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

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 %), abdominaI/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.