A. Sadraoui et al., HEMODYNAMIC DIAGNOSIS OF AN AORTOCAVAL FI STULA COMPLICATING AN AORTIC-ANEURYSM, Annales francaises d'anesthesie et de reanimation, 13(3), 1994, pp. 403-406
A 78-year-old man with a history of hypertension was admitted for a fa
ll with back pain. The blood pressure was at 110/50 mmHg and the pulse
at 115 b . min-1. A pulsatile abdominal mass was palpated. No signs o
f respiratory insufficiency or congestive heart failure were found. Th
e diagnosis of abdominal aortic aneurysm was promptly confirmed by ech
ography. Before laparotomy, a pulmonary artery catheter was inserted f
or haemodynamic monitoring which showed a high cardiac output, low sys
temic vascular resistances, increased pulmonary artery wedge pressure
and a high Svo2BAR (93 %). This was not consistent with a hypovolaemic
shock but rather an aortocaval fistula. After incision and aortic cla
mping, surgical procedure consisted of transaortic closure of the fist
ula and restoration of arterial continuity with a prosthetic graft. In
itial control of venous bleeding was obtained by passing a Foley's cat
heter distally and by clamping the vena cava. The postoperative course
was initially satisfactory. The patient was extubated, but remained w
ith a major renal insufficiency. After a stay of 15 days in the intens
ive care unit, he died from nosocomial pneumonia. Aortocaval fistulas
are either traumatic or spontaneous. Spontaneous fistulas are more com
mon, and in about 90 % of the cases result from a rupture of an athero
sclerotic aortic aneurysm. Clinical findings include signs of high car
diac output symptoms of venous hypertension and regional arterial insu
fficiency. Haemodynamic changes can be of value for the recognition of
an aortocaval fistula. Most authors emphasize the importance of preop
erative diagnosis, allowing the use of appropriate operative technique
s and a prompt control of the fistula. This could decrase haemodynamic
instability and transfusion requirements.