Ruptured Aortic Aneurysm Complicated by Aortocaval Fistula due to Salmonella Infection

Treatment of Aortocaval Fistula Secondary to Abdominal Aortic Aneurysm: A Systematic Review

BACKGROUND

Aortocaval fistula (ACF) secondary to an abdominal aortic aneurysm is a rare complication, inadvertently caused by a rupture into the inferior vena cava. Different treatment modalities have been applied toward the repair of such lesions, including open surgical and endovascular repair. The aim of this study was to report on ACF treatment and to analyze its early and mid-term outcomes.

METHODS

A systematic search of the English medical literature published between 2000 and 2022 was undertaken, using PubMed, SCOPUS, and CENTRAL databases as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. A study protocol was registered in PROSPERO (CRD42022329058). Studies reporting on primary ACF outcomes following open surgical or endovascular repair were included. The ROBINS-I tool was applied for risk of bias assessment. Outcomes included technical success, 30-day and mid-term survival, endoleak following endovascular repair, and reintervention rates.

RESULTS

In total, 110 case studies, incorporating 196 patients (mean age; 66.2 years, males 96%) were included. Open surgical repair was applied in 78% (153/196). From the available data, technical success rate for each modality was 99% (152/153) and 100% (43/43), respectively. Open and endovascular repair demonstrated 87.5% (126/144) and 97.6% (42/43) 30-day survival, respectively, while mid-term survival was 86% (74/86) and 95.2% (20/21), respectively (medial follow-up: 14 months [1-54 months]). Endoleaks were reported in 19 endovascular cases (39.5%). Type II endoleak was the most frequent with a rate at 32.5% (14/43). Reintervention rates were 2.5% (4/151) and 35.7% (15/42) for open and endovascular repair, respectively.

CONCLUSIONS

Only few case studies were published on the treatment of this rare condition, while almost all invasive procedures were performed in males. Management of ACF repair with both open and endovascular approach was associated with excellent technical success rate and acceptable early and mid-term survival outcomes. Reintervention remained an issue for patients who were managed endovascularly.

Open Surgery and Endovascular Techniques in Treatment of Acute Abdominal Arteriovenous Fistulas

Acute abdominal arteriovenous fistulas in the setting of ruptured abdominal aortic aneurysms are a life-threatening condition; thus, a prompt diagnosis is required for proper treatment. Open, endovascular, and hybrid repair have been proposed for their management, with pros and cons for each method. In particular, the evolution of endoluminal techniques guarantees an increasing feasibility of these procedures, and a significant reduction in morbidity and mortality rates was usually associated with open surgery. Nevertheless, some concerns still remain regarding the midterm and long-term follow-up. The aim of this article was to review and compare the reported clinical and technical results of conventional open surgery and endoluminal techniques in this scenario and to report the case of an acute aorto-iliac fistula due to a ruptured common iliac artery aneurysm into the iliac vein that was managed by endovascular repair at our institution.

Aortocaval fistula: an unusual complication of ruptured abdominal aortic aneurysm

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm, which erodes into the wall of the inferior vena cava, resulting in the formation of a fistula. ACF presents with various inconsistent symptoms and signs. ACF can be a diagnostic dilemma if not suspected and it is lethal if left untreated.A 60-year-old man presented with abdominal and lower back pain of sudden onset. Renal and liver functions were impaired, without signs of cardiac failure. CT angiography revealed an abdominal aneurysm rupture into the inferior vena cava. Patient underwent a successful open repair: ACF ligation from within the aneurysmal sac and an aorto-bi-iliac bypass using a Dacron graft. Renal and liver functions improved and the patient was discharged on the eighth postoperative day. A month later, the patient was fit and well with normal liver and renal functions.Despite progress made in the endovascular treatment of ACF, complications still persist with a reported endoleak rate of 50%. Open repair is still a valid method for ACF repair in patients fit to undergo laparotomy and general anaesthesia. In this case, the patient was fit and along the lack of a suitable stent graft, the vascular team performed an open repair with good results.Open repair of an ACF is a valid treatment method for patients who are fit enough to undergo laparotomy and general anaesthesia, and avoids complications related to endovascular repair, such as endoleaks.

Mycotic aneurysm due to Salmonella species: clinical experiences and review of the literature

The mortality of patients with mycotic aneurysms is high, especially in East Asia, and infection by Salmonella species is the most common. Our study aimed to improve prognosis of adult mycotic aneurysms with early diagnosis and accurate treatment. Four adult patients with mycotic aneurysm caused by Salmonella were included and analyzed by single-center retrospective analysis. Cases reported in the literature during the past 10 years were also summarized. The average age of the 4 male patients was 61.25 years, while that of the 53 cases reported in the literature was 65.13 years. Hypertension, diabetes, and atherosclerosis were common complications. Most patients presented fever and experienced pain at the corresponding position of the aneurysm. Laboratory examination found an increased number of white blood cells accompanied by an increase in inflammatory markers. Most aneurysms were found in the abdominal aorta, while the rupture of an aneurysm was the most common complication. The mortality rates were 21.43 and 7.14% after open surgery or endovascular aneurysm repair (EVAR) intervention, respectively. The recurrence rates of infection were 0 and 17.85% for both treatments, respectively. The mortality rate of mycotic aneurysm caused by Salmonella infection was high in middle-aged males with hypertension, diabetes, and atherosclerosis. The possibility of a Salmonella-infected aneurysm should be considered in these high-risk groups presenting chills, fever, chest, and back pain. Open surgery was superior to EVAR treatment in the clearance of infected foci and the reduction of postoperative recurrence. The recurrence of postoperative infection can be prevented by intravenous antibiotic therapy for 6 weeks post-surgery.