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Management of Type II Endoleak after Endovascular Repair of Arteriocaval Fistula Complicating Aortoiliac Aneurysm: Case Report and Literature Review
BRIEF REPORT
Management of Type II Endoleak after Endovascular Repair of Arteriocaval Fistula Complicating Aortoiliac Aneurysm: Case Report and Literature Review Eisuke Ueshima, MD, Masato Yamaguchi, MD, PhD, Akhmadu Muradi, MD, Takuya Okada, MD, PhD, Koji Idoguchi, MD, Keitaro Sofue, MD, PhD, Yoshikatsu Nomura, MD, Yutaka Okita, MD, PhD, and Koji Sugimoto, MD, PhD
ABSTRACT Endovascular treatment for arteriocaval fistula (ACF) has become the preferred alternative to open repair. However, endoleaks sometimes occur and maintain the ACF. A 64-year-old man presented with persistent fistula after placement of a bifurcated stent-graft for ACF complicating an aortoiliac aneurysm that was maintained by endoleaks from the inferior mesenteric and lumbar arteries. Transarterial embolization of the aneurysm sac and inferior mesenteric artery successfully resolved the problem without any complications observed over 16 months of follow-up. A literature review and discussion of the management options for this entity are presented. A combination of inflow and outflow control is important to obtain better long-term outcomes.
ABBREVIATIONS ACF = arteriocaval fistula, EVAR = endovascular aneurysm repair, IMA = inferior mesenteric artery, IVC = inferior vena cava
An arteriocaval fistula (ACF) is an uncommon complication of an aortoiliac aneurysm; it can manifest with various symptoms leading to delayed diagnosis with subsequent poor outcomes. Conventional treatment is surgical repair, but this is associated with a high mortality rate (1,2). The evolution of endovascular aneurysm repair (EVAR) has offered a minimally invasive management option. However, endoleaks sometimes occur and maintain the ACF. Conservative management, open ligation, and several other techniques involving endovascular interventions have been reported as treatment options (2–14). In this article, a patient is described who presented with a persistent fistula despite successful From the Center for Endovascular Therapy (E.U., M.Y., A.M., T.O., K.I., Y.N., K.Su.), Kobe University Hospital, Kobe, Japan; Department of Radiology (E.U., M.Y., T.O., K.So., K.Su.) and Cardiovascular Division, Department of Surgery (Y.N., Y.O.), Kobe University Graduate School of Medicine, 7-5-2, Kusunokicho, Chuo-ku, Kobe, 650-0017, Japan; and Vascular and Endovascular Division, Department of Surgery (Y.N., Y.O.), Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia. Received March 11, 2014; final revision received and accepted June 23, 2014. Address correspondence to E.U.; E-mail: [email protected] None of the authors have identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1809–1815 http://dx.doi.org/10.1016/j.jvir.2014.06.021
EVAR for an aortocaval fistula complicating an abdominal aortic aneurysm secondary to a type II endoleak from the inferior mesenteric artery (IMA) and lumbar arteries. It was successfully treated with secondary coil embolization of the aneurysm sac and the IMA. Additionally, the possible management options reported in the literature are reviewed.
CASE REPORT The patient provided informed consent, and the study design was exempt from ethics review board approval. A 64-year-old man presented to the emergency department of a university hospital with acute dyspnea and general fatigue. The patient did not have a history of cardiac disease or chronic obstructive pulmonary disease. Physical examination revealed an alert patient with hypertension, tachycardia, tachypnea, hypoxia, and a pulsatile abdominal mass with abdominal bruit. Laboratory data showed no hepatic or kidney dysfunction. A chest radiograph showed cardiomegaly with a cardiothoracic ratio of 54% and slight pulmonary edema with a butterfly appearance in the perihilar region. Contrast-enhanced computed tomography (CT) showed an infrarenal abdominal aortic aneurysm (maximum diameter, 63 mm) with an aortocaval fistula anatomically
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suitable for EVAR (Fig 1). Because of the patient’s acute heart failure, emergent EVAR was performed. Aortography revealed the aneurysm, and a rapid flow of contrast material from the aorta into the dilated inferior vena cava (IVC) confirmed the diagnosis of aortocaval fistula (Fig 2a). An Excluder bifurcated stent graft (W. L. Gore & Associates, Flagstaff, Arizona) was used to perform exclusion. Although the final angiogram showed evidence of a type II endoleak from the lumbar arteries
Figure 1. Contrast-enhanced CT image shows an infrarenal abdominal aortic aneurysm, IVC dilatation, loss of the fat plane between the aorta and the IVC, and early equivalent contrast enhancement of the dilated IVC.
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(Fig 2b), it was a very slow-flowing endoleak, and no obvious flow into the IVC was observed; no further intervention was performed. The patient’s heart failure symptoms quickly disappeared after the procedure. On postoperative day 5, a contrast-enhanced CT scan demonstrated persistence of the aortocaval fistula secondary to a type II endoleak from the reconstituted IMA and lumbar arteries. To prevent long-term complications, an additional transarterial coil embolization was performed on postoperative day 9. We used a coaxial catheter system (4-F RC9 catheter; Medikit Co, Ltd, Tokyo, Japan; 2.0-F Parkway Soft microcatheter; Asahi Intecc Co, Ltd, Nagoya, Japan) via a 4-F sheath (Super Sheath; Medikit), which was inserted into the right common femoral artery. Selective superior mesenteric arteriography confirmed the persistent aortocaval fistula from the IMA, which was reconstituted by a patent Riolan arcade (Fig 3a). After advancing the tip of the microcatheter into the aneurysm sac via the Riolan arcade, sequential embolization of the sac and the IMA trunk was performed with a combination of detachable microcoils (Interlock Fibered IDC Occlusion System; Boston Scientific, Natick, Massachusetts) and pushable microcoils (Tornado; Cook, Inc, Bloomington, Indiana; Trufill, Cordis Corporation, Warren, New Jersey) (Fig 3b). Final angiography showed no evidence of endoleaks from the reconstituted IMA or the lumbar arteries (Fig 3b,c). The patient recovered well and was discharged 14 days after the initial procedure. At the 16-month follow-up examination, the patient remained asymptomatic, and a contrast-enhanced CT scan showed complete exclusion of the aneurysm, no endoleaks or fistula, and significant sac shrinkage (Fig 4a,b).
Figure 2. (a) Initial aortogram demonstrates an infrarenal abdominal aortic aneurysm (AAA) and a rapid venous return into the dilated IVC through an aortocaval fistula (arrow). (b) Final angiogram shows a type II endoleak from the third lumbar arteries (arrows) without obvious flow into the IVC.
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Figure 3. (a) Selective superior mesenteric artery angiogram shows a type II endoleak and a persistent aortocaval fistula (arrow) from the IMA reconstituted by a patent Riolan arcade. (b, c) Angiography performed after embolization of the aneurysm sac and IMA shows disappearance of the endoleak and aortocaval fistula.
Figure 4. (a, b) Preoperative and postoperative (at the 16-month follow-up) contrast-enhanced CT images show a significant decrease of the aneurysm sac diameter (dashed arrow, from 63 mm to 47 mm) and the disappearance of the endoleak and aortocaval fistula.
DISCUSSION An ACF is an uncommon complication of an aortoiliac aneurysm, accounting for 0.2%–6% of all aortoiliac aneurysms (2,5,7,9). The classic triad features (ie, low back pain, pulsatile abdominal mass, and abdominal bruit) may be absent in 50% of patients, leading to delayed diagnosis with subsequent poor outcomes (2,10,15). Physician awareness and preoperative recognition of the characteristic findings are essential. Multislice contrast-enhanced CT is the preferred diagnostic tool because it provides important information for planning before treatment (2). If patients are not treated, right-sided heart failure, renal and hepatic insufficiency, deep vein thrombosis, and
pulmonary embolism can occur (1,9,12,15). Emergent intervention saves patients’ lives and prevents irreversible organ failure. Conventional treatment is surgical repair, but it is associated with a high mortality rate of up to 67%, especially in the presence of cardiac decompensation during admission, additional ruptures in the retroperitoneal or intraperitoneal cavity, and missed preoperative diagnosis (9). Since it was first reported in 1998 (7), endovascular stent graft placement for ACFs complicating aortoiliac aneurysms, if anatomically suitable, has become the preferred alternative to open repair and has a high technical success rate of 96% (1). However, studies reporting long-term outcomes are lacking, and persistent ACFs secondary to endoleaks sometimes occurred during the follow-up period.
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Table . Review of Treatment Options for Type II Endoleaks after EVAR for Aortoiliac Aneurysms Associated with Arteriocaval Fistulas
(y) F/84
2013 (3)
Clinical Findings Lower extremity edema, AKI
Imaging IIA aneurysm, 7.5 cm; iliocaval fistula
EVAR Treatment IIA branches
Source of
Management of
Endoleak
Endoleak
Lumbar arteries
Conservative
embolization, bifurcated Excluder
Follow-up and Outcomes 6 mo; endoleak resolved at 1 wk, no sac enlargement at
SG Shah et al, 2013 (2)
M/60
Abdominal pain, dyspnea, lower
Ruptured AAA, 10 cm; ACF (þ)
Bifurcated C3 Excluder SG
Renal artery
Conservative
1 mo; endoleak resolved at 1 mo
AAA, 10 cm; ACF (þ)
Bifurcated Endurant
IMA
Conservative
12 mo; sac shrinkage
extremity edema, CHF, hypotension van de
M/61
Luijtgaarden et al, 2013 (4) LaBarbera et al,
Back and abdominal pain
M/64
2011 (11)
Abdominal pain,
SG AAA, 9 cm; ACF (þ)
hypotension, CHF, AKI
Aorto-uni-iliac Zenith
(þ), persistent endoleak (þ) IMA
SG, CIA occlusion by AMPLATZER plug, F-
AMPLATZER VSD Occluder across ACF
F bypass Melas et al, 2011 (12)
M/76
Acute abdominal pain,
Ruptured AAA, 9 cm; ACF ()
hypotension
Jeuriens-van de
M/69
Ven et al, 2011 (8)
Progressive dyspnea, CHF, pneumonia
Bilateral CIA
Aorto-uni-iliac UniFit SG, CIA occlusion
Sac and IMA coiling,
ACF
on day 13 Lumbar arteries (at 1 mo)
Conservative - IVC SG because of
with occluder, F-F
enlarged fistula and
bypass
signs of cardiac failure at 6 mo
Bifurcated Zenith SG
NR, no endoleak or
Management of Endoleak Associated with ACF
Akamatsu et al,
Sac Diameter and Fistula on Preoperative
’
Study
Patient Sex/Age
IMA
Conservative -
aneurysm, 5.5 cm and 2.5 cm; iliocaval
dyspnea returned IMA ligation -
fistula
persistent endoleak
36 mo; no endoleak or ACF, sac shrinkage (þ)
6 mo; no endoleak or fistula
and fistula from lumbar artery collaterals - open Akwei et al, 2011
Cardiovascular
AAA, 11 cm; ACF (þ)
Aorto-uni-iliac Zenith
collapse, lower
SG, CIA occlusion
extremity edema, AKI with
with occlude, F-F bypass
IIA branch
ligation Untreated because of
Died 1 d after EVAR
unstable condition
anuria
’
(Continued)
Ueshima et al
(15)
M/74
JVIR
(y) M/74
2010 (9)
Clinical Findings Back pain, AKI
Imaging AAA, 10 cm; ACF (þ)
EVAR Treatment
Source of
Management of
Endoleak
Endoleak Conservative -
with hematuria, lower extremity
- aorto-uni-iliac Zenith SG, CIA
branch
edema
occlusion, F-F
IMA ligation and
bypass
failed IIA branches embolization -
continued renal impairment - open
Outcomes 6 mo; no endoleak or fistula
November
IMA and IIA
’
Bifurcated Talent SG
Follow-up and
fistula ligation at
2010 (5) Kopp et al, 2006
AKI with anuria,
AAA, 7 cm; ACF (þ)
Bifurcated Excluder SG
NR
6 mo Conservative
hypotension
1 y; endoleak resolved at 6 mo, no endoleak
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Patient Sex/Age
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Table. Review of Treatment Options for Type II Endoleaks after EVAR for Aortoiliac Aneurysms Associated with Arteriocaval Fistulas (continued )
or fistula 6 mo; no endoleak or
M/68
Back pain, anemia
AAA, 6.5 cm; ACF (þ)
Bifurcated Zenith SG
IMA
IMA coiling at day 4
Vetrhus et al, 2005 (6)
M/66
Dyspnea and lower extremity
AAA, 8.6 cm; ACF (þ)
Bifurcated Tri-Fab design SG
Lumbar arteries
Conservative
12 mo, endoleak resolved at 4 wk, sac
Burke et al, 2003 (14)
M/66
Back pain, hypotension
AAA, 8 cm; ACF (þ)
Bifurcated AneuRx SG
IMA
IVC SG, sac emboli with glue on day 4
NR
Lau et al, 2001 (10)
M/61
Dyspnea, lower
AAA, 5.5 cm; ACF (þ)
Aorto-uni-iliac Talent
CIA (incomplete
Open ligation of CIA
12 mo; no endoleak or
fistula
(13)
edema
shrinkage (þ)
SG, CIA coiling, F-F bypass
extremity edema, CHF,
fistula
coiling)
ascites, AKI, hepatic impairment Beveridge et al,
M/71
1998 (7) Present study
Dyspnea, lower extremity edema, CHF
M/64
Dyspnea, abdominal and back pain
CIA aneurysm 6 cm,
Bifurcated stent or SG
NR
Conservative
ACF (þ) AAA 6.3 cm, ACF (þ)
12 mo, endoleak resolved at 1 wk, no endoleak or fistula
Bifurcated Excluder SG
IMA
Sac and IMA coiling on day 9
6 mo, sac shrinkage (þ), no endoleak or fistula
Note.–Excluder (W.L. Gore & Associates, Flagstaff, Arizona); Zenith (COOK Medical, Bloomington, Indiana); Endurant (Medtronic, Minneapolis, Minnesota); AMPLATZER plug (St. Jude Medical, Minneapolis, Minnesota); AMPLATZER VSD Occluder (St. Jude Medical); UniFit (LeMaitre Vascular, Inc., Burlington, Massachusetts). AAA ¼ abdominal aortic aneurysm; ACF ¼ aortocaval fistula; AKI ¼ acute kidney injury; CHF ¼ congestive heart failure; CIA ¼ common iliac artery; EVAR ¼ endovascular aortic aneurysm repair; F ¼ female; F-F bypass ¼ femorofemoral bypass; IIA ¼ internal iliac artery; IMA ¼ inferior mesenteric artery; M ¼ male; NR ¼ not reported; SG ¼ stent-graft; VSD ¼ ventricular septal defect. 1813
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Two hypotheses of dynamic changes had been made to explain the natural course of type II endoleaks associated with IVC fistulas (8). First, the fistula serves as a “highway” outflow that inhibits spontaneous closure. Second, the persistent pressure gradient probably promotes new collateral routes, maintaining the endoleaks. Theoretically, a persistent high-flow endoleak results. However, some studies disputed this possibility and reported spontaneous resolution of the endoleak and fistula (1–3,5–7). A systematic review of 22 cases of EVAR for major abdominal arteriovenous fistulas revealed favorable results with a type II endoleak rate of 22% (1). Including the present case, 15 cases of type II endoleaks associated with ACFs have been reported (Table). The endoleaks involve aortocaval and iliacocaval fistulas in 12 and 3 cases, respectively (2– 15). Most of the endoleaks were managed conservatively (9 of 15; 60%), and similar to the outcome reported in a previous study (1), the endoleaks had resolved spontaneously at the 6-month follow-up examination in 55.5% (5 of 9) of cases. These findings confirmed that EVAR for ACFs complicating aortoiliac aneurysms is not associated with a greater incidence of persistent endoleaks. Endoleaks persisted in the other four cases managed conservatively, and three of them (75%) required additional intervention, highlighting the hazards of persistent type II endoleaks. Only one case of persistent type II endoleak associated with aortocaval fistula without sac enlargement and systemic manifestations was continuously managed by conservative treatment (4). This study postulated that aortocaval fistula causes a pressure gradient from a high-pressure arterial system to a low-pressure venous system (2–8 mm Hg), resulting in a low-pressure aneurysm sac, decreasing the possibility of sac growth. However, the aneurysmal sac and fistula should be closely observed, and periodic cardiac evaluations should be performed because sac enlargement and subsequent systemic complications may occur (4,12). Preventive repair, as in the present case, either by EVAR (11,13,14) or open repair (10), has also been reported to prevent acute or long-term complications resulting from the ACF. Seven (46.7%) cases, including the failed cases of conservative treatment, were treated by endovascular means using inflow or outflow control, or a combination of both. Outflow control can be achieved by stent graft placement in the IVC, fistula occlusion with a ventricular septal defect occluder, or sac embolization (11,12,14). Because veins are low-flow vessels susceptible to thrombosis, the durability of stent graft patency in the IVC is still questionable. However, IVC endograft placement has been reported for treating this problem (12) and other pathologies (16–18) with favorable results and no complications during follow-up
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periods ranging from 6–36 months. Close surveillance, including lifelong treatment with an oral anticoagulant with or without a combination of antiplatelet therapy, is warranted for IVC endografts because potential complications such as migration, stenosis, and thrombosis theoretically exist (12,16–18). In two cases of failed conservative treatment (8,9), endovascular approaches failed, resulting in a technical and clinical success rate of 71.4% with a reported mean follow-up period of 16 months. In one case, the fistula was maintained by the IMA and branches of the internal iliac artery, resulting in reoccurrence of renal dysfunction. The fistula was not sealed even after an open ligation of the IMA, and an attempt to perform selective embolization of the internal iliac artery branches with coils failed. In another case, the fistula was maintained by the IMA, resulting in reoccurrence of congestive heart failure. It was treated by coil embolization of the IMA, but after a couple of weeks, control angiography showed extensive collateral flow arising from “new” lumbar arteries that were not seen previously. In both cases, open ligation of the fistula resolved the problem. These findings emphasize previous suggestions that the approach to an endoleak should be similar to the approach to an arteriovenous malformation, and embolization of only the feeding or inflow arteries can result in recurrence or persistent endoleaks in 80% of cases (19,20). In the present case, although the lumbar arteries were not addressed, embolization of the aneurysm sac by coils may occlude the orifice of the lumbar arteries, excluding the aortocaval fistula and endoleaks. Embolization of the IMA can decrease blood flow, enhance formation and stabilization of the thrombus, and decrease the recanalization rate in the sac. Embolization of the aneurysm sac followed by control of the feeding arteries using a modified transarterial technique described by Stavropoulos et al (20) is considered the best alternative minimally invasive approach to obtain better midterm results. Although our literature review consists of a relatively small number of cases with short-term to mid-term follow-up, the natural course and approaches of type II endoleak after EVAR were similar between cases with or without associated ACFs. A conservative approach can be safely performed with close and careful observation. However, an endovascular approach is preferred to prevent or treat long-term complications, and surgery is reserved for failed endovascular attempts or a lack of endovascular facilities. In conclusion, EVAR for ACFs complicating aortoiliac aneurysms is feasible and safe. A combination of inflow and outflow control is important for obtaining better outcomes in the management of persistent ACFs maintained by type II endoleaks.
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REFERENCES 1. Antoniou GA, Koutsias S, Karathanos C, Sfyroeras GS, Vretzakis G, Giannoukas AD. Endovascular stent-graft repair of major abdominal arteriovenous fistula: a systematic review. J Endovasc Ther 2009; 16: 514–523. 2. Shah TR, Parikh P, Borkon M, et al. Endovascular repair of contained abdominal aortic aneurysm rupture with aortocaval fistula presenting with high-output heart failure. Vasc Endovasc Surg 2013; 47:51–56. 3. Akamatsu D, Sato A, Goto H, et al. Sudden cardiac arrest immediately after stent graft deployment during treatment of iliac aneurysm with iliocaval fistula. Ann Vasc Surg 2014; 28:1031.e11–13. 4. van de Luijtgaarden KM, Goncalves FB, Rouwet EV, Hendriks JM, Ten Raa S, Verhagen HJM. Conservative management of persistent aortocaval fistula after endovascular aortic repair. J Vasc Surg 2013; 58:1080–1083. 5. Guzzardi G, Fossaceca R, Divenuto I, Musiani A, Brustia P, Carriero A. Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula. Cardiovasc Intervent Radiol 2010; 33:853–856. 6. Vetrhus M, McWilliams R, Tan CK, Brennan J, Gilling-Smith G, Harris PL. Endovascular repair of abdominal aortic aneurysms with aortocaval fistula. Eur J Vasc Endovasc Surg 2005; 30:640–643. 7. Beveridge CJ, Pleass HCC, Chamberlain J, Wyatt MG, Rose JDG. Aortoiliac aneurysm with arteriocaval fistula treated by a bifurcated endovascular stent-graft. Cardiovasc Intervent Radiol 1998; 21:244–253. 8. Jeuriens-van de Ven SAH, Schouten van der Velden AP, Kool LJMS, Adam van der Vliet J, Berger P. Persisting iliaco-caval fistula after EVAR maintained by a type II endoleak. Ann Vasc Surg 2011; 25:1142.e7–1142.e9. 9. Sfyroeras GS, Moulakakis KG, Bessias N, et al. Persistent endoleak after endovascular exclusion of an aortocaval fistula, producing renal insufficiency. Vasa 2010; 39:98–102.
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10. Lau LL, O’Reilly MJG, Johnstan LC, Lee B. Endovascular stent-graft repair of primary aortocaval fistula with an abdominal aortoiliac aneurysm. J Vasc Surg 2001; 33:425–428. 11. LaBarbera M, Nathanson D, Hui P. Percutaneous closure of aortocaval fistula using the Amplatzer Muscular VSD Occluder. J Invasive Cardiol 2011; 23:343–344. 12. Melas N, Saratzis A, Saratzis N, Lazaridis I, Kiskinis D. Inferior vena cava stent-graft placement to treat endoleak associated with an aortocaval fistula. J Endovasc Ther 2011; 18:250–254. 13. Kopp R, Weidenhagen R, Hoffman R, et al. Immediate endovascular treatment of an aortoiliac aneurysm ruptured into the inferior vena cava. Ann Vasc Surg 2006; 20:525–528. 14. Burke C, Mauro MA. SIR 2003 film panel case 8: aortocaval fistula supplied by a type II endoleak. J Vasc Interv Radiol 2003; 14:813–817. 15. Akwei S, Altaf N, Tennant W, MacSweeney S, Braithwaite B. Emergency endovascular repair of aortocaval fistula—a single center experience. Vasc Endovasc Surg 2011; 45:442–446. 16. Briggs CS, Morcos OC, Moriera CC, Gupta N. Endovascular treatment of iatrogenic injury to the retrohepatic inferior vena cava. Ann Vasc Surg In press May 21, 2014, (available online). 17. Falkowski A, Wiernicki I. Stent-graft implantation to treat an inferior vena cava aneurysm. J Endovasc Ther 2013; 20:714–717. 18. de Naeyer G, Degrieck I. Emergent infrahepatic vena cava stenting for life-threatening perforation. J Vasc Surg 2005; 41:552–554. 19. Scali ST, Vlada A, Chang CK, Beck AW. Transcaval embolization as an alternative technique for the treatment of type II endoleak after endovascular aortic aneurysm repair. J Vasc Surg 2013; 57:869–874. 20. Stavropoulos SW, Park J, Fairman R, Carpenter J. Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization. J Vasc Interv Radiol 2009; 20:1299–1302.
Management of Type II Endoleak after Endovascular Repair of Arteriocaval Fistula Complicating Aortoiliac Aneurysm: Case Report and Literature Review Eisuke Ueshima, MD, Masato Yamaguchi, MD, PhD, Akhmadu Muradi, MD, Takuya Okada, MD, PhD, Koji Idoguchi, MD, Keitaro Sofue, MD, PhD, Yoshikatsu Nomura, MD, Yutaka Okita, MD, PhD, and Koji Sugimoto, MD, PhD
ABSTRACT Endovascular treatment for arteriocaval fistula (ACF) has become the preferred alternative to open repair. However, endoleaks sometimes occur and maintain the ACF. A 64-year-old man presented with persistent fistula after placement of a bifurcated stent-graft for ACF complicating an aortoiliac aneurysm that was maintained by endoleaks from the inferior mesenteric and lumbar arteries. Transarterial embolization of the aneurysm sac and inferior mesenteric artery successfully resolved the problem without any complications observed over 16 months of follow-up. A literature review and discussion of the management options for this entity are presented. A combination of inflow and outflow control is important to obtain better long-term outcomes.
ABBREVIATIONS ACF = arteriocaval fistula, EVAR = endovascular aneurysm repair, IMA = inferior mesenteric artery, IVC = inferior vena cava
An arteriocaval fistula (ACF) is an uncommon complication of an aortoiliac aneurysm; it can manifest with various symptoms leading to delayed diagnosis with subsequent poor outcomes. Conventional treatment is surgical repair, but this is associated with a high mortality rate (1,2). The evolution of endovascular aneurysm repair (EVAR) has offered a minimally invasive management option. However, endoleaks sometimes occur and maintain the ACF. Conservative management, open ligation, and several other techniques involving endovascular interventions have been reported as treatment options (2–14). In this article, a patient is described who presented with a persistent fistula despite successful From the Center for Endovascular Therapy (E.U., M.Y., A.M., T.O., K.I., Y.N., K.Su.), Kobe University Hospital, Kobe, Japan; Department of Radiology (E.U., M.Y., T.O., K.So., K.Su.) and Cardiovascular Division, Department of Surgery (Y.N., Y.O.), Kobe University Graduate School of Medicine, 7-5-2, Kusunokicho, Chuo-ku, Kobe, 650-0017, Japan; and Vascular and Endovascular Division, Department of Surgery (Y.N., Y.O.), Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia. Received March 11, 2014; final revision received and accepted June 23, 2014. Address correspondence to E.U.; E-mail: [email protected] None of the authors have identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1809–1815 http://dx.doi.org/10.1016/j.jvir.2014.06.021
EVAR for an aortocaval fistula complicating an abdominal aortic aneurysm secondary to a type II endoleak from the inferior mesenteric artery (IMA) and lumbar arteries. It was successfully treated with secondary coil embolization of the aneurysm sac and the IMA. Additionally, the possible management options reported in the literature are reviewed.
CASE REPORT The patient provided informed consent, and the study design was exempt from ethics review board approval. A 64-year-old man presented to the emergency department of a university hospital with acute dyspnea and general fatigue. The patient did not have a history of cardiac disease or chronic obstructive pulmonary disease. Physical examination revealed an alert patient with hypertension, tachycardia, tachypnea, hypoxia, and a pulsatile abdominal mass with abdominal bruit. Laboratory data showed no hepatic or kidney dysfunction. A chest radiograph showed cardiomegaly with a cardiothoracic ratio of 54% and slight pulmonary edema with a butterfly appearance in the perihilar region. Contrast-enhanced computed tomography (CT) showed an infrarenal abdominal aortic aneurysm (maximum diameter, 63 mm) with an aortocaval fistula anatomically
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suitable for EVAR (Fig 1). Because of the patient’s acute heart failure, emergent EVAR was performed. Aortography revealed the aneurysm, and a rapid flow of contrast material from the aorta into the dilated inferior vena cava (IVC) confirmed the diagnosis of aortocaval fistula (Fig 2a). An Excluder bifurcated stent graft (W. L. Gore & Associates, Flagstaff, Arizona) was used to perform exclusion. Although the final angiogram showed evidence of a type II endoleak from the lumbar arteries
Figure 1. Contrast-enhanced CT image shows an infrarenal abdominal aortic aneurysm, IVC dilatation, loss of the fat plane between the aorta and the IVC, and early equivalent contrast enhancement of the dilated IVC.
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(Fig 2b), it was a very slow-flowing endoleak, and no obvious flow into the IVC was observed; no further intervention was performed. The patient’s heart failure symptoms quickly disappeared after the procedure. On postoperative day 5, a contrast-enhanced CT scan demonstrated persistence of the aortocaval fistula secondary to a type II endoleak from the reconstituted IMA and lumbar arteries. To prevent long-term complications, an additional transarterial coil embolization was performed on postoperative day 9. We used a coaxial catheter system (4-F RC9 catheter; Medikit Co, Ltd, Tokyo, Japan; 2.0-F Parkway Soft microcatheter; Asahi Intecc Co, Ltd, Nagoya, Japan) via a 4-F sheath (Super Sheath; Medikit), which was inserted into the right common femoral artery. Selective superior mesenteric arteriography confirmed the persistent aortocaval fistula from the IMA, which was reconstituted by a patent Riolan arcade (Fig 3a). After advancing the tip of the microcatheter into the aneurysm sac via the Riolan arcade, sequential embolization of the sac and the IMA trunk was performed with a combination of detachable microcoils (Interlock Fibered IDC Occlusion System; Boston Scientific, Natick, Massachusetts) and pushable microcoils (Tornado; Cook, Inc, Bloomington, Indiana; Trufill, Cordis Corporation, Warren, New Jersey) (Fig 3b). Final angiography showed no evidence of endoleaks from the reconstituted IMA or the lumbar arteries (Fig 3b,c). The patient recovered well and was discharged 14 days after the initial procedure. At the 16-month follow-up examination, the patient remained asymptomatic, and a contrast-enhanced CT scan showed complete exclusion of the aneurysm, no endoleaks or fistula, and significant sac shrinkage (Fig 4a,b).
Figure 2. (a) Initial aortogram demonstrates an infrarenal abdominal aortic aneurysm (AAA) and a rapid venous return into the dilated IVC through an aortocaval fistula (arrow). (b) Final angiogram shows a type II endoleak from the third lumbar arteries (arrows) without obvious flow into the IVC.
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Figure 3. (a) Selective superior mesenteric artery angiogram shows a type II endoleak and a persistent aortocaval fistula (arrow) from the IMA reconstituted by a patent Riolan arcade. (b, c) Angiography performed after embolization of the aneurysm sac and IMA shows disappearance of the endoleak and aortocaval fistula.
Figure 4. (a, b) Preoperative and postoperative (at the 16-month follow-up) contrast-enhanced CT images show a significant decrease of the aneurysm sac diameter (dashed arrow, from 63 mm to 47 mm) and the disappearance of the endoleak and aortocaval fistula.
DISCUSSION An ACF is an uncommon complication of an aortoiliac aneurysm, accounting for 0.2%–6% of all aortoiliac aneurysms (2,5,7,9). The classic triad features (ie, low back pain, pulsatile abdominal mass, and abdominal bruit) may be absent in 50% of patients, leading to delayed diagnosis with subsequent poor outcomes (2,10,15). Physician awareness and preoperative recognition of the characteristic findings are essential. Multislice contrast-enhanced CT is the preferred diagnostic tool because it provides important information for planning before treatment (2). If patients are not treated, right-sided heart failure, renal and hepatic insufficiency, deep vein thrombosis, and
pulmonary embolism can occur (1,9,12,15). Emergent intervention saves patients’ lives and prevents irreversible organ failure. Conventional treatment is surgical repair, but it is associated with a high mortality rate of up to 67%, especially in the presence of cardiac decompensation during admission, additional ruptures in the retroperitoneal or intraperitoneal cavity, and missed preoperative diagnosis (9). Since it was first reported in 1998 (7), endovascular stent graft placement for ACFs complicating aortoiliac aneurysms, if anatomically suitable, has become the preferred alternative to open repair and has a high technical success rate of 96% (1). However, studies reporting long-term outcomes are lacking, and persistent ACFs secondary to endoleaks sometimes occurred during the follow-up period.
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Table . Review of Treatment Options for Type II Endoleaks after EVAR for Aortoiliac Aneurysms Associated with Arteriocaval Fistulas
(y) F/84
2013 (3)
Clinical Findings Lower extremity edema, AKI
Imaging IIA aneurysm, 7.5 cm; iliocaval fistula
EVAR Treatment IIA branches
Source of
Management of
Endoleak
Endoleak
Lumbar arteries
Conservative
embolization, bifurcated Excluder
Follow-up and Outcomes 6 mo; endoleak resolved at 1 wk, no sac enlargement at
SG Shah et al, 2013 (2)
M/60
Abdominal pain, dyspnea, lower
Ruptured AAA, 10 cm; ACF (þ)
Bifurcated C3 Excluder SG
Renal artery
Conservative
1 mo; endoleak resolved at 1 mo
AAA, 10 cm; ACF (þ)
Bifurcated Endurant
IMA
Conservative
12 mo; sac shrinkage
extremity edema, CHF, hypotension van de
M/61
Luijtgaarden et al, 2013 (4) LaBarbera et al,
Back and abdominal pain
M/64
2011 (11)
Abdominal pain,
SG AAA, 9 cm; ACF (þ)
hypotension, CHF, AKI
Aorto-uni-iliac Zenith
(þ), persistent endoleak (þ) IMA
SG, CIA occlusion by AMPLATZER plug, F-
AMPLATZER VSD Occluder across ACF
F bypass Melas et al, 2011 (12)
M/76
Acute abdominal pain,
Ruptured AAA, 9 cm; ACF ()
hypotension
Jeuriens-van de
M/69
Ven et al, 2011 (8)
Progressive dyspnea, CHF, pneumonia
Bilateral CIA
Aorto-uni-iliac UniFit SG, CIA occlusion
Sac and IMA coiling,
ACF
on day 13 Lumbar arteries (at 1 mo)
Conservative - IVC SG because of
with occluder, F-F
enlarged fistula and
bypass
signs of cardiac failure at 6 mo
Bifurcated Zenith SG
NR, no endoleak or
Management of Endoleak Associated with ACF
Akamatsu et al,
Sac Diameter and Fistula on Preoperative
’
Study
Patient Sex/Age
IMA
Conservative -
aneurysm, 5.5 cm and 2.5 cm; iliocaval
dyspnea returned IMA ligation -
fistula
persistent endoleak
36 mo; no endoleak or ACF, sac shrinkage (þ)
6 mo; no endoleak or fistula
and fistula from lumbar artery collaterals - open Akwei et al, 2011
Cardiovascular
AAA, 11 cm; ACF (þ)
Aorto-uni-iliac Zenith
collapse, lower
SG, CIA occlusion
extremity edema, AKI with
with occlude, F-F bypass
IIA branch
ligation Untreated because of
Died 1 d after EVAR
unstable condition
anuria
’
(Continued)
Ueshima et al
(15)
M/74
JVIR
(y) M/74
2010 (9)
Clinical Findings Back pain, AKI
Imaging AAA, 10 cm; ACF (þ)
EVAR Treatment
Source of
Management of
Endoleak
Endoleak Conservative -
with hematuria, lower extremity
- aorto-uni-iliac Zenith SG, CIA
branch
edema
occlusion, F-F
IMA ligation and
bypass
failed IIA branches embolization -
continued renal impairment - open
Outcomes 6 mo; no endoleak or fistula
November
IMA and IIA
’
Bifurcated Talent SG
Follow-up and
fistula ligation at
2010 (5) Kopp et al, 2006
AKI with anuria,
AAA, 7 cm; ACF (þ)
Bifurcated Excluder SG
NR
6 mo Conservative
hypotension
1 y; endoleak resolved at 6 mo, no endoleak
2014
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’
Guzzardi et al,
Number 11
Sfyroeras et al,
Sac Diameter and Fistula on Preoperative
’
Study
Patient Sex/Age
Volume 25
Table. Review of Treatment Options for Type II Endoleaks after EVAR for Aortoiliac Aneurysms Associated with Arteriocaval Fistulas (continued )
or fistula 6 mo; no endoleak or
M/68
Back pain, anemia
AAA, 6.5 cm; ACF (þ)
Bifurcated Zenith SG
IMA
IMA coiling at day 4
Vetrhus et al, 2005 (6)
M/66
Dyspnea and lower extremity
AAA, 8.6 cm; ACF (þ)
Bifurcated Tri-Fab design SG
Lumbar arteries
Conservative
12 mo, endoleak resolved at 4 wk, sac
Burke et al, 2003 (14)
M/66
Back pain, hypotension
AAA, 8 cm; ACF (þ)
Bifurcated AneuRx SG
IMA
IVC SG, sac emboli with glue on day 4
NR
Lau et al, 2001 (10)
M/61
Dyspnea, lower
AAA, 5.5 cm; ACF (þ)
Aorto-uni-iliac Talent
CIA (incomplete
Open ligation of CIA
12 mo; no endoleak or
fistula
(13)
edema
shrinkage (þ)
SG, CIA coiling, F-F bypass
extremity edema, CHF,
fistula
coiling)
ascites, AKI, hepatic impairment Beveridge et al,
M/71
1998 (7) Present study
Dyspnea, lower extremity edema, CHF
M/64
Dyspnea, abdominal and back pain
CIA aneurysm 6 cm,
Bifurcated stent or SG
NR
Conservative
ACF (þ) AAA 6.3 cm, ACF (þ)
12 mo, endoleak resolved at 1 wk, no endoleak or fistula
Bifurcated Excluder SG
IMA
Sac and IMA coiling on day 9
6 mo, sac shrinkage (þ), no endoleak or fistula
Note.–Excluder (W.L. Gore & Associates, Flagstaff, Arizona); Zenith (COOK Medical, Bloomington, Indiana); Endurant (Medtronic, Minneapolis, Minnesota); AMPLATZER plug (St. Jude Medical, Minneapolis, Minnesota); AMPLATZER VSD Occluder (St. Jude Medical); UniFit (LeMaitre Vascular, Inc., Burlington, Massachusetts). AAA ¼ abdominal aortic aneurysm; ACF ¼ aortocaval fistula; AKI ¼ acute kidney injury; CHF ¼ congestive heart failure; CIA ¼ common iliac artery; EVAR ¼ endovascular aortic aneurysm repair; F ¼ female; F-F bypass ¼ femorofemoral bypass; IIA ¼ internal iliac artery; IMA ¼ inferior mesenteric artery; M ¼ male; NR ¼ not reported; SG ¼ stent-graft; VSD ¼ ventricular septal defect. 1813
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’
Management of Endoleak Associated with ACF
Two hypotheses of dynamic changes had been made to explain the natural course of type II endoleaks associated with IVC fistulas (8). First, the fistula serves as a “highway” outflow that inhibits spontaneous closure. Second, the persistent pressure gradient probably promotes new collateral routes, maintaining the endoleaks. Theoretically, a persistent high-flow endoleak results. However, some studies disputed this possibility and reported spontaneous resolution of the endoleak and fistula (1–3,5–7). A systematic review of 22 cases of EVAR for major abdominal arteriovenous fistulas revealed favorable results with a type II endoleak rate of 22% (1). Including the present case, 15 cases of type II endoleaks associated with ACFs have been reported (Table). The endoleaks involve aortocaval and iliacocaval fistulas in 12 and 3 cases, respectively (2– 15). Most of the endoleaks were managed conservatively (9 of 15; 60%), and similar to the outcome reported in a previous study (1), the endoleaks had resolved spontaneously at the 6-month follow-up examination in 55.5% (5 of 9) of cases. These findings confirmed that EVAR for ACFs complicating aortoiliac aneurysms is not associated with a greater incidence of persistent endoleaks. Endoleaks persisted in the other four cases managed conservatively, and three of them (75%) required additional intervention, highlighting the hazards of persistent type II endoleaks. Only one case of persistent type II endoleak associated with aortocaval fistula without sac enlargement and systemic manifestations was continuously managed by conservative treatment (4). This study postulated that aortocaval fistula causes a pressure gradient from a high-pressure arterial system to a low-pressure venous system (2–8 mm Hg), resulting in a low-pressure aneurysm sac, decreasing the possibility of sac growth. However, the aneurysmal sac and fistula should be closely observed, and periodic cardiac evaluations should be performed because sac enlargement and subsequent systemic complications may occur (4,12). Preventive repair, as in the present case, either by EVAR (11,13,14) or open repair (10), has also been reported to prevent acute or long-term complications resulting from the ACF. Seven (46.7%) cases, including the failed cases of conservative treatment, were treated by endovascular means using inflow or outflow control, or a combination of both. Outflow control can be achieved by stent graft placement in the IVC, fistula occlusion with a ventricular septal defect occluder, or sac embolization (11,12,14). Because veins are low-flow vessels susceptible to thrombosis, the durability of stent graft patency in the IVC is still questionable. However, IVC endograft placement has been reported for treating this problem (12) and other pathologies (16–18) with favorable results and no complications during follow-up
Ueshima et al
’
JVIR
periods ranging from 6–36 months. Close surveillance, including lifelong treatment with an oral anticoagulant with or without a combination of antiplatelet therapy, is warranted for IVC endografts because potential complications such as migration, stenosis, and thrombosis theoretically exist (12,16–18). In two cases of failed conservative treatment (8,9), endovascular approaches failed, resulting in a technical and clinical success rate of 71.4% with a reported mean follow-up period of 16 months. In one case, the fistula was maintained by the IMA and branches of the internal iliac artery, resulting in reoccurrence of renal dysfunction. The fistula was not sealed even after an open ligation of the IMA, and an attempt to perform selective embolization of the internal iliac artery branches with coils failed. In another case, the fistula was maintained by the IMA, resulting in reoccurrence of congestive heart failure. It was treated by coil embolization of the IMA, but after a couple of weeks, control angiography showed extensive collateral flow arising from “new” lumbar arteries that were not seen previously. In both cases, open ligation of the fistula resolved the problem. These findings emphasize previous suggestions that the approach to an endoleak should be similar to the approach to an arteriovenous malformation, and embolization of only the feeding or inflow arteries can result in recurrence or persistent endoleaks in 80% of cases (19,20). In the present case, although the lumbar arteries were not addressed, embolization of the aneurysm sac by coils may occlude the orifice of the lumbar arteries, excluding the aortocaval fistula and endoleaks. Embolization of the IMA can decrease blood flow, enhance formation and stabilization of the thrombus, and decrease the recanalization rate in the sac. Embolization of the aneurysm sac followed by control of the feeding arteries using a modified transarterial technique described by Stavropoulos et al (20) is considered the best alternative minimally invasive approach to obtain better midterm results. Although our literature review consists of a relatively small number of cases with short-term to mid-term follow-up, the natural course and approaches of type II endoleak after EVAR were similar between cases with or without associated ACFs. A conservative approach can be safely performed with close and careful observation. However, an endovascular approach is preferred to prevent or treat long-term complications, and surgery is reserved for failed endovascular attempts or a lack of endovascular facilities. In conclusion, EVAR for ACFs complicating aortoiliac aneurysms is feasible and safe. A combination of inflow and outflow control is important for obtaining better outcomes in the management of persistent ACFs maintained by type II endoleaks.
Volume 25
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Number 11
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November
’
2014
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10. Lau LL, O’Reilly MJG, Johnstan LC, Lee B. Endovascular stent-graft repair of primary aortocaval fistula with an abdominal aortoiliac aneurysm. J Vasc Surg 2001; 33:425–428. 11. LaBarbera M, Nathanson D, Hui P. Percutaneous closure of aortocaval fistula using the Amplatzer Muscular VSD Occluder. J Invasive Cardiol 2011; 23:343–344. 12. Melas N, Saratzis A, Saratzis N, Lazaridis I, Kiskinis D. Inferior vena cava stent-graft placement to treat endoleak associated with an aortocaval fistula. J Endovasc Ther 2011; 18:250–254. 13. Kopp R, Weidenhagen R, Hoffman R, et al. Immediate endovascular treatment of an aortoiliac aneurysm ruptured into the inferior vena cava. Ann Vasc Surg 2006; 20:525–528. 14. Burke C, Mauro MA. SIR 2003 film panel case 8: aortocaval fistula supplied by a type II endoleak. J Vasc Interv Radiol 2003; 14:813–817. 15. Akwei S, Altaf N, Tennant W, MacSweeney S, Braithwaite B. Emergency endovascular repair of aortocaval fistula—a single center experience. Vasc Endovasc Surg 2011; 45:442–446. 16. Briggs CS, Morcos OC, Moriera CC, Gupta N. Endovascular treatment of iatrogenic injury to the retrohepatic inferior vena cava. Ann Vasc Surg In press May 21, 2014, (available online). 17. Falkowski A, Wiernicki I. Stent-graft implantation to treat an inferior vena cava aneurysm. J Endovasc Ther 2013; 20:714–717. 18. de Naeyer G, Degrieck I. Emergent infrahepatic vena cava stenting for life-threatening perforation. J Vasc Surg 2005; 41:552–554. 19. Scali ST, Vlada A, Chang CK, Beck AW. Transcaval embolization as an alternative technique for the treatment of type II endoleak after endovascular aortic aneurysm repair. J Vasc Surg 2013; 57:869–874. 20. Stavropoulos SW, Park J, Fairman R, Carpenter J. Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization. J Vasc Interv Radiol 2009; 20:1299–1302.