Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 284-286

Endovascular therapy for high output failure due to iatrogenic iliac-caval fistula

1 Department of Cardiology, Care Hospitals, Hyderabad, Telangana, India
2 Department of Pediatric Cardiology, Care Hospitals, Hyderabad, Telangana, India
3 Department of Pediatric Cardiology, Rainbow Children Heart Institute, Hyderabad, Telangana, India

Date of Submission24-Oct-2019
Date of Decision20-Nov-2019
Date of Acceptance06-Dec-2019
Date of Web Publication12-Sep-2020

Correspondence Address:
Nageshwara Rao Koneti
Department of Pediatric Cardiology, Rainbow Children Heart Institute, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_85_19

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50-year-female presented with features suggestive of high output cardiac failure. She had lumbar discectomy seven years back. Meticulous diagnostic evaluation revealed a large right iliac to lower inferior vena caval communication with continuous shunt. The fistula was closed successfully using a 12 mm muscular ventricular septal occluder. Patient improved dramatically in 24 hours.

Keywords: High-output heart failure, iatrogenic fistula, iliac to caval fistula

How to cite this article:
Menon R, Chikkagoudar K, Koneti NR, Bhakru S, Dhulipudi B. Endovascular therapy for high output failure due to iatrogenic iliac-caval fistula. Indian J Vasc Endovasc Surg 2020;7:284-6

How to cite this URL:
Menon R, Chikkagoudar K, Koneti NR, Bhakru S, Dhulipudi B. Endovascular therapy for high output failure due to iatrogenic iliac-caval fistula. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2022 Dec 6];7:284-6. Available from:

  Introduction Top

High-output congestive heart failure (CHF) in adults is usually due to anemia, thyrotoxicosis, beriberi, and uncommonly due to systemic arteriovenous fistulas (AVFs).[1] Iatrogenic and traumatic AVFs are rare and often remain undiagnosed.[2],[3],[4] Meticulous examination gives subtle but essential clinical clues for the diagnosis. Therapy is based on the underlying condition, and dramatic improvement is seen in most of the cases. We report a case of iatrogenic iliac to caval fistula (ICF) presenting with CHF which was subsequently closed by transcatheter technique using muscular ventricular septal defect (mVSD) occluder.

  Case Report Top

A 50-year-old female presented with palpitations and dyspnea on exertion New York Heart Association Class II. On examination, the heart rate was 88/min with high volume pulse, blood pressure of 160/70 mmHg, and raised jugular venous pressure. Cardiovascular system examination revealed normal heart sounds and a short systolic murmur on the left parasternal border. In view of clinical suspicion of high-output failure, a careful evaluation for a peripheral shunt was done. A loud bruit was audible on the lower abdomen and periumbilical area. Historically, she underwent spinal surgery for lumbar disc prolapse (L4-5) 7 years ago. Careful interrogation revealed that the symptoms started immediately following surgery but was undiagnosed for a long time. Chest X-ray showed a cardiothoracic ratio of 0.6 with increased pulmonary vascularity [Figure 1]. The electrocardiogram showed no abnormality. Transthoracic echocardiogram showed dilated all four chambers and increased flow across the valves. The left ventricular ejection fraction was 62%, and there was no pulmonary hypertension. The ultrasound examination of the abdomen revealed dilated inferior vena cava (IVC) and hepatic veins. Computerized tomography demonstrated a fistulous communication between the right common iliac artery and IVC at L4-L5 disc level suggestive of ICF [Figure 2]. After informed consent, the patient was planned for elective transcatheter device closure. Right femoral vein and left femoral artery access were obtained. Heparin was given as per the protocol. Angiograms in anteroposterior and right anterior oblique views revealed the tortuous AV communication of 8.4 mm [Figure 3]. A 6 Fr internal mammary catheter and angulated guide wire were chosen to cross the fistula. The exchange length guidewire was snared using gooseneck snare (ev3 Endovascular Inc. Plymouth, MN, USA) from the IVC. The AV loop was established. A 10 F Mullen's sheath (Cook medical corp., Bloomington, USA) was advanced over the guide wire into contralateral femoral vein [Figure 4]a. A 12-mm muscular occluder (Cera, Lifetech sciences, Schenzen) was chosen to close ICF. The device was positioned as close as possible to the fistula in the iliac artery. The central waist and caval disc were deployed after confirming the position. Check angiogram did not show any residual shunt across the communication [Figure 4]b. The pulse pressure was reduced from 90 to 70 mmHg, and Nicoladoni-Branham sign was positive (Reflex bradycardia after systemic AVF closure) once fistula was closed. The patient was observed for 24 h and had dramatic improvement in symptoms. The follow-up assessment showed significant improvement in symptoms, reduction in cardiac size, and normal flow in IVC and iliac arteries. Follow-up scans showed nonobstructive flows in both IVC and iliac arteries.
Figure 1: Chest X-ray suggestive of cardiomegaly, pulmonary plethora with pleural effusion

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Figure 2: Computed tomography contrast angiogram with an axial cut at the level of L4 shows iliac artery to inferior vena cava connection. The inferior vena cava is aneurysmal due to systemic arteriovenous fistula

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Figure 3: An injection to the left iliac artery showing opacification of dilated inferior vena cava through fistulous communication

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Figure 4: (a) Terumo wire is crossed across the fistula and an arteriovenous loop is formed. 10 F Mullin's sheath seen on the right femoral venous side. (b) 12-mm muscular VSD occluder across a fistula. Angiogram at iliac artery bifurcation showing no residual leak without obstruction to the aorta (VSD: Ventricular septal defect)

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  Discussion Top

Extracardiac causes of high-output failure in adults are commonly due to anemia, beriberi, thyrotoxicosis, and rarely peripheral AVF. The AVF following disc surgery producing heart failure is a rare complication, and managing such patients is challenging.[2],[3],[5] Abdominal aorta aneurysm can erode to adjacent vena cava and form AV communication.[4],[6] Iatrogenic iliac injury due to lumbar disc surgery is uncommon and reported in the range of 1–5/10,000 disc operations.[7]

In our case, we presume that the iliac caval fistula was formed postspinal surgery (details of spinal surgery were not available). Lumbar discectomy involving the L4-L5 disc is the most common site for AVF formation and approximately 90.9% of fistulas formed due to this procedure occur between the iliac artery and iliac vein or vena cava.[5] The clinical presentation depends on the size and type of communication. Our patient typically presented with dyspnea following surgery, but symptoms were overlooked by various physicians. Her symptoms worsened over the period of time and developed overt heart failure due to ICF. The fistula was suspected because of peripheral signs of high-output failure in the absence of intracardiac shunt. High volume pulse, wide pulse pressure, bruit over the lumbar region, and peri-umbilical area gave clues to suspect the fistula. The increased cardiothoracic ratio by chest X-ray and dilated all four chambers with increased flows by transthoracic echocardiogram revealed indirect evidence of high-output state. Surgical or transcatheter closure is advised for the systemic AVF. Successful transcatheter closure of AVF was previously reported in the literature.[8],[9],[10],[11],[12] Transcatheter endovascular techniques include stent-graft repair and balloon-expandable covered stent insertion. Endovascular repair of an iatrogenic large vessel AVF has many potential advantages over open repair, including lower mortality and morbidity, particularly in patients with a hostile abdomen, rapid recovery, and shorter hospital stay.[12]

However, in our case, the fistula was associated with a dilated aneurysmal sac and appeared suitable for the device closure. The decision of mVSD occluder device was purely based on the anatomy of ICF. Device closure is simple and cost-effective as compared to stent graft or covered stent. A 3 mm oversizing of the device was done due to the long tract of the ICF so that the device can be stretched to occlude the entire length without causing traction on the vascular structures. Device occlusion of the peripheral fistula is a newer modality in the literature, and it can be used as a substitute for the covered stent, but case selection depends on the anatomical lesion. The patient showed dramatic improvement on follow-up.

  Conclusion Top

A high-degree clinical suspicion is needed to diagnose systemic AVF in the presence of high-output failure. Transcatheter treatment is one of the modalities in selected cases where favorable anatomy is present.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bonow RO, Mann DL, Zipes DP, Libby P. Diagnosis and management of heart failure syndrome. In: Zile MR, Little WC. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. Part IV, 9th ed., Ch. 27. Philadelphia, PA: Saunders; 2015.  Back to cited text no. 1
Ferrari E, Baudouy M, Taillan B, Fredenrich A, Tomi M, Grinda JM, et al. Cardiac insufficiency caused by arteriovenous fistula. An unusual complication of spinal surgery. Arch Mal Coeur Vaiss 1990;83:1727-8.  Back to cited text no. 2
Santos E, Peral V, Aroca M, Hernández Lezana A, Serrano FJ, Vilacosta I, et al. Arteriovenous fistula as a complication of lumbar disc surgery: Case report. Neuroradiology 1998;40:459-61.  Back to cited text no. 3
Brewster DC, Cambria RP, Moncure AC, Darling RC, LaMuraglia GM, Geller SC, et al. Aortocaval and iliac arteriovenous fistulas: Recognition and treatment. J Vasc Surg 1991;13:253-64.  Back to cited text no. 4
Jarstfer BS, Rich NM. The challenge of arteriovenous fistula formation following disk surgery: A collective review. J Trauma 1976;16:726-33.  Back to cited text no. 5
Franzini M, Altana P, Annessi V, Lodini V. Iatrogenic vascular injuries following lumbar disc surgery. Case report and review of the literature. J Cardiovasc Surg (Torino) 1987;28:727-30.  Back to cited text no. 6
Ewah B, Calder I. Intraoperative death during lumbar discectomy. Br J Anaesth 1991;66:721-3.  Back to cited text no. 7
Serrano Hernando FJ, Paredero VM, Solis JV, Del Rio A, Lopez Parra JJ, Orgaz A, et al. Iliac arteriovenous fistula as a complication of lumbar disc surgery. Report of two cases and review of literature. J Cardiovasc Surg (Torino) 1986;27:180-4.  Back to cited text no. 8
Cronin P, McPherson SJ, Meaney JF, Mavor A. Venous covered stent: Successful occlusion of a symptomatic internal iliac arteriovenous fistula. Cardiovasc Intervent Radiol 2002;25:323-5.  Back to cited text no. 9
Müller-Wille R, Feuerbach S, Zorger N. Arteriovenous fistula after intervertebral disc operation: Fistula occlusion by percutaneous stent graft implantation. Rofo 2008;180:757-8.  Back to cited text no. 10
Sarmiento JM, Wisniewski PJ, Do NT, Vo TD, Aka PK, Tayyarah M, et al. Bifurcated endograft repair of ilio-iliac arteriovenous fistula secondary to lumbar diskectomy. Ann Vasc Surg 2010;24:551.e13-7.  Back to cited text no. 11
Kim JH, Ko GY, Kwon TW, Nam GB, Cho YP. Endovascular treatment of an iatrogenic large vessel arteriovenous fistula presenting as high output heart failure: A case report. Vasc Endovascular Surg 2012;46:495-8.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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