Endovascular Treatment of a Large Iliac Vein Aneurysm and High-Flow Arteriovenous Fistula

Abstract

Iliac arteriovenous fistulas (AVFs) are rare but can cause significant morbidity. This report illustrates the endovascular management of a patient with an iliac vein aneurysm caused by an AVF. A 35-year-old pregnant woman was found on routine ultrasound examination to have a left 4.5-cm aortoiliac aneurysm. Past medical history included anxiety, obesity, Lyme disease, methadone use, and hypothyroidism. In addition, she had four emergency department visits during a 2.5-year period leading to diagnoses of pulmonary hypertension (right ventricular pressure of 62 mm Hg) and high-output heart failure of unclear etiology requiring chronic diuresis. Her surgical history included lumbar disk surgery and two cesarean sections. She had no history of abdominal trauma. On examination, she had lower extremity swelling and a pulsating abdominal mass. Because of the high-risk nature of the pregnancy, elective termination was recommended and subsequently performed. Computed tomography angiography showed a left common iliac vein aneurysm measuring 5.5 × 4.2 cm (Fig) and a left common iliac artery to common iliac vein AVF with associated mega cava. The AVF was thought to be related to prior spine surgery. The patient underwent percutaneous endovascular repair of the AVF with placement of a bifurcated aortic AFX stent graft (Endologix, Irvine, Calif). As the AVF was close to the left iliac artery bifurcation, the left internal iliac artery was embolized with an Amplatzer plug (St. Jude Medical, St. Paul, Minn) and the stent graft extended to the left external iliac artery. Completion angiography showed resolution of the AVF. Recovery was uneventful, and the patient was discharged on a 3-month course of coumadin to prevent thrombosis. She had complete resolution of cardiopulmonary symptoms with a decrease in right ventricular pressure to 30 mm Hg at 2 months after the procedure. Computed tomography angiography at 6 months showed no evidence of AVF and shrinkage of the left iliac vein aneurysm to 2.5 cm (Fig). AVF can unusually present as a venous aneurysm. Endovascular treatment of the AVF can resolve the aneurysm and reverse systemic hemodynamic changes.