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A Journal on Vascular and Endovascular Surgery

Official Journal of the Italian Society of Vascular and Endovascular Surgery
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Giornale Italiano di Chirurgia Vascolare 2002 September;9(3):269-82

language: English, Italian

Aortocaval fistulae. Clinical and diagnostic aspects and results of 9 cases treated

Freyrie A., Ferri M., Di Iasio G., Buresta P., Palumbo N., Curti T., Faggioli G. L.

Depart­ment of Sur­gical and Anes­the­sio­log­ical Sci­ence Uni­ver­sity of ­Bologna, Bologna Oper­ating ­Unit and Depart­ment of Vas­cular Sur­gery Pol­i­clinico S. ­Orsola, ­Bologna


Back­ground. The rup­ture of an abdom­inal ­aortic aneu­rysm (AAA) in the infe­rior ­vena ­cava is a ­rare ­event, ­with an inci­dence of ­between 0.3 and 10%. How­ever, it is ­extremely ­severe and ­often ­cannot be diag­nosed pre­op­er­a­tively. The aim of ­this ­paper is to ­present our expe­ri­ence ­regarding the char­ac­ter­is­tics of its pres­en­ta­tion, the ­methods of treat­ment and the anal­ysis of per­i­op­er­a­tive ­results, com­paring ­them ­with the ­main ­series ­reported in the lit­er­a­ture.
­Methods. The ­study ­included all the ­cases of aor­toc­aval fis­tula (ACF) ­treated by our ­unit ­over the ­past 14 ­years, eval­u­ating the char­ac­ter­is­tics of ­their pres­en­ta­tion, the ­methods of pre­op­er­a­tive diag­nosis, the diam­eter of the aneu­rysm, the ­type of sur­gery and the ­results ­obtained ­based on per­i­op­er­a­tive mor­tality and mor­bidity (30 ­days). ­This ­group was ­also com­pared ­with a ­group of ­patients ­treated for rup­tured aneu­rysm and con­tained rup­tured aneu­rysm.
­Results. A ­total of 9 ­patients ­with AAA asso­ciated ­with the pres­ence of ACF ­were oper­ated ­during ­this ­period. ­Eight ­patients ­were symp­to­matic at the ­time of obser­va­tion: ­right car­diac decom­pen­sa­tion was ­apparent in 3 ­cases (33%), abdom­inal/­lumbar ­pain and ­shock ­were ­present in 5 ­cases (55%), symp­toms of hep­at­or­enal insuf­fi­ciency in 2 ­cases (22%) and 2 ­cases of iso­lated ­renal insuf­fi­ciency. ­There ­were ­also 2 ­cases of ­lower ­limb ­ischemia and 2 of ­venous ­stasis. ­Among the ­signs of rup­ture, abdom­inal ­bruit was ­noted in 2 ­cases (22%). A ­state of ­anemia ­with Hb <12 mg/dl was ­found in 7 ­cases (77%). ­Only 1 ­patient (11%) was com­pletely asymp­to­matic. The ­interval ­between the ­onset of symp­toms and sur­gery ­ranged ­from a few ­hours (­within 12 ­hours) to 6 ­days. Diag­nosis was intra­op­er­a­tive in 4 ­cases (44%). Pre­op­er­a­tive angio­graphy was per­formed in 3 ­cases for diag­nostic pur­poses. The ­mean diam­eter of the aneu­rysm was 7.3 cm. In 4 ­cases, ACF was asso­ciated ­with ret­ro­per­i­to­neal rup­ture. Sur­gery ­took the ­form of aneu­rys­mec­tomy and pros­thetic ­graft and endo­aneu­rys­matic ­suture of the ­caval ­opening; liga­tion of the ­vena ­cava was ­only ­required in 1 ­case. Per­i­op­er­a­tive mor­tality was 1 ­case (11%): 1 of the 4 ­patients ­with ACF asso­ciated ­with rup­tured AAA, there­fore the mor­tality in ­this ­group was 25%. No ­deaths ­occurred in the ­group ­with iso­lated ACF. Two ­cases of ­deep ­vein throm­bosis (DVT) and 2 of ­lower ­limb ­ischemia ­occurred ­during the post­op­er­a­tive ­period: of the ­latter, 1 ­case was ­resolved by throm­bec­tomy, ­while the ­other ­required demol­i­tive treat­ment (ampu­ta­tion at the ­thigh). Func­tional param­e­ters ­returned to ­normal ­after sur­gery in ­patients ­with ­renal and hep­at­or­enal insuf­fi­ciency. The mor­tality ­rate in rup­tured aneu­rysms was 16.6% (8/48) and 8.3% in con­tained rup­tured aneu­rysms (2/24).
Con­clu­sions. The clin­ical symp­toms of ACF are ­very sim­ilar to the fis­su­ra­tion ­crisis of AAA. In our expe­ri­ence, per­i­op­er­a­tive mor­tality was rel­a­tively low and was lim­ited to ­cases ­with rup­tured aneu­rysm.

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