Abdominal aortic aneurysms ruptured to the vena cava: a case series and literature review

Oliveira, Carolina de; Schmid, Bruno Pagnin; Molinari, Giovani José Dal Poggetto; Guillaumon, Ana Terezinha

doi:10.1590/1677-5449.200174

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Brasil

Jornal Vascular Brasileiro

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Sumário

CASE REPORT • J. Vasc. Bras. 20 • 2021 • https://doi.org/10.1590/1677-5449.200174 copy

Abdominal aortic aneurysms ruptured to the vena cava: a case series and literature review

Aneurismas de aorta abdominal rotos para a veia cava: uma série de casos e revisão de literatura

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Ruptured abdominal aortic aneurysms (RAAA) evolving aortocaval fistula (AF) can have catastrophic hemodynamic effects. Surgical repair is imperative, but the optimal technical approach is still under debate. Our objective is to present 3 cases treated with endovascular repair (EVAR) at a University Hospital. Case #1, a 71-year-old man presenting a 7.1cm RAAA with AF, repaired with a monoiliac stent graft and femoral-femoral bypass; Case #2, a 76-year-old man presenting a 9.9cm RAAA with AF, repaired with a bifurcated stent graft; Case #3, a 67-year-old man with previous history of EVAR, presenting a type 3 endoleak with late rupture related to AF, repaired with a tubular stent graft. All cases unfolded with delayed recovery and significant complication rates, although AF symptoms had resolved by hospital discharge. EVAR techniques for AF may require secondary interventions but are feasible, despite the lack of consensus, considering the rarity of this RAAA presentation.

Keywords:
aneurysm, ruptured; aortic aneurysm, abdominal; arteriovenous fistula; case series; vascular fistula

Case	1	2	3
Date of operation	May 9, 2017	December 11, 2017	April 26, 2017
Age (years)	71	76	67
Gender	Male	Male	Male
Hypertension	No	Yes (requiring >2 drugs)	Yes (requiring >2 drugs)
Tobacco use	Yes (quit 20 years ago)	No	Yes (quit 3 years ago)
Diabetes	No	No	No
Renal status	Normal	Evidence of renal disease, GFR> 90	Normal
Cardiac status	Asymptomatic, with normal electrocardiogram	Poorly compensated, congestive heart failure	Asymptomatic, with normal electrocardiogram
Previous surgical procedures	No	No	EVAR AFX (Endologix® Inc; Irvine, CA) for RAAA
Clinical presentation	Abdominal pain, central pulsatile mass, loud continuous machinery-like midabdominal bruit	Abdominal pain, central pulsatile mass, acute renal failure, hematuria	Abdominal pain, central pulsatile mass, bilateral limb and scrotal edema, hematuria
Hemodynamic presentation	Stable	Stable	Stable
Imaging findings	RAAA (7.6cm, infrarenal) with AF	RAAA (9.9 cm, infrarenal) with AF	Type 3 Endoleak with late rupture related to AF (and possible left type 1b endoleak)

	Case 1	Case 2	Case 3
Surgical procedure	EVAR Endurant II, (Medtronic® Vascular Inc., Santa Rosa, CA) Monoiliac stent graft + proximal extension + iliac extension and femoral-femoral bypass	EVAR Zenith Flex, (Cook Medical® Inc., Bloomington, IN) Bifurcated stent graft	EVAR Endurant II, (Medtronic® Vascular Inc., Santa Rosa, CA) Tubular aortic stent graft + LIIA coil embolization +external left iliac extension
Intraoperative red blood cell transfusion (#packs)	5	6	3
Total operating time (hours)	5.5	4	4 (first operation) 5 (reintervention)
Complications	Dacron infection	Type 2a Endoleak, Acute renal failure (needed temporary dialysis), Klebsiella ESBL bacteremia, Pulmonary thromboembolism	Acute renal failure (needed temporary dialysis)
Reintervention	Femoral graft excision and autologous great saphenous vein femoral-femoral bypass (postoperative day 41).	No	EVAR Endurant II, Medtronic ® Vascular Inc., Santa Rosa, CA Monoiliac stent graft + right iliac extension + LCIA occlusion + femoral-femoral bypass (postoperative day 14).
Length of hospital stay(days)	25	81	34
Imaging follow-up (Angiotomography)	2.7 years	23 days	1.5 years
Clinical follow-up (years)	3.07	Death - 4 months after surgical repair (acute myocardial infarction)	2.97

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.