Retroaortic left renal vein is a malformation in which the left renal vein courses dorsal to the abdominal aorta. In patients with abdominal aortic aneurysm, an aorto-left renal vein fistula can form if the left renal vein is sandwiched between the aneurysm wall and lumbar vertebrae. The patient was an 84-year-old man with lower back pain. We performed a contrast-enhanced computed tomography (CT), although renal dysfunction was noted. The CT showed a ruptured juxta-renal abdominal aortic with aorto-left renal vein fistula. This clinical condition can cause severe renal dysfunction, in spite of which an enhanced contrasted CT scan would be extremely informative preoperatively.
aorto-left renal vein fistula; abdominal aneurysm; retroaortic left renal vein
Patient: Male, 76
Final Diagnosis: Aorto-enteric fistula
Symptoms: Abdominal pain • bloody vomiting • shock
Clinical Procedure: CT abdomen with contrast
Specialty: Gastroenterology • vascular surgery
Primary Aorto-Enteric Fistula (PAEF) is a unique and rare life threatening communication between the Aorta and Gastrointestinal Tract with an unusually high mortality rate and delayed diagnosis. Aortic abdominal aneurysms are implicated in a vast majority of cases while cancer as an etiology of PAEF is extremely rare.
We present the first case report of a PAEF secondary to Large B-Cell Lymphoma, followed by a review of literature in regards to malignant aorto-enteric fistulae.
We conclude that physicians should maintain a high index of suspicion for PAEF in any patient with unexplained anemia and history of aortic abdominal aneurysm complicated by cancer.
gastrointestinal hemmorage; aortoenteric fistula; lymphoma
Spontaneous rupture of an abdominal aortic aneurysm into a retroaortic left renal vein is an uncommon occurrence. A 55-year-old woman presented with shortness of breath, vomiting, and diffuse abdominal pain that had radiated to her back and legs for the preceding 10 days. A pulsatile abdominal mass, hematuria, renal insufficiency, and heart failure were present at the initial evaluation. Computed tomography showed an infrarenal abdominal aortic aneurysm that communicated with a retroaortic left renal vein. After urgent surgical repair, cardiac and renal function were dramatically improved. To the best of our knowledge, this is the 1st reported case of a woman with such a fistula. We review treatments reported in the literature.
Aortic aneurysm, abdominal/complications; arteriovenous fistula/diagnosis/etiology/surgery; renal veins/abnormalities; rupture, spontaneous; tomography, X-ray computed
Spontaneous aortocaval fistula is a rare complication of abdominal aortic aneurysms. We describe two cases of spontaneous aortocaval fistula. The first patient is a woman who was admitted with abdominal pain and pulsatile abdominal mass. Another patient was a man admitted with progressive abdominal pain and hypotension. Computed tomography (CT) scan in both patients showed an infrarenal aortic aneurysm and simultaneous contrast enhancement in the inferior vena cava. Both patients underwent an urgent laparotomy in which the diagnosis of an aortocaval fistula was confirmed. We review the literature on spontaneous aortocaval fistula as a consequenceof complicated aortic aneurysms.
Spontaneous; Aortocaval fistula; Abdominal aortic aneurysm; Iran
Acute occlusion of an abdominal aortic aneurysm is a rare phenomenon. Its possible complications include distal spasm followed by arterial thrombosis, ischemia of the distal limbs, distal embolization, acidosis, hyperkalemia, and the development of venous thrombosis of the lower limbs. Surgical correction is often complicated by cardiac decompensation, renal failure, fatal pulmonary embolism, and metabolic derangements related to toxins released from the revascularized limb. Unless contraindicated, immediate systemic heparinization must be undertaken when the diagnosis is first suspected.
We present a case of sudden occlusion of an abdominal aortic aneurysm complicated by venous thrombosis involving both lower extremities. After undergoing surgical revascularization, the patient sustained massive fatal pulmonary emboli. Prophylactic interruption of the inferior vena cava may be indicated in patients who present with this complication of abdominal aortic aneurysm.
Spontaneous rupture of abdominal aortic aneurysm into the inferior vena cava is rare and is associated with high mortality and morbidity. The clinical presentation can be variable and thus the diagnosis can be difficult. It can present with symptoms and signs of an abdominal emergency, venous hypertension, or systemic hypoperfusion. The traditional method of repair has been open surgery which is associated with high rate of complications. We report a case of aortocaval fistula (ACF) presenting with acute renal failure and heart failure, which was treated successfully with a novel, endovascular approach.
The renal veins drain the kidney into the inferior vena cava and unite in a variable fashion to form the renal vein. The left renal vein is normally located in front of the aorta. However, the retro-aortic renal vein may course posterior to the aorta due to embryological developmental anomalies. During educational dissection, a rare variation of the left renal vein was found in a 66-year old male cadaver. The double retro-aortic renal veins coursed behind the aorta to drain into the inferior vena cava. The superior retro-aortic renal vein drained into the inferior vena cava at the lower border of the L2 vertebra, and the inferior retro-aortic renal vein drained into the inferior vena cava at the upper border of the L4 vertebra. Such a variant is rare, and is a clinically important observation which should be noted by vascular surgeons, oncologists, and traumatologists.
Renal veins; Variation; Retro-aortic
Abnormalities of the inferior vena cava (IVC) and renal veins are extremely rare. However, with the increasing use of computed tomography (CT), these anomalies are more frequently diagnosed. The majority of venous anomalies are asymptomatic and they include left sided IVC, duplicated IVC, absent IVC as well as retro-aortic and circumaortic renal veins. The embryological development of the IVC is complex and involves the development and regression of three sets of paired veins. During renal surgery, undiagnosed venous anomalies may lead to major complications. There may be significant hemorrhage or damage to vascular structures. In addition, aberrant vessels may be mistaken for lymphadenopathy and may be biopsied. In this review we discuss the embryology of the IVC and the possible anomalies of IVC and its tributaries paying particular attention to diagnosis and implications for renal surgery.
inferior vena cava; renal veins; venous anomalies
Abdominal aortic mural thrombus is uncommon in the absence of aneurysm or atherosclerosis.
We report the case of a 46-year-old man who presented to our institution with perforated appendicitis for which he initially declined surgery. Four days after admission he ultimately consented to appendectomy and abdominal washout. Follow-up imaging to evaluate for intra-abdominal abscess revealed mural thrombus of the infra-renal abdominal aorta extending into the left iliac artery. This thrombus was not present on the admission CT scan. The patient had no clinical signs of limb ischemia. Conservative treatment with therapeutic anticoagulation resulted in resolution of the thrombus.
While portal, mesenteric, and major retroperitoneal venous thrombosis are well associated with major intra-abdominal infection and inflammatory bowel disease, aorto-iliac arterial thrombus formation in the absence of associated aneurysm, atherosclerosis or embolic source is exceedingly rare. We are unaware of other reports of in-situ aorto-iliac arterial thrombus formation secondary to perforated appendicitis.
aorta; thrombosis; abdominal abscess
Six cases of acute aortocaval fistula are reported, which illustrate the difficulties of diagnosis and management in a rare life-threatening condition. Five cases arose from spontaneous rupture of aortic aneurysms and one from trauma. In four cases the diagnosis was made before surgery. Useful diagnostic features included inappropriate jugular venous distension in five patients, lower abdominal and trunk cyanosis in three patients and a palpable thrill in three patients. Preoperative diagnosis permitted attempts to control venous haemorrhage in three cases, one by balloons through the aortic sac and two by transvenous positioning of balloon catheters in the vena cava before aortic opening. The use of transvenous balloon catheters was found to be helpful in reducing haemorrhage. Four patients left hospital alive. Preoperative recognition of the signs of an acute aortocaval rupture and preliminary balloon tamponade appear to be valuable in the management of acute aortocaval fistulas.
A case of asymptomatic right gastroepiploic artery and vein aneurysms with an arteriovenous (AV) fistula coexisting with an abdominal aortic aneurysm (AAA) is presented. A 68-year-old man was referred for treatment of AAA (6 cm in diameter) and he was incidentally diagnosed as having right gastroepiploic artery and venous aneurysms (3 cm and 8 cm in diameter, respectively) with an AV fistula. Resection of the aneurysms and closure of the fistula were successfully completed with AAA repair. He had a history of gastrectomy, and these gastroepiploic aneurysms with an AV fistula were considered a late complication due to mass ligation of vessels during gastrectomy.
gastroepiploic artery aneurysm; gastroepiploic venous aneurysm; arteriovenous fistula
Although endovascular transcatheter embolization of arteriovenous fistulas is minimally invasive, the torrential flow prevailing within a fistula implies the risk of migration of the deployed embolization devices into the downstream venous and pulmonary circulation. We present the endovascular treatment of a giant postnephrectomy arteriovenous fistula between the right renal pedicle and the residual renal vein in a 63-year-old man.
The purpose of this case report is to demonstrate that the Amplatzer vascular plug (AVP) can be safely positioned to embolize even relatively large arteriovenous fistulas (AVFs). Secondly, we illustrate that this occluder can even be introduced to the fistula via a transvenous catheter in cases where it is initially not possible to advance the deployment-catheter through a tortuous feeder artery. Migration of the vascular plug was ruled out at follow-up 4 months subsequently to the intervention.
Thus, the Amplatzer vascular plug and the arteriovenous through-and-through guide wire access with subsequent transvenous deployment should be considered in similar cases.
arteriovenous fistula; AV-fistula; nephrectomy; embolisation; endovascular treatment; arteriovenous access; through-and-through; transvenous access; Amplatzer vascular plug
Final Diagnosis: Dural arterio-venous fistula
Symptoms: Eye redness • post-trauma headache • tinnitus
Clinical Procedure: Fistula embolization
Mistake in diagnosis
A dural arteriovenous fistula (DAVF), is an abnormal direct connection (fistula) between a meningeal artery and a meningeal vein or dural venous sinus. The pathogenesis of DAVF still remains unclear. Sinus thrombosis, head trauma, chronic central nervous system, hypercoagulable state, surgery, and hormonal influence are the pre-disposing factors that initiate this disease. The symptoms experienced by the patient will depend on the location of the fistula.
Thirty-two year old Hispanic male who presented one day after a rear ended motor vehicle collision (MVC) with a severe throbbing headache in the left parietal region, left eye redness but no retro-orbital pain and tinnitus in the left ear. He was initially misdiagnosed to have a carotid-cavernous fistula but upon cerebral angiogram was actually diagnosed with a dural arterio-venous fistula in the posterior fossa venous system followed by successful embolization of the fistula.
A cerebral angiography is the gold standard for detection and characterization of a DAVF and will distinguish it from a CCF. Endovascular surgery involves a catheter-based technique for embolization of the lumen of arteries feeding the DAVF, or directly into the vein draining the DAVF. It is very important to recognize the typical findings of patients presenting with a DAVF then quickly proceeding with a cerebral angiogram to determine the exact location of the fistula and the appropriate treatment plan. By diagnosing and treating a DAVF as early as possible, the associated fatal complications can be averted.
dural arteriovenous fistula; cerebral angiography; endovascular embolization; trauma
An aortoenteric fistula is a communication between the aorta and an adjacent loop of the bowel. Here we report a case with this rare complication with typical herald bleeding.
A 66-year-old man underwent elective repair of a large supra-renal abdominal aortic aneurysm and returned 6 months later to our clinic after experiencing a melena with hematochezia. The source of bleeding could not be identified by gastroscopy but the following day he vomited a large volume of blood, rapidly became haemodynamically unstable and died of hypotensive shock. A CT scan on the same day showed an increasing area of low-density soft tissue around the graft wall compared with the previous CT scan images obtained initially after the aortic repair. An aortoenteric fistula was confirmed by autopsy.
In patients that underwent abdominal aortic surgery, both the occurrence of herald bleeding and CT findings of increasing para graft soft tissue might play a crucial role in early detection of aortoenteric fistula.
Arteriovenous fistula between major abdominal vessels is an uncommon occurrence. It most frequently occurs between the aorta and the inferior vena cava; however, when occurring between the other arteries and veins, it is much rarer and has usually been secondary to surgical trauma or penetrating wounds.
This is the report of an unusual case of an arteriovenous fistula, secondary to erosion of an atherosclerotic left iliac artery aneurysm into the left iliac vein.
Extrinsic oesophageal compression leading to dysphagia is a recognised but uncommon sole presentation of thoracic aortic aneurysms. This has been referred to as Dysphagia Aortica, and is a late presentation of large thoracic aneurysms, or a symptom of impending aorto-oesophageal fistula. We present the case of a 67 year old woman who presented repeatedly with dysphagia and weight loss over a 3 month period to specialists in three different disciplines. Eventually, a type II thoraco-abdominal aortic aneurysm causing extrinsic compression of the oesophagus was discovered. When dealing with patients who present with dysphagia, if no other cause is discovered, a thoracic aortic aneurysm should form part of the differential diagnosis, as this is potentially curable, and delays in diagnosis and treatment predispose to rupture and death.
Aorto-duodenal fistulae (ADF) are the most frequent aorto-enteric fistulae (80%), presenting with upper gastrointestinal bleeding. We report the first case of a man with a secondary aorto-duodenal fistula presenting with a history of persistent occlusive syndrome. A 59-year old man who underwent an aortic-bi-femoral bypass 5 years ago, presented with dyspepsia and biliary vomiting. Computed tomography scan showed in the third duodenal segment the presence of inflammatory tissue with air bubbles between the duodenum and prosthesis, adherent to the duodenum. The patient was submitted to surgery, during which the prosthesis was detached from the duodenum, the intestine failed to close and a gastrojejunal anastomosis was performed. The post-operative course was simple, secondary ADF was a complication (0.3%-2%) of aortic surgery. Mechanical erosion of the prosthetic material into the bowel was due to the lack of interposed retroperitoneal tissue or the excessive pulsation of redundantly placed grafts or septic procedures. The third or fourth duodenal segment was most frequently involved. Diagnosis of ADF was difficult. Surgical treatment is always recommended by explorative laparotomy. ADF must be suspected whenever a patient with aortic prosthesis has digestive bleeding or unexplained obstructive syndrome. Rarely the clinical picture of ADF is subtle presenting as an obstructive syndrome and in these cases the principal goal is to effectively relieve the mechanical bowel obstruction.
Aorto-duodenal fistula; Surgery; Dyspepsia; Duodenotomy; Explorative laparotomy
Historically, open surgical repair of thoracoabdominal aortic aneurysms has been associated with high morbidity and mortality rates. Furthermore, endovascular exclusion alone can restrict blood flow to visceral arteries. We report a case of thoracoabdominal aortic aneurysm that was repaired using a hybrid approach: surgery followed by an endovascular procedure. A 53-year-old woman was admitted to our hospital for endovascular exclusion of a thoracoabdominal aortic aneurysm that included the superior mesenteric artery and the celiac artery. Aorto–mesenteric and aorto–celiac artery bypass grafting was performed to create a landing zone for subsequent endovascular exclusion of the aneurysm, which was completed successfully 6 weeks after the bypass procedure.
For thoracoabdominal aortic aneurysms that extend beyond the superior mesenteric artery and the celiac or renal arteries, a hybrid approach, consisting of limited surgical treatment followed by endovascular exclusion of the aneurysm, may yield optimal results in selected patients with serious preoperative comorbidities.
Aortic aneurysm, abdominal; aortic aneurysm, thoracic; blood vessel prosthesis implantation; stents
To remark the feasibility of endovascular treatment of an aorto-caval fistula in a old high risk patient with “hostile” abdomen for previous surgeries.
In September 2009 a 81-years-old patient was admitted in emergency at our department because of abdominal pain and massive oedema of the lower extremities associated to dyspnoea (New York Heart Association (NYHA) functional class III). A CT scan showed an aorto-caval fistula involving the abdominal aorta below the renal arteries. This abnormal communication was likely due to the previous abdominal surgeries, was complicated by occlusion of the inferior vena cava at the diaphragm and was responsible for the massive oedema of the lower extremities. Because of unstable conditions and hostile abdomen the patient was considered unfit for conventional surgery and an endovascular approach was planned. After unsuccessful attempt by positioning of an Amplatzer vascular ring into the fistula, a Medtronic covered stent-grafts were implanted from the renal arteries to the both common iliac arteries. The patient had an impressive improvement characterized by a 18 Kg weight loss and a complete restoration of the functional capacity (from NYHA class III to NYHA class I) associated to a complete resolution of the lower extremities oedema as confirmed at the a month-CT-scan.
Endovascular surgery of aorto-caval fistula represents a good option in alternative to conventional surgery mostly in old high risk patient.
Deep Vein Thrombosis (DVT) is an important cause of morbidity and is the first cause of maternal death after delivery in Western Nations. The risk of venous thromboembolism is present throughout the pregnancy and is maximal during postpartum, especially after twin delivery. Many of the signs and symptoms of DVT overlap those of a normal pregnancy causing difficulty for diagnosis.
We report the case of a 33 year-old woman transferred to our Department one week after caesarean section for twin delivery. She presented with severe abdominal pain, fever, abdominal distension and shortness of breath. She had no personal or family history of thromboembolism. Computerized Tomography Scan revealed right ovarian vein thrombosis, left renal vein thrombosis extending up to the Inferior Vena Cava and pulmonary embolism with bilateral pleural effusion. Caval filter was positioned and anticoagulation therapy associated with antibiotics was instituted. Pancreatitis showed up two days after and was promptly treated. Three months after discharge the caval filter was removed and oral anticoagulation was stopped. During a 12-months follow-up, she remained stable and symptom free.
Ovarian vein thrombosis is rare but recognition of signs and symptoms is fundamental to start adequate therapy and avoid potential serious sequelae. The risk for maternal postpartum ovarian vein thrombosis is increased by caesarean section delivery of twins. Such patients should be closely monitored. We illustrated how an underestimated condition can lead to massive complications.
Twin delivery; Postpartum ovarian vein thrombosis; Pulmonary emboli
Arteriovenous fistulas are widely used for hemodialysis patients with end-stage renal failure. Due to the lack of suitable veins because of the arteriovenous fistulas previously opened in the upper extremity, alternative access routes are being tested. Few complications of long-term alternative arteriovenous fistulas have been reported in the literature. We report the results of surgical repairs of aneurysms that occurred on anterior tibial-saphenous arteriovenous fistulas (along the vein) in patients with end-stage renal disease after 5 years on hemodialysis.
vascular access; aneurysm; saphena magna; renal failure; long term
Arterioportal fistula (APF) is a rare cause of portal hypertension and may lead to death. APF can be congenital, post-traumatic, iatrogenic (transhepatic intervention or biopsy) or related to ruptured hepatic artery aneurysms. Congenital APF is a rare condition even in children. In this case report, we describe a 73-year-old woman diagnosed as APF by ultrasonography, computed tomography, and hepatic artery selective arteriography. The fistula was embolized twice but failed, and she still suffered from alimentary tract hemorrhage. Then, selective arteriography of the hepatic artery was performed again and venae coronaria ventriculi and short gastric vein were embolized. During the 2-year follow-up, the patient remained asymptomatic. We therefore argue that embolization of venae coronaria ventriculi and short gastric vein may be an effective treatment modality for intrahepatic APF with severe upper gastrointestinal bleeding.
Congenital intrahepatic arterioportal fistula; Liver; Embolization; Portal hypertension; Angiography
Aorto-atrial fistulas (AAF) are rare but important pathophysiologic conditions of the aorta and have varied presentations such as acute pulmonary edema, chronic heart failure and incidental detection of the fistula. A variety of mechanisms such as aortic dissection, endocarditis with pseudoaneurysm formation, post surgical scenarios or trauma may precipitate the fistula formation. With increasing survival of patients, particularly following complex aortic reconstructive surgeries and redo valve surgeries, recognition of this complication, its clinical features and echocardiographic diagnosis is important. Since physical exam in this condition may be misleading, echocardiography serves as the cornerstone for diagnosis. The case below illustrates aorto-left atrial fistula formation following redo aortic valve surgery with slowly progressive symptoms of heart failure. A brief review of the existing literature of this entity is presented including emphasis on echocardiographic diagnosis and treatment.
Primary aortoenteric fistula is a rare clinical situation with a high mortality rate. One should suspect that condition when an abdominal aortic aneurysm is known to be present. We describe the case of a 60 year old man who presented with upper gastrointestinal bleeding as the first and sole manifestation of an abdominal aortic aneurysm, due to the rupture of the aneurysm in the jejunum.
PRESENTATION OF CASE
The patient was admitted with hematemesis and melena. He reported no abdominal pain. Upper gastrointestinal endoscopy disclosed no bleeding or lesions of the stomach and duodenum. Bleeding stopped the following day, only to recur 4 days later. The patient was then subjected to abdominal CT scan, which revealed the presence of a subrenal aortic aneurysm, with fistulization to the small intestine. At laparotomy the aortic aneurysm was adherent to the first centimeters of jejunum. The diseased aorta was excised and replaced with a Dacron Y graft in situ.
Primary aortojejunal fistulas are only rarely encountered. They usually are the result of a nonspecific aneurysm of the abdominal aorta. They usually manifest with premonitory bleeding, followed by catastrophic hemorrhage few days later. Even with surgery the mortality rate is high.
Diagnosis of primary aortoenteric fistula requires a high index of suspicion in cases of upper gastrointestinal bleeding, especially when endoscopy is negative and there is no knowledge of the existence of an abdominal aortic aneurysm. CT scan and prompt surgery are crucial to the survival of these patients.
Aortojejunal fistula; Primary; Abdominal aneurysm; Left thoracotomy; Abdominal aneurysm repair
A 61 year old patient was found to have an aneurysm extending from the aortic root to the suprarenal region. He underwent first stage surgery with aortic root and arch replacement, prosthetic aortic valve replacement, and coronary artery bypass grafting. Four weeks later, he presented with breathlessness and signs of heart failure and pleural effusion. Computed tomography showed that the left atrium was compressed between the aortic aneurysm posteriorly and the left ventricle and sternum anteriorly. Obstruction of the superior vena cava, bronchus, oesophagus, and rarely right atrium by an aortic aneurysm has been described before but presentation with left atrial compression has not been reported.
thoracic aneurysm; heart failure; left atrial compression