Aortographic Demonstration of an Aortocaval Fistula

Abstract

Since 1909, only 5 cases of a fistula between the aorta and vena cava appear to have been reported. None was associated with arteriosclerotic aneurysm, and in only 1 instance was there even mention of arteriographic study. Lehman (1) in 1938 reported a case of aortocaval fistula with an underlying syphilitic abdominal aortic aneurysm. He found no other example in the literature after 1909. In his case the abnormal communication had existed for a maximum of four months prior to attempted surgical repair, which the patient did not survive. Other cases, appearing more recently, are those of Bigger (2), Pemberton et al. (3), Freeman and Storck (4) and Decker (5). All of these followed bullet wounds. Duration of the fistula varied from four months in Freeman and Storck's case to twelve years in that reported by Decker. The degree of cardiovascular disturbance appeared to be related directly to duration of the lesion. Thus, there was little or no abnormality of circulation in Freeman's case of four months duration, while in Decker's, after twelve years, invalidism with marked cardiac enlargement, congestive failure, and anasarca ensued. In every instance there was some modification of the direct shunt either by a traumatic aneurysm or an organized hematoma. It is probable, as pointed out by Freeman, that an unmodified communication between the two major vessels of the body is incompatible with any but very brief survival. Only in the case reported by Decker was any form of vascular opacification utilized in diagnosis. He makes mention of angiography but does not offer a detailed description. Case Report A white male of 68 years was admitted to Los Angeles County General Hospital on March 7, 1957. For eight months prior to admission he was known to have diabetes, which was easily controlled. For the past two months he had also been under treatment for mild congestive failure with dyspnea, mild orthopnea, and ankle edema. Present hospitalization was prompted by a sudden attack of severe, generalized, non-radiating chest pain which occurred initially while straining at stool and recurred one day later. Demerol was required for relief of pain. Date of the initial episode was March 3, 1957. On admission and during his hospital course, the patient showed signs of congestive failure with cardiac enlargement and basal Réné. His blood pressure was normal, and repeated electrocardiograms showed no evidence of coronary occlusion. A second recurrence of crushing chest pain was experienced March 7. The most significant physical finding on admission and subsequent examinations was a loud bruit over the entire abdomen and back. Neither history, physical findings, roentgenographic studies, nor serology suggested syphilis. Roentgenograms of the chest showed cardiac enlargement, pulmonary congestion, and moderate bilateral hydrothorax.