Spontaneous Aortocaval Fistula,☆☆,

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Abstract

Rupture of an abdominal aortic aneurysm into the inferior vena cava is uncommon. A classic syndrome of high-output heart failure, continuous abdominal bruit, and renal insufficiency has been described and permits a clinical diagnosis if an aortocaval fistula is considered in the differential diagnosis. Classic signs and symptoms can be misinterpreted and are present in less than 50% of cases. Physicians should consider abdominal ultrasonography and aortography in stable patients, followed by prompt surgical intervention. We report the case of a patient with an aortocaval fistula.

[Potyk DK, Guthrie CR: Spontaneous aortocaval fistula. Ann Emerg Med March 1995;25:424-427.]

Section snippets

INTRODUCTION

Atherosclerotic abdominal aortic aneurysms (AAAs) account for more than 90% of the spontaneous aortocaval fistulas reported in the literature.1 The incidence of atherosclerotic AAAs appears to be increasing, a finding independent of the aging population and improved diagnostic capabilities.2 As the prevalence of aneurysmal disease increases, so will its complications.

Spontaneous rupture of an AAA into the inferior vena cava occurs in approximately 3% of ruptured AAAs.1, 3 Aneurysm due to such

CASE REPORT

A 76-year-old man with a history of tobacco use and bronchiectasis was well until 4 days before admission, when he began experiencing shortness of breath and fatigue. He presented to the emergency department with the following vital signs: blood pressure, 125/54 mm Hg; pulse, 102; respirations, 22; and temperature, 36.3°C. Physical findings included jugular venous distention, scattered wheezes on pulmonary examination, and bipedal pitting edema.

New-onset congestive heart failure was initially

DISCUSSION

Most AAAs resulting in an aortocaval fistula are quite large, with an average diameter of 9 cm.7 The formation of an aortocaval fistula has been attributed to periaortic inflammation, adherence of adjacent vessels, and pressure necrosis of the vascular wall combining to cause an arteriovenous communication. Presenting signs and symptoms are manifestations of a large shunt from the high-resistance arterial circuit into the lower-resistance, high-capacitance venous circuit. The physiologic

SUMMARY

Aortocaval fistulas are uncommon. Physical findings can be nonspecific, but the symptom complex of high-output cardiac failure, a continuous abdominal bruit, renal insufficiency, and distended superficial veins over the abdomen or lower extremities allows a clinical diagnosis to be made. An aortocaval fistula also should be suspected in patients with known AAA who present with hematuria or rectal bleeding. A heightened awareness of aortocaval fistulas that leads to prompt diagnosis and

References (13)

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  • Delayed Endovascular Aneurysm Repair for Aorto-caval Fistula with Correction of Physiologic and Metabolic Abnormalities: A Disease Process Review

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    When performed traditionally, the surgical strategy is to gain proximal and distal control of the aorta, open the aneurysm sac, control massive venous bleeding with direct pressure using sponge sticks, oversew lumbar arteries, followed by oversewing the fistula from within the aneurysm sac. While oversewing the fistula and maintaining hemostasis care needs to be taken to avoid embolizing debris into the fistula6 or creating air embolism. The use of Trendelenburg positioning can be considered to help prevent proximal air embolism.

  • Aortic emergencies

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  • Aortocaval fistula in ruptured aneurysms

    1999, European Journal of Vascular and Endovascular Surgery
  • Evidence-Based Physical Diagnosis, Fourth Edition

    2017, Evidence-Based Physical Diagnosis, Fourth Edition
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From the Department of Internal Medicine, University of California at Los Angeles and Southern California/Permanente Medical Group*; and the Department of Surgery, University of Southern California School of Medicine.

☆☆

Address for reprints: Darryl Potyk, MD, FACP, Internal Medicine Spokane, 101 West 8th Avenue, PO Box 2555, Spokane, Washington 99220-2555

Reprint no. 47/1/62587

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