Managing a Ruptured Giant Abdominal Aortic Aneurysm with Aortocaval Fistula

Abstract

Aortocaval fistula (ACF) is an unusual complication of ruptured abdominal aortic aneurysm (AAA), involving less than 6% of all ruptured cases. There are only a few reports on giant AAA with ACF in the literature review. A 52-year-old gentleman presented with sudden onset of lower abdominal pain radiating to the back. On examination, he was tachycardic but otherwise hemodynamically stable. A non-tender pulsatile abdominal mass was found during the examination. An infrarenal giant AAA with a maximal anteroposterior diameter of 13 cm in size involving the bilateral common iliac arteries (CIA) was detected. A ruptured AAA with a possible ACF was diagnosed, and an open abdominal aortic aneurysm repair was decided as an emergency. Intraoperatively, upon opening the aneurysmal sac, there was excessive venous bleeding, which turned out to be from the inferior vena cava (IVC) revealing an ACF between the right CIA to IVC was revealed. The fistula defect on the IVC was repaired with a Prolene 6/0 suture. Subsequently, an aorto-bifemoral graft (16 x 7 mm) bypass was performed due to a calcified iliac vessel. Ruptured giant AAA with ACF is a life-threatening emergency that needs rapid planning and intervention. The decision for an open or endovascular approach should be based on clinicians' experiences and the availability of resources. In open surgery, various methods can be used to control the bleeding from IVC, and it is paramount that clinicians are aware of this to prevent exsanguination during surgery.