Endovascular Treatment of Abdominal Aorto-Caval Fistula With Occluder Devices: Case Report and Systematic Literature Review

Abstract

Aortocaval fistula (ACF) is a life-threatening condition secondary to abdominal aortic aneurysms (AAA) rupture or previous trauma/intervention. The treatment of ACF by an occluder device deployment is a rare but increasingly common approach. We report a case of ACF secondary to ruptured AAA treated with an occluder device after endograft deployment. A 66-year-old male was treated in an emergent setting for a ruptured AAA with ACF deploying aorto-bi-iliac endograft. At 3-month computed tomography angiography (CTA), the persistence of aorto-caval communication and the increased sac reperfusion (type II endoleak) from the lumbar and inferior mesenteric artery were detected. Under local anesthesia and through percutaneous left brachial arterial access and percutaneous right femoral venous access, a 7-mm Amplatzer Septal Occluder was deployed with the “left” atrial end in the aneurysmal sac and the “right” atrial end in the inferior vena cava. The adjunctive embolization of the aneurysmal sac was performed. The post-procedural CTA and 6-month contrast-enhanced ultrasound confirmed the disappearance of endoleak and the exclusion of ACF. A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was conducted regarding the use of occluder devices to treat ACF (PROSPERO; CRD42024512167). Including the current case, 10 patients (male 100%; age range 24–74 years) in 10 publications were found. ACF after trauma and after AAA rupture was described in 6 and 4 patients, respectively. Occluder device deployment was a primary procedure in 6/10 cases and a secondary intervention in 4/10 cases. Different types of occluder devices (vascular 4/10, atrial septal 3/10, duct 2/10, ventricular septal 1/10) were used. Technical success was 100%, with no intraoperative complications. Postoperative complications occurred in 2/10 patients (vascular plug migration and iliac deep vein thrombosis). Three out 10 patients required reintervention within 30 days for persistent patency of ACF (1 endovascular abdominal aneurysm repair, 1 re-embolization of fistula with coils, 1 patient underwent adjunctive septal occluder device and iliolumbar embolization). In 8/10 patients (length of follow-up: 1–80 months), no residual arterio-venous communication. In 3 patients with AAA, aneurysm shrinkage occurred in 3/3 patients, with type II endoleak in 1 case. Although a scarce number of patients are available in the literature, occluder device deployment into abdominal arterio-venous fistula is feasible. For a traumatic ACF, the occluder device deployment could be proposed as the primary treatment, while, after a ruptured AAA, endograft deployment is mandatory.

Clinical Impact

The use of occluder device for the occlusion of an aorto-caval fistula (ACF) is an off-label technique reported in literature. The technical success mainly depends from the type of deployed occluder device. This treatment should be proposed as first approach in post-traumatic ACF without aneurysms; in case of aneurysmal rupture treated with endograft, the occluder device placement should be considered for persistent endoleak from inferior vena cava.