ABSTRACT
We report a case of arteriovenous fistula (AVF) secondary to spontaneous rupture of the right common iliac aneurysm into the right common iliac vein. In February 2003, an 81-year-old woman was admitted with dyspnea. Diuretics and digitalis were given under a provisional diagnosis of primary heart failure. Afterwards the heart failure turned out to be high output failure due to AVF. In June the patient complained of swelling of her right leg and was referred to our department. Ultrasonography to determine deep vein thrombosis of the right femoral vein revealed a dilatation of the left femoral vein, but there was no thrombosis. A pulse Doppler detected an arterial blood flow signal during early systolic pulse in the right femoral vein, confirming the suspicion of an AVF in abdominal cavity near this location. A pulsatile mass associated with bruit and thrill was palpable in the lower abdomen. Digital subtraction angiography showed a 50mm aneurysm of the right common iliac artery. Rapid visualization of the inferior vena cava and retrograde opacification of the right iliac vein indicated the presence of an AVF between the common iliac artery and vein. Operation was done by laparotomy on June 24, 2003. An occlusive balloon catheter was inserted from the right femoral vein and the balloon was dilated to patch the fistula before opening the aneurysm. After clamping the proximal and distal arteries the aneurysm was opened. By this maneuver there was no bleeding from the fistula. The AVF was closed from inside the aneurysm by 3 interrupted 4-0 monofilament sutures. The aneurysm was replaced with a prosthetic graft (Hemashield 8mm). The postoperative course was uneventful. The lower limb edema subsided and heart failure improved.
ABSTRACT
The indications of steroid therapy for inflammatory abdominal aortic aneurysm (IAAA) is controversial. We here report a rare case whose persistent postoperative high fever and duodenal obstruction due to adhesion to the residual aortic wall were successfully treated by steroid. A 73-year-old man was referred to our hospital because of abdominal pain and a pulsating mass in his umbilical region. CT scan showed a remarkably dilated infrarenal abdominal aorta (10cm in diameter) with a mantle sign. Preoperatively C-reactive protein (CRP) was high, however temperature was normal. We replaced the aneurysm with a bifurcated prosthetic graft (18×9mm collagen impregnated knitted Dacron) by laparotomy on April 10, 2001. The aneurysm showed a thick and fibrous surface tightly adhering to the jejunum, sigmoid colon and ureters. We tried to minimize surgical injury to perianeurysmal fibrotic tissue. However the right ureter was injured and repaired using a double-J catheter. Histopathological examination revealed lymphoplasmocystic infiltration in the wall of the aorta, which was compatible with IAAA. From the 10th postoperative day high fever (38 to 39°C) persisted and CT revealed perigraft seroma with air density. Graft infection was suspected and the perigraft fluid was drained by puncture. However cultures of the serous fluid was negative. Moreover, approximately 1, 500ml gastric juice was drained per day via a nasogastric tube. Therefore we suspected postoperative inflammatory reactions to the impregnated Dacron graft and/or inflammation of the residual aortic wall. This patient was given 20mg prednisolone intravenously 18 days after the operation and the dose of steroid was then tapered. This therapy had an obvious effect on the recovery of the general condition. Body temperature and CRP was normal when he was discharged 46 days after surgery. The patient had no complaints and the thickness of the residual aortic wall around the graft was found to have decreased one year after the operation on follow up CT.