Figure 1
Abdominal ultrasound exam
Incidentally, a huge abdominal aortic aneurysm with an intramural thrombus in the right posterior wall of the aorta is discovered by ultrasound study.
Aortocaval fistula
SectionCardiovascular
Case TypeClinical Cases
AuthorsAlbert Dorca Duch, María Vicente Quílez, Itziar Oronoz Mitxelena
Connected authors
80 years, male
Clinical History
An 80-year-old male patient with history of chronic renal failure was admitted to the emergency department due to anuria, incessant lumbar pain, lower limb swelling, and paraesthesia.
At admission, the patient was haemodynamically stable. On physical examination, a pulsatile epigastric mass was palpable, suggestive of an abdominal aortic aneurysm.
At admission, the patient was haemodynamically stable. On physical examination, a pulsatile epigastric mass was palpable, suggestive of an abdominal aortic aneurysm.
Imaging Findings
An abdominal ultrasound showed signs of severe chronic kidney disease but no urinary tract obstruction. Additionally, a huge infrarenal aortic aneurysm was visible.
In order to discard complication, an abdominal CT in arterial phase was performed, disclosing the presence of a partially thrombosed infrarenal aortic aneurysm (9 cm of maximum transverse diameter). Furthermore, similar opacification of the inferior vena cava (IVC) to that of the aorta was visible, suggesting fistulisation between this two structures. Direct communication between the two vascular lumens through an ulcer of a mural thrombus in the right wall of the aorta confirmed the suspicion.
Permeability of the deep venous system could not be fully assessed in the absence of a venous phase, however no indirect signs of mesenteric vein thrombosis (bowel mural thickening) were visible. Furthermore, an ultrasound confirmed permeability of the lower limb venous system.
No signs of aneurysm rupture into the retroperitoneum were visible.
In order to discard complication, an abdominal CT in arterial phase was performed, disclosing the presence of a partially thrombosed infrarenal aortic aneurysm (9 cm of maximum transverse diameter). Furthermore, similar opacification of the inferior vena cava (IVC) to that of the aorta was visible, suggesting fistulisation between this two structures. Direct communication between the two vascular lumens through an ulcer of a mural thrombus in the right wall of the aorta confirmed the suspicion.
Permeability of the deep venous system could not be fully assessed in the absence of a venous phase, however no indirect signs of mesenteric vein thrombosis (bowel mural thickening) were visible. Furthermore, an ultrasound confirmed permeability of the lower limb venous system.
No signs of aneurysm rupture into the retroperitoneum were visible.
Discussion
Rupture of an abdominal aortic aneurysm into the inferior vena cava is an uncommon and devastating condition, involving less than 5% of cases of aneurysmatic aortic rupture.
A clinical diagnosis is sometimes difficult because the classic diagnostic signs (pulsatile abdominal mass with bruit, acute venous congestion and low back pain) may be absent in many cases [1, 2]. Additionally, aortocaval fistula can debut with or without rupture into the abdominal cavity. In some cases the clinical presentation can lead to confusion, mimicking other cardiovascular conditions such as congestive heart failure, causing lower extremity oedema and paraesthesia [2]. Therefore, acknowledgement of this disease is essential for an early diagnosis and treatment.
Acute renal failure due to shock state or venous hypertension has been widely described. Interstitial renal oedema in venous hypertension may cause a rapid renal function decrease [3], often associated with haematuria. Other atypical forms of presentation may be paradoxical pulmonary embolism from an aortic thrombus, or angina due to increased myocardial oxygen demand, following the spontaneous rupture of the aneurysm [4].
Conventionally, treatment has been open surgical repair with its attendant complications, including a mortality rate of up to 30%. In our patient, endovascular aneurysm repair (EVAR) managed to exclude the fistula [5].
A clinical diagnosis is sometimes difficult because the classic diagnostic signs (pulsatile abdominal mass with bruit, acute venous congestion and low back pain) may be absent in many cases [1, 2]. Additionally, aortocaval fistula can debut with or without rupture into the abdominal cavity. In some cases the clinical presentation can lead to confusion, mimicking other cardiovascular conditions such as congestive heart failure, causing lower extremity oedema and paraesthesia [2]. Therefore, acknowledgement of this disease is essential for an early diagnosis and treatment.
Acute renal failure due to shock state or venous hypertension has been widely described. Interstitial renal oedema in venous hypertension may cause a rapid renal function decrease [3], often associated with haematuria. Other atypical forms of presentation may be paradoxical pulmonary embolism from an aortic thrombus, or angina due to increased myocardial oxygen demand, following the spontaneous rupture of the aneurysm [4].
Conventionally, treatment has been open surgical repair with its attendant complications, including a mortality rate of up to 30%. In our patient, endovascular aneurysm repair (EVAR) managed to exclude the fistula [5].
Differential Diagnosis List
Spontaneous aortocaval fistula (ACF)
A wide spectrum of thoracic and abdominal acute conditions (pulmonary embolism
cardiac failure
aortic dissection etc.)
Other nonvascular abdominal emergencies (acute pancreatitis
renal colic etc.)
Final Diagnosis
Spontaneous aortocaval fistula (ACF)
References
[1] V. Hervas, J.M Esteban & L. García-Ferrer. Radiology Service of the Consorcio Hospital General Universitario de Valencia (2007) Aortocaval Fistula Presenting with Hematuria and Renal Failure. European Journal of endovascular surgery 34, 622
[2] T Wang, B Huang, J Zhao, Y Yang, D Yuan (2016) Aortocaval fistula resulting from rupture of the abdominal aortic dissecting aneurysm treated by delaied endovascular repair. A case report. Medicine (Baltimore) 95, 18 (PMID: 27149481)
[3] Emmanouil D. Psathas, Stella Lioudaki, Mikes Doulaptsis, Petros Charalampoudis, Chris Klonaris, and Chris Verikokos. (2012) Clinical Manifestations of Aortocaval Fistulas in Ruptured Abdominal Aortic Aneurysm: Report of Two Cases. Case Reports in Surgery 2012, 4 (PMID: 23150843)
[4] R. Alpera, F. Ardoy, J.A. Gallego. (2002) Fístula aortocava: complicación infrecuente tras la rotura de aneurisma de aorta abdominal. Radiología 44, 4
[5] Handandeep T, Choi L, Mastouri N, Kadambi P.V. (2012) Aortocaval fistula: A rare cause of venous hypertension and acute renal failure. Case Report Surgery 2012:487079. (PMID: 23346449)
Case information
| URL: | https://www.eurorad.org/case/15470 |
| DOI: | 10.1594/EURORAD/CASE.15470 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Contrast-enhanced CT angiography. Axial image sequences
Infrarenal abdominal aortic aneurysm with a thrombotic ulcer in its wall is confirmed (A,B,C). There is arterialisation of the IVC and the iliac veins (C).
Oedema around the aorta (D) indicates periaortitis.
Figure 3
CT angiography. Maximum intensity projection (MIP) reconstruction
Coronal reconstruction image. Early enhancement of the inferior vena cava (IVC), synchronous and equivalent to that of the aortic lumen.
In addition, it is showed the severe atherosclerosis of the aorta and great vessels.
Figure 4
CT angiography. Maximum intensity projection (MIP) reconstruction
Sagittal reconstruction image (rotated).
Directed communication between the two lumens through the aortic ulcer. Arterial opacification of the inferior vena cava indicates aortocaval fistula.
Abdominal ultrasound exam
Incidentally, a huge abdominal aortic aneurysm with an intramural thrombus in the right posterior wall of the aorta is discovered by ultrasound study.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.
Contrast-enhanced CT angiography. Axial image sequences
Infrarenal abdominal aortic aneurysm with a thrombotic ulcer in its wall is confirmed (A,B,C). There is arterialisation of the IVC and the iliac veins (C).
Oedema around the aorta (D) indicates periaortitis.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.
CT angiography. Maximum intensity projection (MIP) reconstruction
Coronal reconstruction image. Early enhancement of the inferior vena cava (IVC), synchronous and equivalent to that of the aortic lumen.
In addition, it is showed the severe atherosclerosis of the aorta and great vessels.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.
CT angiography. Maximum intensity projection (MIP) reconstruction
Sagittal reconstruction image (rotated).
Directed communication between the two lumens through the aortic ulcer. Arterial opacification of the inferior vena cava indicates aortocaval fistula.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.
Hospital Universitario de Bellvitge, Deparment of Radiology. L'Hospitalet de Llobregat, Barcelona, Spain.