Successful endovascular treatment of post-traumatic iliac arteriovenous fistula

A 76-year-old man presented with breathlessness and left lower limb edema for 2 months.He had a history of spine surgery for a traumatic lumbar fracture 7 years ago.Cardiac auscultation reveals a grade 3/6 systolic murmur in the apical region.Laboratory tests revealed the elevated N-terminal prohormone of brain natriuretic peptide (5185 pg/mL; reference, <125 pg/mL).Transthoracic echocardiography showed cardiomegaly, dilated ascending aorta, mild aortic regurgitation, moderate mitral regurgitation, and pulmonary hypertension.Computed tomography angiography suggested limited dissection of the right common iliac artery (RCIA) (A), arteriovenous fistula (AVF) between the RCIA and left common iliac vein (LCIV) (B and C), and aneurysmal dilatation of the inferior vena cava and LCIV (D/Cover and E).Aortic angiography confirmed the AVF between the RCIA and LCIV (F and Supplementary Video 1, online only).The fistula was occluded using Gore 23 mm 14 mm 12 cm and 16 mm 10 mm 10 cm endograft stent (Supplementary Video 2, online only).The patient had an uneventful recovery and was discharged 3 days after the postoperative endovascular therapy.At a 3-month follow-up, the patient's symptoms of heart failure were relieved remarkably, and the left lower extremity edema significantly improved.Traumatic iliac AVFs (IAVFs) are extremely rare, and the majority occur secondary to penetrating injuries 1 The typical clinical presentation includes the characteristic triad of high-output heart failure, a pulsatile abdominal mass with unilateral limb ischemia, or signs of venous congestion. 2 The initial diagnosis of IAVFs is challenging because patients may present with progressive cardiac failure or even hemodynamic shock as the primary symptom. 3Early recognition of the IAVFs could prevent the risk of heart failure and improve outcomes.Angiography and computed tomography angiography may help to facilitate correct preoperative diagnosis and therapeutic strategies for vascular injuries.Currently, there is no consensus regarding the optimal therapeutic strategy of IAVFs.Open surgery was the first-line treatment for IAVFs in the past decades but may have a high mortality and morbidity. 4With the development of interventional devices and techniques, successful applications of endovascular approaches to IAVFs have been reported.Our case highlights endovascular techniques that may be a safe and effective alternative to open surgical repair for iatrogenic iliac injuries, especially in patients with multiple comorbidities and anatomically challenging injuries.The studies involving human participants were reviewed and approved by the institutional Ethics boards of the Wuhan Aisa Heart Hospital.The patients/participants provided written informed consent to participate in this study.We have obtained the patient's informed consent to publish their anonymized clinical data.