Endovascular Repair of an Aortocaval Fistula Following Penetrating Abdominal Trauma

Rashad Choudry, MD, Christopher Byrne, MD, Christine Trankiem, MD, Amy Goldberg, MD, John Blebea, MD and Krish Soundararajan, MD
Temple University, Philadelphia, PA

Objective(s): Aortocaval fistulas are rare, being typically associated with degenerative aortic aneurysms. Atraumatic etiology is much less common with endovascular repair seldom reported with only three such cases in the medical literature. Fistulas may be entirely asymptomatic or present with abdominal pain, bruit, persistent tachycardia, or heart failure. Repair is recommended when feasible.
Methods: A 47 year old man suffered multiple gunshot wounds to his left flank. He was emergently taken to the operating room where repair of the terminal ileum and anterior venorrhaphy of an inferior vena cava (IVC) tear was performed at the L4 level. Hemodynamic instability required abdominal packing, second-look laparotomy and delayed fascial closure 48 hours later. Physical examination revealed a mild tachycardia (105 bpm) and a mid-abdominal bruit. A fever of unknown origin on day 7 prompted a CT scan which demonstrated early filling of the IVC with intravenous contrast suggestive of a fistula. An abdominal duplex ultrasound revealed pulsatile flow within the IVC. Arteriography showed both an aortic pseudoaneurysm and aortocaval fistula above the aortic bifurcation. Upon resolution of fever and leukocytosis, the patient was taken to the operating room (day 16).
Results: An aortic stent graft (20 mm x 37.5 mm; Medtronic AneuRx) was deployed across the fistula and pseudoaneurysm orifice from the level of the inferior mesenteric artery to just above the aortic bifurcation. Immediate resolution of tachycardia (105 to 85 bpm - Branham’s sign) and elimination of the abdominal bruit was observed. A post-operative CT scan confirmed excellent graft position and the patient was discharged home without complications.
Conclusions: Correct diagnosis of an aorto-caval fistula may require multiple imaging modalities prior to therapy. Open aortic surgery may be hazardous in unstable patients or in those with a hostile abdomen. Endovascular repair allows for definitive treatment in a minimally invasive manner for post-traumatic vascular fistulas.