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Bilateral Leg Swelling. History. CC: Bilateral leg swelling

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Presentation Transcript
history
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.
history3
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
physical exam
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 scan7
CT Scan
  • 5+ cm AAA
  • Early visualization of contrast within IVC
  • Consistent with fistula
  • Next steps?
aortogram9
Aortogram
  • Infrarenal AAA extending into both common iliacs
  • Iliac calcification and stenosis
  • Early appearance of contrast within IVC
  • Next steps?
operative findings
Operative Findings
  • Large AAA with bulge to left at bifurcation, distended IVC, bilateral CIA aneurysms.
operative findings11
Operative Findings

IVC

FOOT

HEAD

AORTA

operative findings12
Operative Findings

IVC

Left CIV

FOOT

HEAD

AORTA

procedure
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
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%