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Novel endovascular approach of an aortocaval fistula complicating a AAA
BACKGROUND- Aortocaval fistula (ACF) is a rare complication (3-4%) of abdominal aortic aneurysm (AAA).
METHODS- We report a novel method of endovascular repair of a AAA rupture into the inferior vena cava.
RESULTS- A 54 year old man with abdominal and back pain abdomen was found to have a ruptured10 cm infrarenal AAA on computed tomography (CT). He was hemodynamically stable and a candidate for endovascular repair. Arteriogram revealed an AAA with extension to the right iliac artery, and an associated aortocaval fistula. Repair was undertaken with a bi-modular stent graft with selective embolization of the right internal iliac artery. Initial attempt at exclusion of the ACF were unsuccessful, however. Eight days postop follow up CT revealed an ongoing ACF. He was returned to the operating room, where a venogram through the femoral vein revealed ongoing ACF and aortogram through the femoral artery revealed a type 2 endoleak involving the inferior mesenteric artery (IMA). The IMA was cannulated by catheterizing the SMA and traversing a patent meandering artery and embolized with coils. Through a percutaneous approach through the IVC the aortic aneurysm sac was cannulated through the fistulous tract and embolized with multiple coils. Follow up angiogram revealed obliteration of the ACF and type IIa endoleak. At 14 months follow up the aneurysm sac remained stable with no evidence of ACF recurrence.
CONCLUSIONS- Endovascular treatment of ACF complicating ruptured AAA has been reported in case reports and small series. Long term follow-up and large series are lacking. Our case represents a unique endovascular approach to a rare complication of AAA.