsatisfactory despite these maneuvers, venous ligation may be necessary despite the high risk of postoperative ilio‐caval venous thrombosis [18].…”

“…Aortic repair is achieved by insertion of a tubular or bifurcated prosthetic graft in the usual manner. In some cases of traumatic AC fistula, primary aortic or arterial repair is feasible [7, 29].…”

“…Surgery for ACF is usually associated with excessive blood loss. Even when bleeding control is satisfactory, intraoperative blood loss is an important issue, making the use of autotransfusion mandatory [7, 18, 29].…”

“…One of the rare forms of abdominal aortic aneurysm rupture is rupture into great abdominal veins, such as the inferior vein cava (IVC) or the iliac veins of left renal vein, with the formation of direct or indirect aorto-caval fistula (ACF). The incidence of ACF caused by spontaneous rupture of the AAA ranges from 0.2% to 6% [2][3][4][5][6][7].…”