Introduction
An aneurysm is a widening of artery by at least 50% compared with the unchanged part located above and it is the result of pathological changes occurring in the wall of the vessel. The wall of the aneurysm is weaker compared with healthy vessel wall, as amended in terms of morphological, histological, mechanical and therefore more susceptible to rupture. Aortic aneurysm rupture is directly life-threatening condition. More than 95% of abdominal aortic aneurysms rupture into retroperitoneal space [1] where relatively narrow and limited retroperitoneal space easily drives to tamponage of disruption by forming a solid hematoma. Contrary, the aneurysm rupture into the peritoneal cavity having large spatial resources greatly reduces the chances of patient survival, because creation of hematoma being great enough to tamponage of disruption is associated with significantly greater loss of circulating blood.
Rarely, in about 4% of cases, ruptures of abdominal aortic aneurysm comprise the rupture into the inferior vena cava with aortocaval fistula formation [1, 2]. Aortic aneurysms also rarely rupture into the duodenum with primary aortoduodenal fistula formation [1, 2]. Another rare type of abdominal aortic aneurysm rupture is called ‘contained chronic rupture’, with clinical and radiological chronic rupture symptoms without rapid symptoms of haemodynamic shock [1].
In 2006 in The Department of General and Vascular Surgery of M. Pirogow Hospital in Lodz 4 patVVvients were hospitalized due to an aneurysm rupture into a large vein. Two cases involved rupture of iliac artery aneurysm into iliac vein, two ¾ abdominal aortic aneurysm rupture into the inferior vena cava.
Case reports
Case no I
A 76 years old male was admitted because of abdominal pain, diagnosed with abdominal aortic aneurysm before and not assented to an elective surgery. The patient was admitted in the general condition fairly severe, with a noticeable large, pulsating, painful intra-abdominal tumor. Underwent angio-CT, stating abdominal aortic aneurysm ruptured into the peritoneal cavity, the width 91 mm. Abdominal aortic aneurysm begins below the renal arteries and contains a bifurcation of aorta. Aneurysm of the left common iliac artery was 83 mm with direct connection to the sacrum and the left llio-lumbar muscle, with partial loss of posterior lateral wall. Aneurysm of the right common iliac artery was 51 mm wide.
Patient was qualified for emergency surgical treatment due to clinical examination and the result of computed tomography (CT) as a ruptured abdominal aortic aneurysm.
The operation was performed using transperitoneal approach. After proximal neck and iliac arteries clamping the main shoulder of prosthesis was sewn to the top of the aneurysm neck. Distal branches of the graft were sewn to femoral arteries. Common femoral arteries were ligated in the proximal segments. The left iliac artery aneurysm was cut and fistula into iliac vein was revealed, and was sutured with a continuous stitch. Right iliac artery aneurysm was cut and sewn around the distal aneurysm neck further. Intraoperative blood loss was estimated as 4000 ml. Patient received 6 units of packed red blood cells and 3 units of fresh frozen plasma.
In the third postoperative day after the operation the symptoms of sudden bleeding into the gastrointestinal tract were observed. Despite intensive treatment the patient died.
Case no II
A 64 years old male was admitted because of edema of lower limbs and lumbar pain, hypotension and tachycardia. Symptoms appear suddenly. For diagnostic purposes duplex ultrasonography examination was used, which states:
– abdominal aorta at the level of renal arteries width of 31 mm below widens to 97.5 mm with the circular thrombus to 33 mm thick in the lumen extending the bifurcation occurs and it involves the iliac arteries; no signs of hematoma around the aorta, inferior vena cava and in retroperitoneal space;
– width of the right iliac arteries — 25 mm, left — 45 mm;
– common femoral arteries unobstructed width 16.5–17.5 mm, the rear walls of atherosclerotic lesions up to 4 mm;
– deep thigh arteries 9.5–10.5 mm width with the flow towards physiological;
– superficial femoral arteries changed, unobstructed with two-phase flow;
– popliteal arteries 11.5–12.5 mm width, with the flow to the corresponding femoral arteries; ¾ deep veins of both lower limbs overcrowded, with poor phase flow — picture raises suspicion of aortocaval fistula.
On the basis of clinical examination and by duplex ultrasonography patient was qualified for surgical treatment in an emergency.
The operation was performed using transperitoneal approach. Intraoperatively infrarenal abdominal aortic aneurysm was found, including the bifurcation of aorta and iliac arteries. Vena cava was adhered to aneurysm tightly, at its proximal part a little pulsate rate was felt. Below the widened iliac veins were adhered to iliac arteries tightly. Evaluation of their pulsating was difficult due to the strict adherence to the iliac arteries. The aorta was clamped at the proximal aneurysm neck. After cutting the aneurysm fistula between the aorta and vena cava was found to exist at length about 4 cm. Fistula was probably obscured by thrombus in the aneurysm and the blood flow was therefore limited. After removal of thrombi very intense bleeding were observed. Intravascular balloon (Foley’s catheter) was inserted via the fistula into the proximal part of inferior vena cava to control bleeding. Despite this bleeding persisted. After estimated changes in the iliac veins and inferior vena cava and due to very heavy bleeding it was decided to ligate vena cava and iliac veins. Then the aortic reconstruction with bifurcated prosthesis end-to-end the aorta and iliac arteries was performed. Estimated intraoperative blood loss was 5500 ml. The patient required a transfusion of 6 units of packed red blood cells and 3 units of fresh frozen plasma. At the postoperative course there were no complications. In the ninth postoperative day the patient in good general condition was discharged home.
Case no III
A 69 years old male was admitted into the emergency room of one of the other hospital, where he went because of painful swelling of the right lower extremity and severe dyspnea. Initial diagnosis was the painful blue edema of the right lower extremity complicated by pulmonary embolism. After a few days, run diagnostics, completed the duplex ultrasonography showed abdominal aortic aneurysm with hematoma around the aorta, whereas there was no deep venous thrombosis, the patient was referred to the local department with the diagnosis of ruptured abdominal aortic aneurysm. Delay of the right diagnosis and patient transfer resulted from a poor experience in vascular surgery of the large abdominal arteries. Dyspnoea, incorrectly associated with pulmonary embolism in this case, was the result of right ventricular overload due to a fistula between the iliac artery aneurysm and iliac vein. At the admission to over department the patient was in the overall average condition, with dyspnoea at rest, cardiac arrhythmias. In terms of the right lower limb, from foot to groin, there was extensive edema (difference circuits in comparison with the left side was at the level of the leg 23 cm, at the level of thigh 34 cm). There was a strong pain in the leg and thigh, superficial and deep sensory disturbances in the foot. Abdomen was soft, painless, with palpable pulsating resistance in the area right below the hip. It was duplex ultrasonography and computed tomography (angio-CT) performed, which were, respectively:
– duplex ultrasonography of veins of the lower limbs — deep veins of both lower extremities way, without evidence of boundary thrombi, features drainage difficulties in the deep venous system, larger on the right, veins enlarged, pulsating, distended (common femoral vein width on the right side — 19 mm, left — 13 mm), with limited susceptibility to pressure; — duplex ultrasonography of the aorta and arteries of lower limbs — aorta and iliac arteries in the proximal parts were not available to see during the examination because of the patient tightens the abdominal wall, right iliac artery aneurysm extended to the transverse dimension of 77 mm with a boundary thrombus on the wall right and back to 26 mm, common femoral arteries, the right 15 mm, left 12 mm of two-phase flow preserved, popliteal arteries 6 mm — two-phase flow, tibial arteries — two-phase flow preserved;
– angio-CT — ruptured right common iliac artery aneurysm with extensive surrounding hematoma, the two-phase study at L5-S1 features of arteriovenous fistula with the flowing of contracted arterial blood to the right common iliac vein (fig. 1–3), including backwards, with a significant widening of its catchment veins, pelvic veins, within the right buttock, femoral vein associated with significant swelling of the right lower extremity.
Figure
1. Computed tomography. Right common iliac artery aneurysm
ruprured into right common iliac vein
Rycina 1. Tomografia komputerowa. Widoczne peknięcie
tętniaka prawej tętnicy biodrowej wspólnej do żyły
biodrowej wspólnej w jej początkowym odcinku
Figure
2. Computed tomography. Visible concomitant contraced blood
flow in aorta and in inferior vena cava
Rycina 2. Tomografia komputerowa. Jednoczasowe
zakontrastowanie podziału aorty i żyły głównej dolnej
On the basis of clinical examination and additional tests results the patient was qualified for surgical treatment in the emergency with diagnosis of ruptured aneurysm of the common right iliac artery and arteriovenous fistula. The operation was performed using transperitoneal approach. Ruptured right common iliac artery aneurysm contains its bifurcation and external and internal iliac artery was found intraoperatively. The abdominal symptoms of venous overload were observed. Bifurcation of aorta, free section of the right common iliac artery and the right external iliac artery at the bottom of the iliac fossa were dissected. After right iliac artery clamping aneurysm sack was cut and very heavy bleeding from the fistula created by rupture of the aneurysm to the iliac vein over a length of 4 cm was detected. Fistula was repaired by direct suture from inside the aneurysm after vein tamponading, right internal iliac artery was ligated. Right iliac artery was reconstructed with prothesis. After releasing the clamps a clot in the external iliac artery was detected, which was removed by incision of the prosthesis. Incision was sewn, pulsating flow throught the prothesis was detected. After surgery pulsating flow was detected on femoral arteries bilaterally. Estimated intraoperative blood loss was 3200 ml. During operations patient required transfusion of crystalloids, 7 units of packed red blood cells and 3 units of frozen plasma.
Figure
3. Computed tomography. Visible concomitant contraced blood
flow in right femoral vein and in right femoral artery and a significant
swelling of the right thigh
Rycina 3. Tomografia komputerowa. Widoczne
jednoczasowe zakontrastowanie prawej żyły udowej, prawej
tętnicy udowej oraz znaczny obrzęk prawego uda
Postoperative course was complicated by clinical and biochemical signs of renal insufficiency, which gradually disappeared during treatment. In the fourth day after surgery the patient was discharged to the Cardiology Department, where, after several days of observation was discharged home. In a further period of treatment a slight swelling of the right leg was observed, which responds well to compression.
Case no IV
A 79 years old male was admitted because of abdominal pain and a pulsating tumor felt in the abdomen. At admission the patient was in fairly severe general condition, with symptoms developing haemodynamic shock. The patient underwent CT examination of the abdominal cavity, which showed abdominal aortic aneurysm stating the width 12 cm, with a fistula between the aneurysm sac and inferior vena cava. No signs of hematoma around the aorta, inferior vena cava and in retroperitoneal space. Patient was selected for surgical treatment in an emergency.
Figure
4. Abdominal aortic aneurysym ruptured into interior vena cava
(visible place of the fistula and contracted blood flow in
inferior venacava)
Rycina 4. Widoczne pęknięcie tętniaka aorty brzusznej
do żyły głównej dolnej (widoczne miejsce przetoki oraz
zakontrastowanie żyły głównej dolnej)
Figure
5. View of concomitant contraced blood flow in
aorta and in inferior vena cava (por tytul pol)
Rycina 5. Badanie na poziomie pnia trzewnego — widoczne
równoczasowe zakontrastowanie aorty i żyły głównej dolnej
The operation was performed using transperitoneal approach. Abdominal aortic aneurysm width of 12 cm and the characteristics of venous congestion were detected intraoperatively. Aorta above the aneurysm and the iliac arteries were dissected, the inferior mesenteric artery was ligated. After aorta, iliac arteries clamping and inferior vena cava tamponading, the aneurysm sack, fistulised into the vena cava inferior, was opened. Fistula between aneurysm and inferior vena cava was repaired by direct suture from inside of aneurysm, lumbar arteries were ligated. Aortic aneurysm was excluded by vascular graft. Pulsatile flow was obtained in the femoral artery. Intraoperative blood loss was 2900 ml. During hospitalization, the patient required transfusion of 9 units of packed red blood cells. Postoperative course was complicated by biochemical signs of renal failure, which resolved after conservative treatment. In the twelfth postoperative day the patient in good general condition was discharged home.
Discussion
Aneurysm rupture into the lumen of the abdominal organs is a rare complication. In this small group of cases the first place is taken by rupture of the aneurysm into the inferior vena cava, iliac vein then to the left renal vein and finally into the lumen of the small intestine (mainly duodenum) [1–5].
Fistula between the aneurysm and a large vein was first described by James Syme in 1831 as a complication of abdominal aortic aneurysm caused by syphilis [1]. It is now ascertained in a few percent of the aneurysms ruptured abdominal, also as a complication of rare diseases such as Ehlers-Danlos syndrome syndrome, Marfan syndrome [6]. In 30-70% of cases was ascertained only intraoperatively after removal of thrombus from the aneurysm bag [6, 7]. This is because the clinical manifestation of an aneurysm rupture into a large vein can proceed with the range of different symptoms, masking other disease entities, depending on location, size of fistula, the patient’s age, his endurance cardio-pulmonary and renal function [7]. Typical symptoms of the fistula, such as venous congestion, as evidenced by swelling of the lower limbs, scrotum, enlargement of veins within the abdominal wall, heart failure resulting from right ventricular overload with accompanying shortness of breath with painful vibrant co-resistance in the abdomen and coexisting symptoms of hemorrhage (aneurysm rupture), there are only 20-50% of cases [4, 5, 8, 9]. Other less common symptoms include: jaundice, back pain, fever, renal failure, hematuria, acute coronary syndrome [9–11], pulmonary embolism. Thus, preoperative diagnosis of fistula solely on the basis of clinical examination is difficult. The additional test method of choice in the diagnosis of fistula between the aneurysm and a large vein is computed tomography with contrast [2, 12]. Characteristic of the fistula is contrasting arterial and venous system, venous congestion symptoms ¾ widening, vein congestion, strict adherence to a large vein aneurysm, sometimes by the aneurysm pressing on her, and finally visualization of the fistula. Other diagnostic methods are magnetic resonance imaging, ultrasound Doppler and arteriography.
Still the primary method of treatment of aneurysm rupture into a large vein is the classic surgical treatment, involving the closure of the fistula and reconstruction of the aorta with graft [2, 13]. The main risk factors for open surgical treatment are massive blood loss, pulmonary and peripheral embolism (aneurysmal thrombus, atherosclerotic plaques) [6, 14, 15]. The method allows at least to some extent, avoid these complications are intraoperative vein pressing on before opening the aneurysm sac. If this can not stop the bleeding it is acceptable to ligate the vein.
An alternative to open surgery is the intravascular grafting [16–19]. This method, in general in the case of aortic aneurysm rupture, is efficacious because of reduction of blood loss. There are limited available reports on the treatment of the aneurysm rupture into a large vein due to the rarity of this complication, the reports are open on both open and endovascular method [20, 21]. However, in recent years few cases of endovascular treatment of aortocaval fistula have been reported. Place of fistula has been closed by means of injection of cyanoacrylate glue between the branch of the graft and damaged vessel wall [22]. Perioperative mortality in patients with aneurysm rupture into the lumen of a large vein is about 16–70%.