Staged endovascular repair of an abdominal aortic aneurysm adjacent to a chronic high-flow iliocaval traumatic arteriovenous fistula

Abstract

Large-vessel chronic traumatic arteriovenous fistulas are a rare complication after trauma. Delayed presentation can consist of one or more features of high-output cardiac failure, pulsatile abdominal mass, bruit, limb ischemia, and venous congestion. We describe a patient with a complex iliocaval fistula secondary to a remote gunshot wound associated with a large 8.5-cm aortic aneurysm. Informed consent of the patient was obtained for publication of the case.

Fig 1

A, Preoperative computed tomography angiography (CTA) demonstrated a large 8.5-cm infrarenal abdominal aortic aneurysm (AAA) concerning for impending rupture and signs of a left-sided iliocaval traumatic arteriovenous fistula (tAVF). B, There was significant collateralization in the retroperitoneum, making an open operation prohibitively risky. C, Fistulous connection is observed between the left common iliac artery (CIA) and the proximal right common iliac vein (CIV) or distal vena cava (arrow).

Fig 2

A-C, During the index procedure, injection of the right common iliac artery (CIA; arrow) demonstrated flow through pelvic collaterals to the left CIA. An anomalous connection was discovered from the left CIA to the inferior vena cava (arrow). D, An aortouni-iliac Gore Excluder was deployed to temporize the abdominal aortic aneurysm (AAA), with an excellent angiographic result. E, Three-dimensional reconstruction of the postoperative result.

Fig 3

A, Through the superior mesenteric artery, an inferior mesenteric artery (IMA; arrow) angiogram was obtained to visualize the large type II endoleak. B, Several microcoils (arrow) were deployed between the IMA origin and the left colic takeoff to thrombose the endoleak source. C, Through the left common femoral vein, the fistulous track (arrow) was identified. D, An Amplatzer II vascular plug was deployed to close the traumatic arteriovenous fistula (tAVF; arrow).

Fig 4

A, Computed tomography angiography (CTA) at 18-month follow-up demonstrated stable position of the endograft and microcoils (arrow). B, The previously identified type II endoleak was not observed. C, The Amplatzer device (arrow) was in good position, with no further evidence of traumatic arteriovenous fistula (tAVF).