Acute renal failure as a presentation of an aortocaval fistula associated with abdominal aortic aneurism
Insuficiencia renal aguda como forma de presentación de una fístula aortocava asociada a un aneurisma de aorta abdominal
, M.. ARRUCHE HERREROb, V.. RUIZ GARCÍAb, A.I.. CASTILLO ESCUDEROc, C.. GÓMEZ MIRANDAc, N.. RODRÍGUEZ ESPINOSAd, C.. VILLAVICENCIO LUJÁNe, A.. MARTÍNEZ VEAb
b Unidad de Nefrología, Hospital Universitari Joan XXIII de Tarragona,
c Servicio de Radiodiagnóstico, Hospital Universitari Joan XXIII de Tarragona,
d Servicio de Cirugía Vascular, Hospital Universitari Joan XXIII de Tarragona,
e Unidad de Cuidados Intensivos, Hospital Universitari Joan XXIII de Tarragona,
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Abdominal aorta aneurism and aortocaval fistula" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor,</span></p><p class="elsevierStylePara">Aortocaval fistula (ACF) is an uncommon complication of abdominal aortic aneurysms (AAA) that requires urgent action. However, they are diagnosed in only half of cases, which increases postoperative mortality. Indicative of this condition are a continuous abdominal murmur and the presence of high-output heart failure (HF) or regional venous hypertension. Acute renal failure (ARF) may be the presentation of the ACF, as in the case described.</p><p class="elsevierStylePara">This is the case of a 71-year-old patient with a history of dyslipidaemia, hypertension, truncal obesity and coronary artery bypass. The patient was transferred to our hospital from the emergency department of another hospital due to anuric ARF unresponsive to dopamine or furosemide. The patient complained of self-limited sweating episodes, and had malaise, agitation, disorientation, and tachypnoea, blood pressure at 108/62mm Hg, a pulse of 91 beats/min and central venous pressure (CVP) of 30cm H<span class="elsevierStyleInf">2</span>O. An examination revealed bibasilar crackles and painful, enlarged liver, without a pulsatile abdominal mass or ankle oedema. Laboratory tests revealed the following data: urea 108mg/dl, creatinine 4.05mg/dl, pH 7.19 and bicarbonate 10.2mmol/l, with blood count and coagulation normal.</p><p class="elsevierStylePara">The chest x-ray showed a vascular redistribution pattern with small bilateral pleural effusion. A renal Doppler ultrasound showed normal-sized kidneys without signs of obstruction, a dilated right renal vein, and a large AAA. The CT scan with contrast showed an infrarenal, 10cm AAA with atherosclerosis and thrombosis, without retroperitoneal haematoma, as well as the flow of contrast to the vena cava and right renal vein during the arterial phase and the ACF (Figure 1).</p><p class="elsevierStylePara">With the diagnosis of ARF and CHF secondary to ACF, haemodialysis and surgery were performed, with control of the aneurysm neck, which required the ligation of left renal vein, the opening the aneurysmal sac (with the loss of 2 litres of blood), the closure of the ACF and placement of aorto-aortic bypass. The immediate postoperative diuresis was 70ml/h, but the patient developed refractory multiorgan failure and died three days after surgery.</p><p class="elsevierStylePara">The rupture of an aortic aneurysm and into<span class="elsevierStyleBold"> </span>other organs is uncommon. The inferior vena cava is the most common, followed by the iliac veins, the left renal vein and intestine.<span class="elsevierStyleSup">1,2-4</span> Over 80% of ACF cases are due to the rupture of an <span class="elsevierStyleBold">a</span><span class="elsevierStyleBold">therosclerotic aortic aneurysm</span> (average size 11cm),<span class="elsevierStyleSup">2-5</span> with other causes being penetrating abdominal trauma; iatrogenia, mainly lumbar disc surgery or catheterisation; and occasionally others.<span class="elsevierStyleSup">1,3</span></p><p class="elsevierStylePara">Between 31% and 76% of the ACFs are detected during surgery after evacuating the clot from the aneurysm sac, which causes massive bleeding and/or a paradoxical pulmonary embolism.<span class="elsevierStyleSup">3,5-8</span> They are difficult to Identify because 20%-70% are associated with abdominal or retroperitoneal rupture where the characteristic signs (pulsatile abdominal mass, pain, signs of bleeding, abdominal murmur) are absent or may be easily misinterpreted. An aneurysmal thrombus in the fistula, arterial hypotension or compression of the inferior vena cava may mask the clinical signs of an ACF.<span class="elsevierStyleSup">1,3-5,7-9</span></p><p class="elsevierStylePara">The appearance of an ACF involves that aortic arterial blood is flowing to the vena cava, and therefore, arterial resistance is reduced, the renin-angiotensin-aldosterone and sympathetic systems are activated, and a hyperdynamic circulatory state is seen in 30%-50% of cases. If the ACF is large or the heart is unable to increase cardiac output, heart failure and refractory shock appear.<span class="elsevierStyleSup">1,6,8</span> In addition, ACF causes regional venous hypertension due to volume overload that manifests as oedema in the extremities or scrotum, haematuria, priapism, bleeding or dilated abdominal wall veins. The CVP may be low, normal or high, even very high, as in our patient, which should lead to suspecting the possible existence of ACF.<span class="elsevierStyleSup">3,7</span></p><p class="elsevierStylePara">ACF-associated renal manifestations are macroscopic or microscopic haematuria due to renal and/or bladder venous congestion (which is suggestive of ACF in AAA patients)<span class="elsevierStyleSup">3-5,7,10</span> and ARF, present in 7%-77% of cases and related to functional haemodynamic changes, renal venous hypertension and perfusion deficit.<span class="elsevierStyleSup">3,5,6</span> The immediate recovery of diuresis after surgical closure of the ACF and even the absence of renal lesions in the renal biopsy have been reported on many occasions.<span class="elsevierStyleSup">11,12</span></p><p class="elsevierStylePara">The diagnostic method of choice for ACF is CT, which shows early enhancement of the vena cava, isodense with the aneurysm and even the arteriovenous communication. Other findings include the inferior vena cava dilated or compressed by the aneurysm, retrograde opacification of the renal veins during the arterial phase, poor renal enhancement or an increase in size, and pelvic and retroperitoneal congestion.<span class="elsevierStyleSup">13,14</span></p><p class="elsevierStylePara">Post-operative-associated ACF mortality is 16%-72%, and is mainly related to incorrect diagnosis, hypotension, shock with anuria or ruptured aortic aneurysm.<span class="elsevierStyleSup">2-4,7-9</span></p><p class="elsevierStylePara">Specific treatment for ACF is transaortic closure and placement of a prosthetic graft, which improves heart and renal failure.<span class="elsevierStyleSup">3,5,7</span> A proposed alternative treatment to surgery is aortic stenting in the rupture of aortic aneurysms, with good results at centres with extensive experience.<span class="elsevierStyleSup">15</span></p><p class="elsevierStylePara">In summary, ACF is a rare complication of an aortic aneurysm, which requires high diagnostic suspicion because of its high mortality. The ACF may present with haematuria and/or oligoanuric acute renal failure requiring dialysis. Decreased renal perfusion and venous hypertension are the major pathophysiological mechanisms involved in the renal failure of these patients.</p><p class="elsevierStylePara"><a href="grande/10634_108_13132_en_10634_f1.jpg" class="elsevierStyleCrossRefs"><img src="10634_108_13132_en_10634_f1.jpg" alt="CT scan with contrast. Abdominal aorta aneurism and aortocaval fistula "></img></a></p><p class="elsevierStylePara">Figure 1. CT scan with contrast. Abdominal aorta aneurism and aortocaval fistula </p>" "pdfFichero" => "P1-E515-S2802-A10634-EN.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441466" "palabras" => array:1 [ 0 => "Acute kidney failure" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441468" "palabras" => array:1 [ 0 => "Aorto-caval fistula" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10634_108_13132_en_10634_f1.jpg" "Alto" => 1058 "Ancho" => 763 "Tamanyo" => 61676 ] ] "descripcion" => array:1 [ "en" => "CT scan with contrast. 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| Year/Month | Html | Total | |
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| 2023 September | 44 | 31 | 75 |
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| 2023 July | 66 | 34 | 100 |
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| 2022 December | 87 | 37 | 124 |
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| 2021 September | 49 | 40 | 89 |
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| 2020 December | 74 | 12 | 86 |
| 2020 November | 65 | 19 | 84 |
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| 2020 September | 41 | 12 | 53 |
| 2020 August | 53 | 16 | 69 |
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| 2020 May | 88 | 14 | 102 |
| 2020 April | 60 | 14 | 74 |
| 2020 March | 51 | 19 | 70 |
| 2020 February | 60 | 21 | 81 |
| 2020 January | 72 | 22 | 94 |
| 2019 December | 70 | 20 | 90 |
| 2019 November | 57 | 17 | 74 |
| 2019 October | 35 | 13 | 48 |
| 2019 September | 69 | 14 | 83 |
| 2019 August | 47 | 12 | 59 |
| 2019 July | 40 | 21 | 61 |
| 2019 June | 61 | 14 | 75 |
| 2019 May | 51 | 18 | 69 |
| 2019 April | 73 | 35 | 108 |
| 2019 March | 33 | 18 | 51 |
| 2019 February | 32 | 16 | 48 |
| 2019 January | 35 | 19 | 54 |
| 2018 December | 116 | 36 | 152 |
| 2018 November | 160 | 25 | 185 |
| 2018 October | 155 | 25 | 180 |
| 2018 September | 102 | 11 | 113 |
| 2018 August | 48 | 14 | 62 |
| 2018 July | 63 | 13 | 76 |
| 2018 June | 64 | 15 | 79 |
| 2018 May | 58 | 10 | 68 |
| 2018 April | 66 | 7 | 73 |
| 2018 March | 72 | 11 | 83 |
| 2018 February | 72 | 5 | 77 |
| 2018 January | 33 | 6 | 39 |
| 2017 December | 65 | 14 | 79 |
| 2017 November | 53 | 6 | 59 |
| 2017 October | 49 | 9 | 58 |
| 2017 September | 67 | 14 | 81 |
| 2017 August | 59 | 13 | 72 |
| 2017 July | 63 | 11 | 74 |
| 2017 June | 66 | 9 | 75 |
| 2017 May | 92 | 18 | 110 |
| 2017 April | 66 | 22 | 88 |
| 2017 March | 45 | 17 | 62 |
| 2017 February | 63 | 10 | 73 |
| 2017 January | 43 | 13 | 56 |
| 2016 December | 72 | 7 | 79 |
| 2016 November | 107 | 11 | 118 |
| 2016 October | 159 | 16 | 175 |
| 2016 September | 141 | 8 | 149 |
| 2016 August | 213 | 5 | 218 |
| 2016 July | 161 | 11 | 172 |
| 2016 June | 145 | 0 | 145 |
| 2016 May | 137 | 0 | 137 |
| 2016 April | 109 | 0 | 109 |
| 2016 March | 127 | 0 | 127 |
| 2016 February | 124 | 0 | 124 |
| 2016 January | 123 | 0 | 123 |
| 2015 December | 129 | 0 | 129 |
| 2015 November | 99 | 0 | 99 |
| 2015 October | 94 | 0 | 94 |
| 2015 September | 89 | 0 | 89 |
| 2015 August | 78 | 0 | 78 |
| 2015 July | 69 | 0 | 69 |
| 2015 June | 31 | 0 | 31 |
| 2015 May | 46 | 0 | 46 |
| 2015 April | 5 | 0 | 5 |
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