Iliocaval Fistula Presenting with Paradoxical Pulmonary Embolism Combined with High-Output Heart Failure Successfully Treated by Endovascular Stent-Graft Repair: Case Report
A 51-yr-old male was admitted on April 4, 2012, with palpitation and exertional dyspnea gradually deteriorated for a week. He visited other hospital a week ago, because anorexia, nausea, vomiting and abdominal discomfort developed and continued for three weeks without any improvement. In that hospital, right iliac artery aneurysm (4.5 cm in diameter) with iliocaval shunt combined with thrombus was found incidentally by contrast-enhanced computed tomography (CT) (). He was referred to our hospital for proper management of iliocaval fistula. His risk factor of iliac aneurysm was hypertension. However, he have not underwent any abdominal trauma or surgery.\nOn admission to our hospital, his vital sign were blood pressure of 137/82 mmHg, heart rate of 103 beats/min, respiratory rate of 20/min, body temperature of 36.5℃, and oxygen saturation of 96%. His heart sound was regular and rapid. Rale was auscultated on both lower lung field. Bruit detected by auscultation of right inguinal area and palpable mass was not identified. There was no leg edema and normal peripheral arterial pulse was detected in both lower extremities.\nLaboratory test showed a slight elevated C-reactive protein of 0.95 mg/dL (normal range < 0.3 mg/dL) without leukocytosis, creatinine level of 1.45 mg/dL (normal range: 0.5-1.3 mg/dL), aspartate transaminase of 56 IU/L (normal range: 12-33 IU/L) and alanine transaminase of 119 IU/L (normal range: 5-35 IU/L). Platelet, bilirubin, and international normalized ratio was within normal range and electrolyte or acid-base imbalance was not found. CK-MB and Troponin T was within normal range, but NT pro-BNP was elevated to 2,404 pg/mL (normal range: 5-125 pg/mL). Electrocardiogram showed sinus tachycardia without abnormal ST segment or T wave change. Cardiomegaly with pulmonary edema and bilateral pleural effusion in simple chest x-ray was detected. We considered possibility of heart failure, and examined echocardiogram. Ejection fraction was 63% and regional wall motion abnormalities was not observed. These findings suggested high-output heart failure. Right atrial and ventricular dilatation, D-shaped left ventricle, and the dilatation of inferior vena cava was identified incidentally. Contrast-enhanced chest CT was performed and showed pulmonary thromboembolism involved right lower lobe base segmental pulmonary artery (). We checked doppler sonography of lower extremities, tumor markers, and upper and lower endoscopy for evaluate origin of emboli. There were no evidence of deep vein thrombosis or malignancy. Therefore, we concluded that pulmonary emboli was originated from thrombus in iliac aneurysmal sac.\nWe decided to treat his iliocaval shunt by endovascular stent graft implantation for restoring heart function and preventing recurrent pulmonary embolism. For a start embolization of right common iliac artery was performed with PLUG 10mm (Amplatzer vascluar plug, Aga Medical Corp) (). Angiogram showed aneurysmal dilatation of right common iliac artery and iliocaval shunt. Some filling defects near the aneurysm, suggesting of thrombi (). Then two graft stents (Excluder contralateral leg 12/100 mm, 12/120 mm, W.L Gore and Associates) are placed at right common iliac artery. Post-stenting balloon angioplasties were performed (EverCross 12/40 mm, EV3 Inc). After the procedure, aortogram showed well implanted graft stents and no visible of IVC and endoleak (). After the implantation of graft stents, dyspnea was improved and follow up creatinine level and liver enzymes were normalized. Simple chest x-ray showed no pulmonary edema or pleural effusion at discharge. Coumadization was started for resolution and prevention of pulmonary embolism.\nAt routine follow up 6 months after the procedure, the patient was in good clinical condition. Echocardiogram showed that D-shaped left ventricle was completely resolved and right atrial and ventricular size was normalized. CT demonstrated that the stent-graft was patent and well-postioned, without evidence of graft migration, aortacaval communication or endoleak (). Pulmonary embolism was mostly regressed ().