Abstract
An aortocaval fistula (ACF) is a rare complication of a ruptured aortic aneurysm that presents with various symptoms. High-output cardiac failure, one of the clinical presentations of ACF, has a high mortality rate. This study focused on circulatory management during anesthesia for endovascular aneurysm repair (EVAR) of an ACF associated with high-output cardiac failure. A 70-year-old man was transferred to our department for surgical treatment of an abdominal aortic aneurysm (AAA) with probable rupture. Ultrasound examination showed an infrarenal AAA ruptured into the inferior vena cava (IVC), thereby causing high-output cardiac failure with abnormal liver function parameters and enlargement of the right ventricle. His condition deteriorated so rapidly that emergent surgical treatment for the ACF was indicated. EVAR was chosen because it is less invasive than open surgery. Due to the patient's unstable hemodynamic state, general anesthesia was administered during the procedure, but induction of general anesthesia resulted in persistent hypotension that required large amounts of catecholamines. The EVAR was successfully completed without any catastrophic cardiac event. The hemodynamic instability improved immediately with deployment of a stent-graft in the aorta and exclusion of the communication with the IVC. It should be noted that resuscitative endovascular balloon occlusion of the aorta (REVOA), even though just a palliative treatment for ACF, effectively achieves hemodynamic stabilization in patients who fail to respond to inotropic agents.
