Abdominal Aortic Aneurysm SAC Embolization Passing Through an Aortocaval Fistula

Introduction

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA), involving less than 1% of all AAA and about 3% of ruptured aortic aneurysms.

The conventional management of aortocaval fistula involved an open surgical approach, burdened by high mortality rates, while the endovascular repair has progressively become the mainstay of the vascular treatment.

Case Report

A 73-year-old male patient presented to the emergency room with acute respiratory failure and signs of heart failure. A computed tomography angiography (CTA) demonstrated the presence of a 10 cm AAA, with a spontaneous rupture into the adjacent inferior vena cava (IVC). A bifurcated aortic endograft was therefore successfully deployed to exclude the ruptured AAA, with an immediate resolution of symptoms and an improvement in hemodynamic parameters. Nevertheless, a type IA endoleak was detected at a post-operative control CTA: its perfusion was sustained by communication with the IVC. A secondary intervention was deemed necessary, including both the proximal sealing fixation and the fistula closure. The aneurysmal sac was embolized with coils passing through the ACF, then, after performing the Intravascular Lithotripsy (IVL) of the right iliac axis, the Heli-FX EndoAnchor ® system was advanced and used to fix the proximal sealing zone, with a good angiographic and long-term, post-operative result.

Conclusion

The endovascular treatment of ruptured AAA with ACF has proven to have lower morbidity and mortality than the surgical treatment. Numerous endovascular treatments have been used to treat aortocaval fistula: in the present case, the choice was dictated by the need to occlude the aneurysmal sac and to seal the type Ia endoleak in the same intervention. The combination of the aneurysmal sac embolization passing through the IVC and the Heli-FX EndoAnchor ® system seems to be a safe alternative in ruptured AAA with ACF.