Bilateral Leg Swelling

History

CC: Bilateral leg swellingHPI: 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.

History

PMH: cataractsROS: 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

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

CT Scan

Diagnosis?

CT Scan

5+ cm AAAEarly visualization of contrast within IVCConsistent with fistula

Next steps?

Aortogram

Aortogram

Infrarenal AAA extending into both common iliacs

Iliac calcification and stenosisEarly appearance of contrast within IVC

Next steps?

Operative Findings

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

Operative Findings

HEADFOOT

AORTA

IVC

Operative Findings

HEADFOOT

AORTA

IVC

Left CIV

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.

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: arteriographyTreatment: Repair AAA, close fistula from

within aneurysmMortality: 20-50%