Anesthetic implications of surgical repair of an aortocaval fistula

Abstract

Arteriovenous fistulas (AVF) deprive the surrounding tissues of blood supply and nutrients, produce venous hypertension and localized edema, and by overloading the heart can cause congestive heart failure. Clinical manifestations of the AVF depend on its size, its locality, and the presence or absence of concomitant cardiac disease. Aortocaval fistula (ACF) is a recognized complication of an abdominal aortic aneurysm (AAA). 1 Brewster DC Cambria RP Moncure AC et al. Aortocaval and iliac arteriovenous fistulas: Recognition and treatment. J Vasc Surg. 1991; 13: 253-265 Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar Numerous studies published in the surgical journals document significant hemodynamic changes in the presence of ACF. These are a significant reduction in systemic vascular resistance (SVR), <500 dynes.sec.cm−5; a remarkable increase in the cardiac output up to 12 to 15 L/min; and a significant increase in cardiac filling pressures. 2 Ghilardi G Scorza R Bortolani E et al. Rupture of abdominal aortic aneurysms into the major abdominal veins. J Vasc Surg. 1993; 34: 39-47 Google Scholar , 3 Salo JA Verkkala K Ketonen P et al. Diagnosis and treatment of spontaneous aortocaval fistula. J Cardiovasc Surg. 1987; 28: 180-183 PubMed Google Scholar These hemodynamic alterations are reversed by the surgical or endovascular repair of the fistula. 4 Sharma ML George KA Gamble JAS Anesthetic implications of endovascular repair of aortocaval fistula. Anaesthesia. 2000; 55: 697 Crossref PubMed Scopus (5) Google Scholar This sudden normalization of the afterload, 500 dynes.sec.cm−5 to 1,200 dynes.sec.cm−5, and the mobilization of edema fluid can further compromise the already stressed heart. A review of the literature revealed no detailed information on the anesthetic management of patients with ACF. The authors report management of a patient with ACF who presented for its repair.