Ultraschall Med 2016; 37 - PS7_10
DOI: 10.1055/s-0036-1587896

Aorto-caval fistula mimicking severe liver disease – Problems and possibilities of EVAR in a ruptured aortic aneurysm -

M Mehrmann 1, R Kubale 2, P Minko 1, C Ziemann 3, H Wilkens 4
  • 1Uniklinikum des Saarlandes, Radiologie, Homburg/Saar, Germany
  • 2Gemeinschaftspraxis für Radiologie, Pirmasens, Germany
  • 3Uniklinikum des Saarlandes, Abdominal und Gefäßchirurgie, Homburg/Saar, Germany
  • 4Uniklinikum des Saarlandes, Medizinische Klinik V, Homburg/Saar, Germany

Purpose: To show primary and secondary symptoms and diagnostic problems of a high flow aorto-caval fistula.

Material and methods: A 60 year old male was admitted to hospital due to severe pulmonary hypertension (PH), cardiomegaly and liver cirrhosis with ascites. Cardiac output was elevated up to 12 l/min. CT and Color coded duplex sonography (CCDS) without and with contrast (CEUS) are compared with angiography. LFTs and elastography (Shear wave technique) were controlled over more than 6 months.

Results: CT showed an infra-renal aneurysm of 8 × 9 cm with early filling by contrast misinterpreted as a sign of tricuspid insufficiency. CEUS showed a high flow aorta caval fistula proved by angiography. An aortic stent was implemented (Aorfix, Lombard Medical). First control measurements showed a reperfusion by A. mes. inferior and lumbar arteries. After three re-interventions with occlusion of feeding vessels and a coated stent in the IVC only a small leakage persisted with shrinking size of the aneurysm during follow-up.

Ascites disappears immediately after fistula occlusion. Liver stiffness reduces after 3 month from more than 3 m/s to 1.5 m/s.

Conclusions:

  • High volume fistula and severe right heart failure can mimic severe liver cirrhosis. Especially high pressure in the liver can cause false positive fibrosis measurements with Fibroscan® and ARFI technique.

  • EVAR in cases of persistent fistula showed a high rate of reperfusion. In this case 3 interventions were necessary and helpful for reducing the HZMV slowly.

  • In cases with severe hypertension a systematic search for fistula should be done.