Karoline Evelyn Barbosa Gomes et al. Eduardo Koltun Sanvesso Edwaldo Edner Joviliano Maurício Serra Ribeiro Elisa Helena Subtil Zampieri
Aortocaval fistula is a rare complication of aortic aneurysm, occurring in approximately 0.2% to 6.04% of all abdominal aortic aneurysms. It may occur in the context of aortic aneurysm rupture, aortitis, Ehlers-Danlos syndrome, Marfan syndrome, or penetrating abdominal trauma., The classic clinical signs are abdominal pain, abdominal thrill, and symptoms of decompensated heart failure. It is usually diagnosed via computed tomography angiography, and typical findings include early contrast enhancement of the inferior vena cava (prior to contrast of the renal and hepatic parenchyma) and retrograde enhancement of the renal or iliac veins. Open surgical treatment has high associated morbidity and mortality, with reported rates of approximately 30%. With the advent of endovascular therapy, these rates have been reduced, with success rates as high as 96%.
An 85-year-old male patient, with hypertension and history of tobacco use, was admitted to the emergency unit with a history of sudden onset of abdominal pain four days prior, associated with a pulsating abdominal mass in the hypogastric region. Tomography angiography of the total aorta was performed, showing a pararenal abdominal aortic aneurysm with a diameter of 11.5 cm, extending from the right renal artery to the aortic bifurcation, with signs of tamponade rupture into the retroperitoneum (), associated with an aortocaval fistula with a point of communication at the level of the iliac veins. In the tomography image, retrograde and early enhancement of the iliac veins was observed in the arterial phase ( and ). During clinical evaluation, the patient presented hemodynamic instability, and an emergency surgical procedure was indicated. Intraoperatively (), an aneurysm with signs of rupture was found, showing thrill on palpation. The patient evolved with refractory hypotension and died.
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