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CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 48-50

Spontaneous inferior vena cava dissection and aneurysm with ilio-caval fistula


1 CT Division, Dr. Gulati Imaging Institute, New Delhi, India
2 Medical Student, Maulana Azad Medical College, New Delhi, India

Date of Web Publication25-Jan-2016

Correspondence Address:
Parveen Gulati
CT Division, Dr. Gulati Imaging Institute, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-7438.174831

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  Abstract 

A case of spontaneous inferior vena cava dissection and aneurysm with ilio caval fistula in a 40 years male presenting with complaints of pain and swelling in right illiac fossa and swelling of right leg with no history of trauma is reported. The diagnosis was based upon the ultrasound, Doppler and contrast CT findings with clinical profile.

Keywords: Aneurysm, Ilio-caval fistula, spontaneous


How to cite this article:
Pooja B P, Hak S, Gulati A, Gulati P. Spontaneous inferior vena cava dissection and aneurysm with ilio-caval fistula. MAMC J Med Sci 2016;2:48-50

How to cite this URL:
Pooja B P, Hak S, Gulati A, Gulati P. Spontaneous inferior vena cava dissection and aneurysm with ilio-caval fistula. MAMC J Med Sci [serial online] 2016 [cited 2019 Sep 22];2:48-50. Available from: http://www.mamcjms.in/text.asp?2016/2/1/48/174831


  Introduction Top


Arteriovenous fistula (AVF) is usually secondary to rupture/erosion of an abdominal aortic aneurysm in the contiguous venous system. Less frequently, they are secondary to traumatic and iatrogenic injuries or associated with mycotic aneurysm, connective tissue diseases, and Takayasu arteritis, among others. We present a case with no history of trauma or iatrogenic injury with spontaneous abdominal AVF.


  Case Report Top


A 40-year-old male patient presented with the complaints of pain and swelling in the right iliac fossa, swelling of unilateral right leg, and occasional breathlessness of 3 months duration. There was no history of trauma, no previous surgeries, and any known systemic diseases. On examination, his vitals were within normal limits and biochemical analysis revealed no significant abnormalities. A pulsatile swelling was seen in the right iliac fossa with palpable bruit. There was diffuse swelling of right lower limb. No tenderness, skin changes, or varicosities was seen. The distal pulses were diminished in the right leg.

Ultrasound of abdomen was performed, which showed aneurysmal dilatation of infrarenal inferior vena cava (IVC) with irregular lobulated outline. There was a close approximation of right common iliac artery to the IVC. On color Doppler, turbulence and aliasing were seen with mixed arterial and venous spectral waveform in the dilated IVC [Figure 1].
Figure 1: Ultrasonography with color Doppler study showing lobulated saccular dilatation of the inferior vena cava with aliasing on color Doppler. Mixed venous and arterial waveform is seen with low velocity flows. IVC: Inferior vena cava

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Chest X-ray showed cardiomegaly and bilateral pleural effusion.

Computed tomographic (CT) angiography revealed simultaneous opacification of IVC and aorta in arterial phase. There was aneurysmal dilatation of the infrarenal IVC with lobulated saccular dilatations. Intraluminal flap was seen in the segment of IVC proximal to dilatation with opacification of both false and true lumen. Fistulous communication of right common iliac artery with the dilated IVC was seen [Figure 2]. The suprarenal IVC was dilated with dilated hepatic veins [Figure 3].
Figure 2: Contrast-enhanced computed tomography showing aneurysmal dilatation of the infrarenal inferior vena cava with lobulated saccular dilatations. Irregular intraluminal flap is seen in the segment of inferior vena cava proximal to dilatation. Fistulous communication of right common iliac artery with the dilated inferior vena cava is seen. The aorta is normal in caliber and opacification. IVC: Inferior vena cava, RT CIA: Right common iliac artery

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Figure 3: Contrast-enhanced computed tomography showing suprarenal inferior vena cava is dilated with dilated hepatic veins (black arrow). The chest sections reveal cardiomegaly and bilateral pleural effusion (white arrow)

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The right common iliac artery distal to AVF showed mural thickening with luminal stenosis and poststenotic dilatation. There was fusiform dilatation of left common iliac artery [Figure 4]. The rest of abdominal aorta and its branches and renal arteries were normal.
Figure 4: Reformatted images show saccular dilatation of the infrarenal inferior vena cava with fistulous communication of right common iliac artery. There is focal stenosis of right common iliac artery and fusiform dilatation of left common iliac artery. IVC: Inferior vena cava, CIA: Common iliac arterychaotic

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The chest sections revealed enlarged cardiac size and bilateral pleural effusion [Figure 3].


  Discussion Top


Dissection of the IVC is rare, with only a few published reports in the literature. It is usually associated with abdominal injury or iatrogenic injury from a catheter manipulation. Injuries to the IVC are among the most frequent truncal vascular injuries. Most (85–95%) injuries to the IVC are caused by penetrating trauma (primarily gunshot and stab wounds), only 3–10% of IVC injuries are caused by blunt trauma. IVC injury can include contusion, small or large lacerations, or complete transection. Less common than any of these injuries is dissection.[1] Venous dissections are rare due to the lack of well-developed layers in the walls (intima, media, and adventitia), low pressure in the venous system, and the absence of atherosclerotic changes.[2] Unlike arteries, veins do not have three well-developed layers (intima, media, and adventitia) for blood to cleave. Venous intima is composed of endothelial lining adherent to a scant connective tissue layer that is bounded by a poorly defined internal elastic membrane. The media of veins is not as well-developed as that of arteries and provides poor support.[1] In our case, there was no history of trauma or surgery. The IVC showed crescent irregular intraluminal flaps with opacification of lumen and saccular dilatation of the segment distal to it.

Most abdominal AVF are secondary to rupture/erosion of an abdominal aortic aneurysm in contiguous venous system. Less frequently, they are secondary to traumatic and iatrogenic injuries or associated with mycotic aneurysm, connective tissue diseases, and Takayasu arteritis, among others.[3]

Arteriography is still the gold standard examination for diagnosing AVFs. Catheter-based angiography is a dynamic study and in most cases accurately demonstrates the arteries filling the fistula and the exact point of the arteriovenous communication. The major disadvantages of conventional arteriography are the cost of the procedure, the delay that occurs before arteriography, and the need for a specialized team comprising a physician, angiography technologist, and nurse.[4]

CT angiography is a reliable and convenient imaging modality for diagnosing AVF. Contrast-enhanced CT has also an important role in surgical planning because it can reveal where the lesion is, its extension, and its relation to adjacent structures. CT typically shows early contrast filling in the vein during the arterial phase. In chronic AVF, both the artery and the vein dilate and elongate in response to the greater blood flow and shear stress, but the vein dilates more and becomes “arterialized.” Findings include a pseudoaneurysm, large venous aneurysms, and proximal dilation of the artery or hematoma of the vessel wall. As seen in our case, the IVC is dilated with saccular outpouchings with communication to the adjoining iliac artery.

Gray scale ultrasonography shows the site of the AVF when the high flow state has caused dilatation of the vein and artery. Doppler waveform in the feeding artery shows a low resistance pattern with increased diastolic flow. The jet of arterial flow entering the vein can cause a marked flow disturbance and chaotic waveform or an arterial waveform is present,[4] similarly seen in our case.

Early recognition and prompt repair may lead to a significant decrease in the complications such as congestive heart failure or venous hypertension of the limb. AVFs do not resolve spontaneously in the majority of cases. The aim of the treatment is the closure of the AVF, with preservation of patency of the main vessels. Endovascular treatment has emerged as an equally effective technique and less invasive, with fewer perioperative complications and smaller blood loss. It is considered the first therapeutic option in chronic iatrogenic AVF, which may be corrected with arterial or venous covered stents, embolization, or a combination of both techniques.[3],[4],[5] Our patient underwent endovascular repair with stent for fistula closure. Open surgical repair has prohibitive morbidity and mortality, and a minimal invasive technique has emerged as an effective treatment alternative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Singh SP, Canon CL, Treat RC, Crowe DR, O'Dell RH 2nd, Koehler RE. Traumatic dissection of the inferior vena cava. Am J Roentgenol 1997;168:253-4.  Back to cited text no. 1
    
2.
Vaidya SS, Bhargava P, Marder CP, Dighe MK. Inferior vena cava dissection following blunt abdominal trauma. Emerg Radiol 2010;17:339-42.  Back to cited text no. 2
    
3.
Nogueira C, Machado R, Vaz C, Loureiro L, Tavares J, Almeida J. Unconventional endovascular treatment of iatrogenic ilio-cava fistula. Angiologia Cir Vasc 2012;8:177-80.  Back to cited text no. 3
    
4.
Mulatti GC, Queiroz AB, da Silva ES. Traumatic Arteriovenous Fistula. Arteriovenous Fistulas – Diagnosis and Management. Part 5: Diagnostic Imaging. Available from: http://www.dx.doi.org/10.5772/56368. [Last access on 2015 Jun 15].  Back to cited text no. 4
    
5.
Ravi R, Peter SB, Swaminathan TS, Chandrasekar V. Spontaneous aortocaval fistula due to abdominal aortic aneurysm rupture – A case report. Indian J Radiol Imaging 2006;4:453-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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