CASE REPORT
I lia c a n e u r ysm a ssocia t e d w it h a r t e r iove n ou s fist u la
D a n ie l M e n de s Pin t oI; Le on a r do Gh iz on i Be zI; José Olim pio D ia s Jú n iorI I; Ca e t a n o de Sou sa Lope sI; Ar i M a n dilI I I
IVascular surgeons, Hospit al Felício Rocho, Belo Hor izont e, MG, Brazil. I ICardiologist and vascular ult r asonogr aphy, Belo Hor izont e, MG, Brazil.
I I II nt ervent ionist cardiologist , Hospit al Felício Rocho, Belo Horizont e, MG, Brazil.
Correspondence
J Vasc Bras. 2007; 6( 3) : 297- 300.
ABSTRACT
Rupt ure of aor t oiliac aneur ysm s int o t he iliac vein or vena cava is an uncom m on com plicat ion. Many signs and sym pt om s develop as a result of venous hypert ension, w hich m akes preoperat ive diagnosis difficult , such as leg edem a, dyspnea, hem at ur ia, signs of renal or cardiac insufficiency. Abdom inal bruit , associat ed w it h pulsat ile m ass and abdom inal pain, is t he key for clinical
diagnosis. Pr eoper at ive r ecognit ion of art eriovenous fist ula is im port ant for sur gical planning. We report a case of r ight int ernal and com m on iliac art ery aneurysm associat ed w it h fist ula int o t he com m on iliac vein. I nit ial sym pt om s w er e r ight leg edem a and dyspnea, w hich induced t o t he incorrect diagnosis of deep vein t hr om bosis.
Ke yw or ds:I liac aneur ysm , art eriovenous fist ula, r upt ur ed aneurysm .
RESUM O
Pa la vr a s- ch a ve : Aneur ism a ilíaco, físt ula art eriovenosa, aneur ism a r ot o.
I n t r odu ct ion
Spont aneous r upt ur e of aort oiliac aneur ysm s int o iliac veins or vena cava is a r ar e com plicat ion, found in less t han 1% of cases subm it t ed t o surgery.1 , 2 We report a case of of com m on iliac and right int ernal art ery aneurysm w it h fist ula int o t he com m on iliac vein, w hose init ial pr esent at ion w as right low er lim b ( RLL) edem a and dyspnea, causing diagnost ic confusion w it h deep venous t hr om bosis and pulm onar y em bolism .
Ca se r e por t
A 75- year - old pat ient had sudden edem a of t he r ight low er lim b ( RLL) and dyspnea. Alt hough Doppler ult rasound did not reveal signs of venous t hrom bosis, ant icoagulat ion t her apy w as st art ed, due t o suspicion of pulm onar y em bolism . Dur ing out pat ient cont r ol, abdom inal m ur m ur and t hr ill and absence of r ight fem or al pulse w er e diagnosed. An abdom inal ult r asound show ed r ight iliac art ery aneurysm m easur ing 8 cm in diam et er , w hen t he pat ient w as t hen r efer r ed t o a vascular surgeon.
Oral ant icoagulant s w er e suspended, and abdom inal angiogr aphic t om ogr aphy show ed r ight com m on and int er nal iliac art ery aneurysm and sim ult aneous cont rast of t he infer ior vena cava ( Figure 1) . An art erial Doppler exam inat ion of t he RLL revealed r ever se diast olic flow of large am plit ude and dist al flow w it h r educed syst olic velocit ies. Due t o a w ide com m unicat ion bet w een t he aneur ysm and t he venous syst em , abdom inal ar t er iogr aphy did not reveal t he fist ula sit e adequat ely.
There w er e no post operat ive com plicat ions. Six m ont hs lat er, t he pat ient had no dyspnea and present ed palpable t ibial pulses.
D iscu ssion
The art eriovenous fist ula ( AVF) t hat occurs w it h aor t oiliac aneur ysm s is a clinical ent it y described in series of cases in t he lit erat ure, w it h incidence bet w een 0.2 and 2.22% in all infr ar enal aneur ysm s subm it t ed t o surgery,3 and m ay reach 6% am ong r upt ur ed aneur ysm s.2 Besides at her oscler ot ic
aneurysm s, w hich r epr esent t he m aj or it y, ot her causes are syphilit ic, m ycot ic aneur ysm s
secondary t o Mar fan's syndr om e, Ehler s- Danlos syndrom e, Takayasu ar t er it is,4 - 7 aft er surgery for
her niat ed lum bar disc8 and secondar y t o abdom inal penet r at ing or , m or e rarely, blunt t r aum as.9 , 1 0
Many ser ies including a sm all num ber of cases report diagnost ic difficult y. Com m unicat ions
bet w een t he aort a and vena cava account for m ost cases. Few approach ilio- iliac fist ulas.1 1 Davis et al.1 2 r epor t ed only five cases of ilio- iliac fist ulas along 18 cases subm it t ed t o surgery for 27 years.
I n a review art icle, Bonam igo described t he im por t ance of diagnosing AVF associat ed w it h aneurysm and m ent ioned t w o cases t r eat ed w it h pr esence of r upt ur e.1 3
funct ion. I n a r ecent review of 12 cases of independent iliac aneurysm s, Carvalho et al. report ed t hat 83% had unspecific abdom inal pain.1 4 The classical diagnost ic t riad of aneur ysm associat ed
w it h AVF is abdom inal pain, pulsat ile m ass and abdom inal m ur m ur . Abdom inal m ur m ur is t he m ost com m on sign, but it can be m issing due t o pr esence of t hrom bi in t he aneur ysm al sac next t o t he fist ula.1 5
Congest ive cardiac insufficiency is descr ibed bet w een 11.5 and 28% of cases.1 6 I ncreased venous
pressure and com pr ession of adj acent veins lead t o low er lim b edem a. As a consequence of venous hypert ension, t her e m ay be hem at ur ia, r enal insufficiency, scr ot al edem a and r ect al bleeding.1 7
Rupt ure of aor t ic aneur ysm int o t he vena cava has clear sym pt om s of abdom inal pain, w hich leads t o a fast surgical t reat m ent . On t he ot her hand, r upt ur ed iliac aneur ysm s int o t he iliac- caval
syst em has few er sym pt om s; it is com m on for pat ient s t o r em ain w eeks or m ont hs w it hout being diagnosed unt il sur ger y.1 6
I n t he pr esent case, t he pat ient r em ained for 7 w eeks w it hout a definit ive diagnosis of AVF. I nit ial event w as RLL edem a w it h dyspnea. Episodes of dy spnea pr obably r esult ed fr om a t em porary cardiac decom pensat ion aft er physical effort s. Aft er t he sur ger y, episodes of dyspnea w er e discont inued.
Diagnosis w as confir m ed by im aging exam inat ions per for m ed t o invest igat e t he aneur ysm , especially angiogr aphic t om ogr aphy of t he abdom en. Cont rast can be seen in t he iliac veins or vena cava in t he ar t er ial st age ( Figur e 1) . Angiographic t om ography can som et im es reveal t he fist ula sit e, but usually t his inform at ion is obt ained from art eriography.1 8
I dent ifying aor t ocaval fist ula befor e surgery is ext r em ely im port ant for sur gical appr oach. Preoperat ive diagnosis ranges bet w een 17- 70% ( m ean of 34% ) am ong published ser ies.1 2
Perioperat ive m or t alit y is higher w hen AVF is not diagnosed.1 6 Of t he five deat hs r epor t ed by
Cinara et al. ( 19.5% of cases) , any had pr evious diagnosis of t he fist ula.1 1 Those aut hor s focus on t he fact t hat aneurysm r upt ur e int o t he vena cava or iliac vein has low er m or t alit y t han
ret roperit oneal, int r aper it oneal r upt ur e or int o int est inal loops, w hen diagnosed before t he surgery.
Usual t reat m ent is direct sut ur e of t he fist ula, aft er opening of t he aneurysm al sac, follow ed by aort oiliac reconst ruct ion. Ther e ar e r epor t s of ligat ion in t he com m on iliac vein. Ot her less com m on opt ions are use of graft pat ch and vena cava clipping.1 0 , 1 2
There are few report s of st ent- graft s used in t he t r eat m ent of aor t ocaval fist ulas. Nine cases of endovascular t reat m ent for at her oscler ot ic aneur ysm s associat ed w it h AVF have been
published.1 9 , 2 0 AVF can com plicat e endovascular t r eat m ent of aneur ysm s due t o ( 1) dissect ion of
t he com m on fem or al art ery is difficult due t o dilat ed super ficial veins w it h increased flow ; and ( 2) high AVF flow , w hich m akes visualizat ion of r enal art eries difficult .2 1 A hem odynam ic alt erat ion
described by Lau et al. w as sudden incr ease of per ipher al vascular r esist ance, caused by abr upt fall of cardiac out put aft er AVF occlusion w it h st ent- graft r elease.2 2 This leads t o har d- t o- cont rol
hypert ension. Such change is not com m on in open surgery due t o aort ic clam ping and bleeding.
I n conclusion, despit e t he low frequency of AVF in aort oiliac aneurysm s, a careful physical exam inat ion should r aise clinical suspicion. Abdom inal m urm ur is t he m ost com m on sign,
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