Elderly Man With Sudden Onset Back Pain

Abstract

A 65-year-old man with hypertension and ongoing tobacco use presented to the emergency department with complaints of sudden-onset severe back pain and anuria for the past day. He was diaphoretic and tachycardic, and a blood pressure of 80/50 mm Hg was noted. His abdominal examination revealed a large pulsatile lump (Figure 1A, Video). Routine laboratory parameters revealed deranged renal function and severe anemia. An emergency computed tomography (CT) angiogram of the abdominal aorta was performed. Ruptured abdominal aortic aneurysm with aortocaval fistula. The CT aortogram (Figure 1B) showed a large abdominal aortic aneurysm that ruptured into the retroperitoneum and additionally into the inferior vena cava (Figure 2A). Early and simultaneous opacification of the inferior vena cava during the arterial phase of the aortogram confirmed aortocaval communication (Figure 2B). Volume-rendered CT of the aorta showed the presence of an aortocaval fistula (Figure 3). The patient underwent urgent surgical exclusion of the ruptured abdominal aortic aneurysm and aortocaval communication closure. Unfortunately, he succumbed to multiorgan dysfunction.Figure 3Volume-rendered computed tomography showing abdominal aortic aneurysm along with early, synchronous opacification of the IVC through an aortocaval connection (arrow) and compressed infrahepatic IVC due to an adjacent retroperitoneal hematoma.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Aortocaval fistula is a rare complication of abdominal aortic aneurysm, usually secondary to erosion caused by an aneurysm.1Matsubara J. Nagasue M. Nakatani B. et al.Aorto-caval fistula resulting from rupture of an abdominal aortic aneurysm—report and review of Japanese reported cases.Eur J Vasc Surg. 1991; 5: 601-604Abstract Full Text PDF PubMed Scopus (21) Google Scholar Its clinical features include back or abdominal pain, pulsatile abdominal lump, auscultable bruit, and at times, right heart failure in chronic cases.2Cinara I.S. Davidovic L.B. Kostic D.M. et al.Aorto-caval fistulas: a review of eighteen years experience.Acta Chir Belg. 2005; 105: 616-620Crossref PubMed Scopus (32) Google Scholar Even with prompt diagnosis and appropriate management, the outcome of these patients is often dismal.3Ghilardi G. Scorza R. Bortolani E. et al.Rupture of abdominal aortic aneurysms into the major abdominal veins.J Cardiovasc Surg (Torino). 1993; 34: 39-47PubMed Google Scholar,4Paravastu S.C. Jayarajasingam R. Cottam R. et al.Endovascular repair of abdominal aortic aneurysm.Cochrane Database Syst Rev. 2014; 23 (CD004178)Google Scholar https://www.annemergmed.com/cms/asset/929341a1-8805-4876-af53-2397a9629838/mmc1.mp4Loading ... Download .mp4 (8.17 MB) Help with .mp4 files VideoAbdominal examination showing a pulsatile abdominal lump.