A unique method of closure for an aortocaval fistula in association with a ruptured abdominal aortic aneurysm: report of a case

We report herein the case of a 78-year-old man in whom an aortocaval fistula caused by spontaneous rupture of an abdominal aortic aneurysm (AAA) was successfully treated by a unique surgical technique. The aortocaval fistula had been revealed by an aortography after the patient presented with high-output heart failure. During the operation, massive bleeding from the fistula was evident. The fistula measured 2 cm in diameter, and was located between the right posterior wall of the AAA and the inferior vena cava (IVC). Direct suturing of the defect in the IVC failed to close the fistula because the tissue around it would not hold together due to degeneration. However, the bleeding was finally able to be controlled by plugging the fistula with isolated and properly trimmed omentum packed within the excluded aneurysmal sac. Unfortunately, the patient died due to respiratory failure on the 201st postoperative day. A pathological autopsy revealed that the aortocaval fistula had been closed by fibrous tissue and that the IVC was patent. Although such a drastic operative measure to repair an aortocaval fistula has never before been reported, it could be an alternative when direct closure proves unsuccessful.