Simultaneous endovascular repair of an iatrogenic carotid-jugular fistula and a large iliocaval fistula presenting with multiorgan failure: a case report

Abstract

IntroductionIliocaval fistulas can complicate an iliac artery aneurysm. The clinical presentation is classically a triad of hypotension, a pulsatile mass and heart failure. In this instance, following presentation with multiorgan failure, management included the immediate use of an endovascular stent graft on discovery of the fistula.Case presentationA 62-year-old Caucasian man presented to our tertiary hospital for management of iatrogenic trauma due to the insertion of a central venous line into his right common carotid artery, causing transient ischemic attack. Our patient presented to a peripheral hospital with fever, nausea, vomiting, acute renal failure, acute hepatic dysfunction and congestive heart failure. A provisional diagnosis of sepsis of unknown origin was made. There was a 6.5 cm×6.5 cm right iliac artery aneurysm present on a non-contrast computed tomography scan. An unexpected intra-operative diagnosis of an iliocaval fistula was made following the successful angiographic removal of the central line to his right common carotid artery. Closure of the iliocaval fistula and repair of the iliac aneurysm using a three-piece endovascular aortic stent graft was then undertaken as part of the same procedure. This was an unexpected presentation of an iliocaval fistula.ConclusionOur case demonstrates that endovascular repair of a large iliac artery aneurysm associated with a caval fistula is safe and effective and can be performed at the time of the diagnostic angiography. The presentation of an iliocaval fistula in this case was unusual which made the diagnosis difficult and unexpected at the time of surgery. The benefit of immediate repair, despite hemodynamic instability during anesthesia, is clear. Our patient had two coronary angiograms through his right femoral artery decades ago. Unusual iatrogenic causes of iliocaval fistulas secondary to previous coronary angiograms with wire and/or catheter manipulation should be considered in patients such as ours.

Emergent Endovascular Repair of Challenging Aortocaval Fistula With Hostile Anatomy

“…Seven patients were managed conservatively, and 6 of these endoleaks sealed spontaneously. 9,11,12,[16][17][18]20 There was a persistent flow over the ACF with shrinkage of the aneurysm sac in 1 patient at the 2-year follow-up. 20 The other 5 patients with type 2 endoleaks underwent intervention.…”

“…From 1998 to 2015, 17 articles reported on 17 patients presenting with endoleaks after endovascular stent-grafting of ruptured AAA with an ACF (Table 2). 2,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] The site of the fistula was the aortocaval segment in 14 (82%) patients and iliocava segment in 3 (18%) patients. The most common endoleak was type 2 endoleak, which occurred in 12 patients.…”

Endovascular treatment of an ilio-iliac arteriovenous fistula accompanied by venous thromboembolism presenting with multiple organ failure – A case report and literature review

“…Thus, an ilio-iliac AVF presenting with systematic symptoms is rare. 1,11 We searched literatures since 1999 by using PubMed, and found only two patients with ilio-iliac AVF presenting multi-organ dysfunction. 10,12 However, both of them had an extensive fistula orifice, which demonstrated that ilio-iliac AVF may be fatal with specifically unfavorable anatomy.…”

“…The severe venous hypertension and congestive heart failure can cause pulmonary arterial hypertension, which lead to pneumoedema and respiratory failure. 10–12 In such patients, acute renal failure may occur as a result of unusual high renal congestion due to venous hypertension. 13,14 Furthermore, heart failure and associated hypoperfusion may lead to pre-renal failure.…”