© 2012 by the Texas Heart ® Institute, Houston

Volume 39, Number 1, 2012148 Abdominal Aortic Aneurysm Rupture

Rupture of Abdominal Aortic Aneurysmwith Fistula between the Aorta and the Confluence of the Left Renal Vein into the Vena Cava

A 62-year-old man emergently presented with a 2-hour history of severe right-sided abdominal pain. Abdominal ultrasonography identif ied a possibly ruptured abdominal aortic aneurysm (AAA). Computed tomography con-

firmed AAA rupture with a medium-sized retroperitoneal hematoma on the right side of the aorta. During the arterial phase of angiography, contrast medium filled the vena cava and part of the left renal vein (LRV) (Fig. 1). Because of the patient’s un-stable and worsening clinical condition, complete angiography was not performed. Three-dimensional computed tomographic reconstruction showed a large aneurysm, a medium-sized hematoma, and a fistula between the aneurysm and the confluence of the LRV into the vena cava (Fig. 2).

Images inCardiovascularMedicine

Tomislav Istvanic, MDVedrana Vizjak, MDGordan Saric, MDRadivoje Radic, MD, PhDKresimir Pinotic, MDSinisa Pesic, MD

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute at St. Luke’s Episcopal Hospital, 6624 Fannin St., Suite 2480, Houston, TX 77030

From: Departments of Vascular Surgery, Clinic for Surgery (Drs. Istvanic and Pinotic), Nephrology, Clinic of Internal Medicine (Dr. Vizjak), and Radiology (Drs. Pesic and Saric), Clini-cal Hospital Centre Osijek; and Department of Anat-omy, Faculty of Medicine (Dr. Radic), J.J. Strossmayer University of Osijek; 31000 Osijek, Croatia

Address for reprints: Vedrana Vizjak, MD, Vatrogasna 130, 31000 Osijek, Croatia

E-mail: vizjak.vedrana@kbo.hr

Fig. 1 Computed tomographic angiography (transverse image) shows an abdominal aortic aneu-rysm with rupture into the left renal vein and vena cava.

a = vena cava; b = retroaortic left renal vein; c = aortovenous fistula; d = extraperitoneal hematoma; e = aortic aneurysm

Fig. 2 Computed tomography (3-dimensional reconstruction) shows an abdominal aortic aneu-rysm with rupture into the left renal vein and vena cava.

a = vena cava; b = retroaortic left renal vein; c = abdominal aorta; d = aortovenous fistula; e = extra-peritoneal hematoma; f = aortic aneurysm

Texas Heart Institute Journal Abdominal Aortic Aneurysm Rupture 149

Comment

Communication between an AAA and the LRV or vena cava is extremely rare. Approximately 25 cases of f istulae between an AAA and the LRV have been re-ported.1 Aortocaval fistulae have occurred in 3% to 6% of cases of AAA rupture.2 In most instances of LRV fi-stulae, the LRV has been positioned retroaortically.1,3,4 This anatomic variation has a prevalence of 2% to 4% in the general population.1,4,5

Adequate preoperative diagnosis with precise iden-tif ication of the f istula is crucial in reducing the risk of intraoperative complications and heavy bleeding. To our knowledge, this is the first report of AAA rupture with an acutely formed fistula between the AAA and the confluence of the LRV into the vena cava.

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G, Gossetti B. Rupture of abdominal aortic aneurysm into retro-aortic left renal vein: a case report. EJVES Extra 2009; 18(2):21-3.

2. Gilling-Smith GL, Mansfield AO. Spontaneous abdominal arteriovenous fistulae: report of eight cases and review of the literature. Br J Surg 1991;78(4):421-5.

3. Yagdi T, Atay Y, Engin C, Ozbek SS, Buket S. Aorta-left renal vein fistula in a woman. Tex Heart Inst J 2004;31(4):435-8.

4. Mansour MA, Rutherford RB, Metcalf RK, Pearce WH. Spontaneous aorto-left renal vein f istula: the “abdominal pain, hematuria, silent left kidney” syndrome. Surgery 1991; 109(1):101-6.

5. Yesildag A, Adanir E, Koroglu M, Baykal B, Oyar O, Gulsoy UK. Incidence of left renal vein anomalies in routine abdomi-nal CT scans [in Turkish]. Tani Girisim Radyol 2004;10(2): 140-3.