Spontaneous rupture or erosion of an abdominal aortic aneurysm into inferior vena cava (IVC) is the most common cause of aortocaval
fistula (ACF). In rare cases ACFs are the result of penetrating or iatrogenic trauma. We report a unique case of a 32-year old man with chronic
heart failure (CHF) with suspected dilated cardiomyopathy after previous myocarditis. Conservative treatment was not effective in reducing
clinical symptoms. The patient had an abdominal stab wound 1 year earlier. The diagnosis of ACF between the right common iliac artery (RCIA)
and IVC was confirmed by CT angiography. He successfully underwent surgical repair of his ACF with reduction of symptoms.
Aortocaval fistula (ACF) is a rare clinical entity characterized
by abnormal shunting of arterial blood into the venous system.
In most cases it occurs after perforation of an aortic aneurysm
into the veins (80-90%), while in 10-20% of the cases it develops
due to penetrating wounds of the abdomen, either traumatic
or iatrogenic . The clinical symptoms vary from totally
asymptomatic to severe heart failures which depend on the size
of ACF, diameter of artery and vein involved, the proximity to the
heart, the age of the patient, etc. . Usually, it requires surgical
closure by open or endovascular intervention..
A 32-year-old man had a history of surgical treatment due
to penetrating abdominal stab wounds in February 2014. He
noted mild dyspnea on exertion in June 2014, then mild leg
edema appeared in September 2014. An echo exam revealed
cardiomegaly with mild hydro pericardium at that time, and sub
acute myocarditis was suspected. However, despite treatment
severe deterioration of his exercise tolerance was observed and
leg edema worsened.
He was admitted to our Hospital in November 2015 with
shortness of breath on minimal exertion. The breath sounds were
diminished, but no rales were heard on auscultation. The patient
had regular rhythm with HR of 90bpm, BP of 130 and 80mm Hg
and with 18 respirations per minute. The abdomen was soft, but
enlarged due to ascites; the liver was also enlarged. Severe leg
edema was present. The remainder of the physical examination
showed no abnormalities.
ECG was normal. Echocardiography showed moderate LV
dilatation (LVED 67mm) with normal EF (LVEF 72%), dilatation
of the right ventricle (47mm), moderate pulmonary artery
hypertension with pulmonary artery systolic pressure (PASP) of
52mm Hg and severe tricuspid regurgitation. The inferior vena
cava diameter (IVC) was 51mm without any reaction on deep
The laboratory data showed marked hyperbilirubinemia
(55μmol/l), ALT (18U/l), AST (21U/l), increased BNP level up to
855pg/ml, minor proteinuria, while markers of viral hepatitis and
HIV were negative.
Abdominal drainage was performed with a daily evacuation
of up to 1500ml. Cardiac MRI revealed no pathological signals
or perfusion defects. Findings of abdominal CT, cytological
examination of ascetic fluid, and fibro colonoscopy were all
normal and that allowed us to exclude oncological causes of
ascites. Bearing in mind the history of the abdominal stab wound,
normal LVEF, and signs of heart failure, mainly due to the right
heart, examination of IVC was recommended. An aorto-caval
fistula (ACF) between the right common iliac artery (RCIA) and
IVC was revealed by CT angiography (Figure 1A & 1B). The patient
successfully underwent repair of his ACF with a synthetic patch to
close the defect of aorta and RCIA (Figure 1C & 1D).
Echocardiography showed significant reduction of IVC
(24mm), RV (38mm), tricuspid regurgitation (mild) and SPAP
(34mmHg) within a week postoperatively. CT angiography did
not reveal an ACF during the arterial contrast phase (Figure 1E).
The patch was visualized on the anterolateral wall of the RCIA and
aorta (Figure 1F).
Traumatic ACF is a life-threatening complication of
penetrating abdominal wounds. Most patients with ACF die at the
scene of injury. Mortality in the acute phase is around 40-45% due
to a combination of traumatic factors, the difficulty of getting the
vessel exposure during surgery and intra operative bleeding .
Those patients who successfully survive the acute period may
refer for help within months or even years after injury. Young
patients without cardiac diseases are more likely to adapt to those
hemodynamic changes that develop due to ACF. Our 32-year-old
patient showed symptoms and signs of congestive heart failure
and the development of cardiomegaly later on within roughly a
year after penetrating abdominal stab wounds.
The classic ACF triad includes abdominal pain, palpable
pulsatile abdominal mass and machinery-like abdominal bruit.
Small fistulas may be asymptomatic. Large ACFs are characterized
by left-right shunting, causing increased venous return and the
development of edema of the lower extremities, hepatomegaly,
ascites, portal hypertension and heart failure. Renal failure may
occur in some patients due to hypo perfusion of kidneys .
Among non-invasive techniques MRI or CT angiography are
considered as the gold standard for the imaging of ACFs and other
pathology of aorta . Timely surgical treatment, as a rule, leads
to the regression of clinical symptoms.
Svetlana Gudkova and Alia Tukhbatova collected data and
investigations. Svetlana Gudkova and Dmitry Duplyakov wrote
the manuscript. Sergey Khokhlunov supervised the whole work.
All authors were involved in the treatment of the patient and
contributed to the final manuscript.