Open Surgery for Aortocaval Fistula (ACF) Associated with a Ruptured Abdominal Aortic Aneurysm with Concomitant Acute Heart Failure

Abstract

Aortocaval Fistula (ACF) is a rare complication of abdominal aortic aneurysm rupture. We report a case of ACF with concomitant acute heart failure. Case: A 49-year-old man was referred to our hospital for abdominal aortic aneurysm with exertional dyspnea. He did not have any abdominal symptoms, however, pulmonary congestion, pleural effusion and hepatic dysfunction were observed. Transthoracic echocardiography revealed normal functioning cardiac valves and normal left ventricular wall motion. Diagnosis of ACF was suspected at this point, thus, contrast-enhanced CT scan was obtained. It showed ACF caused by a rupture of abdominal aortic aneurysm. We performed emergent open surgical repair. There was no hematoma in the retroperitoneum. Fistula was found in a right side of aneurysmal wall. Through fistula, there was a massive retrograde venous bleeding coming from inferior vena cava. We tried to separate inferior vena cava from aneurysm, however, there was a tight adhesion in between. Fistula and wall of inferior vena cava were sutured jointly, and operation was completed successfully. His heart failure and liver function improved immediately after operation and postoperative course was uneventful. He was discharged on postoperative day 17. ACF is associated with high morbidity and high mortality due to preoperative organ failure. Although precise diagnosis of ACF is required, delayed diagnosis occurs occasionally because symptoms of ACF are often non-specific and variable. Diagnosis of ACF should be elicited in case of abdominal aortic aneurysm with concomitant symptoms of heart failure.