P025: MYCOTIC COMMON ILIAC ARTERY ANEURYSM WITH A COMMUNICATING ILIOCAVAL FISTULA PRESENTING WITH MULTIORGAN SYSTEM FAILURE & SEPSIS
Mohamad El Churafa, DO; Jose Humanez, MD; University of Florida Health
Introduction: Pathological communication between the common iliac artery and the vena cava account for approximately <1% of reported AV fistulous communications. Their formation results from ruptured aneurysms, blunt and penetrating abdominal trauma, genetic connective tissue disease or iatrogenic. Rapid diagnosis and definitive treatment of such fistulas is mandatory due to their high mortality. Therefore, we are presenting the diagnostic, surgical intervention and critical care management of an iliocaval fistula presenting with septic shock and multi-organ system failure.
Case: 71 year-old male with PMH of CKD, HTN and hypothyroidism presented to the ED with complaints of SOB and right-sided abdominal pain for one week. He exhibited AMS, respiratory distress requiring emergent intubation, severe hypotension with widened pulse pressure and electrolyte derangements. Examination revealed scleral icterus, diffuse non-peritoneal abdominal tenderness, abdominal bruit, unilateral lower extremity swelling and weak bilateral lower extremity pulses. Objective findings demonstrated signs of septic shock, heart failure with hepatic congestion, renal failure, and encephalopathy due to a fistula between a mycotic aneurysm in the right common iliac artery and the inferior vena cava. The patient underwent endovascular repair with aortobiiliac endoprosthesis grafts. In the intensive care unit, E. Coli induced septic shock was treated with systemic antibiotics, balanced fluid resuscitation, vasopressors and continuous renal replacement therapy. Resuscitation was guided by bedside TTE. Eventually, the patient was liberated from the ventilator, returned to baseline mental status, hepatic and renal function improved and was able to stop dialysis. He developed a type Ib endoleak adjacent to the left aortobiiliac graft limb which was repaired with graft extension into the external iliac artery and coil embolization of the internal iliac artery. Definite repair required open intervention which the patient refused and elected for hospice care.
Figure 1: chest xray
Figure 2: CTA abdomen/pelvis
Figure 3: pre-intervention fluoroscopy
Figure 4: post-intervention fluoroscopy
Discussion: Early diagnosis of large AV fistulas is important since prompt treatment increase the survival rate from 25% to 50%. The presentation of major vessel AV fistulas comprise a triad of signs: hypotension, pulsatile mass and heart failure. Heart failure is due to increased venous pressure and venous return yielding cardiac overload. Multi-organ failure can result from arterial insufficiency and passive congestion. Measures to manage the physiological consequences of these fistulas are ineffective without definitive repair of the shunt. Surgical intervention aims to repair arterial injury and obliteration of communication with the venous system. Traditionally, large vessel fistulas and aneurysms were repaired by open surgery with the known risk of profound blood loss, longer hospitalization and more frequent complications. Endovascular repair has demonstrated equivalently high success rates, but exposes the patient to an increased risk to reintervention.