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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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