Bilateral Leg Swelling

1
Bilateral Leg Swelling
2
History

• CC Bilateral leg swelling
• HPI This 67 year old white male complained of
  bilateral leg edema beginning several weeks prior
  to admission. He has never had limb edema,
  lymphedema, or deep venous thrombosis. He has had
  no injury or other change in his health status.

3
History

• PMH cataracts
• ROS Positive only for long-standing pain in both
  lower legs when walking two blocks or more.
• PSH lives at home with his wife, smoked
  cigarettes (90 pack-years)
• MED eye drops

4
Physical Exam

• Rales at both bases on auscultation of the chest.
  5 cm pulsatile abdominal mass just to left of
  midline, no tenderness
• LABS WNL

5
CT Scan
6
Diagnosis?
7
CT Scan

• 5 cm AAA
• Early visualization of contrast within IVC
• Consistent with fistula
• Next steps?

8
Aortogram
9
Aortogram

• Infrarenal AAA extending into both common iliacs
• Iliac calcification and stenosis
• Early appearance of contrast within IVC
• Next steps?

10
Operative Findings

• Large AAA with bulge to left at bifurcation,
  distended IVC, bilateral CIA aneurysms.

11
Operative Findings
IVC
FOOT
HEAD
AORTA
12
Operative Findings
IVC
Left CIV
FOOT
HEAD
AORTA
13
Procedure

• AAA resection with aortobifemoral graft placement
  through a midline incision
• Repair of aortocaval fistula from within aneurysm
  sac
• Ligation of left renal Vein for difficult
  proximal exposure
• HOSPITAL COURSE Patient developed acute renal
  failure requiring dialysis. Discharged to home on
  POD 13.

14
Aortocaval Fistula Discussion

• Aneurysm erodes (or ruptures) into vena cava or
  left iliac vein
• Sx syncope, typical rupture pain, swollen legs,
  venous thrombosis, CHF
• Diagnosis arteriography
• Treatment Repair AAA, close fistula from within
  aneurysm
• Mortality 20-50