J Cardiol 2007 Mar; 49（3）: 143 – 147

Progressive Congestive Heart
Failure Due to Common Iliac
Arteriovenous Fistula : A Case
ReportNaoyuki

SATA, MD

Kiyohisa

HIRAMINE, MD

Takashi

HORINOUCHI, MD

Shigeru

AMITANI, MD

Kenkichi

MIYAHARA, MD

Chieri KIMURA, MD＊1
Jun

MOHARA, MD＊1

Yukinori

MORIYAMA, MD＊1

Yasuhiro

TANAKA, MD, FJCC＊2

Hirohito

TSUBOUCHI, MD＊2

Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
Arteriovenous shunt is one of the causes of heart failure, but heart failure caused by common iliac arteriovenous fistula is relatively rare. A 64-year-old man who developed acute heart failure due to venous perforation of a common iliac aneurysm and also had bilateral aneurysms（diameter 58 mm）was referred toour department. On admission, the patient complained of dyspnea and swollen left leg, so diuretic agent
was administered to treat the heart failure. Cardiac catheterization showed a shunt rate of 80.6%, as well as
5.0 Qp/Qs and O2 step-up across perforation of the common iliac vein. Despite the therapy, pleural effusion and ascites exacerbated, and the heart failure became difficult to control, so surgical treatment wasperformed. The aneurysm was replaced with an artificial vessel, and the fistula was closed by direct suturing. Postoperatively, the symptoms disappeared, and the patient is in good health.
─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────J Cardiol 2007 Mar; 49（3）: 143−147

Key Words
Aneurysms common iliac artery

INTRODUCTION
Arteriovenous shunt can affect the heart and vessels, and arteriovenous shunt is common at thecommon iliac level. Most cases are iatrogenic,
sometimes as complications from intraabdominal
surgery or puncture.1,2）Arteriovenous shunt is also
one of the causes of heart failure, including rare

Aortic diseases

Heart failurecases of common iliac arteriovenous fistula. 3）
Rupture of an aneurysm into a vein causes thesymptoms associated with heart failure, but mostaneurysms and arteriovenous fistulas are asymptomatic. Furthermore, edema may occur ipsilateral tothe arteriovenous fistula.4）Vascular abnormalities
that cause heart failure may be closely related to thegeneral condition, so that thorough physical exami-──────────────────────────────────────────────
新杏病院 循環器科，＊ 1 心臓血管外科 : 〒 890−0073 鹿児島県鹿児島市宇宿 3−41−1 ; ＊ 2 鹿児島大学大学院医歯学総合研究科
人間環境学講座消化器疾患・生活習慣病学，鹿児島Divisions of Cardiology and ＊ 1Cardiovascular Surgery, Shinkyo Hospital, Kagoshima ; ＊ 2Department of Digestive and Life-Style
Related Diseases, Human Environmental Sciences, Health Research Studies, Kagoshima University Graduate School of Medical andDental Sciences, Kagoshima
Address for correspondence : SATA N, MD, Division of Cardiology, Shinkyo Hospital, Usuki 3−41−1, Kagoshima, Kagoshima 890−
0073 ; E-mail : sanao@m.kufm.kagoshima-u.ac.jp
Manuscript received July 31, 2006 ; revised November 21 and 28, 2006 ; accepted December 1, 2006143144

Sata, Hiramine, Horinouchi et alnation, including auscultation, is particularly important.
The present patient had heart failure caused byan arteriovenous shunt associated with venous perforation of a right common iliac aneurysm withpain and swelling of the contralateral leg.
Arteriovenous shunt of the leg is one of the causesof heart failure, so should be considered in the differential diagnosis of heart failure.
CASE REPORTA 64-year-old man had no disease requiring periodic hospital visits. Forty years earlier, he underwent surgery to remove kidney stones from theright urinary tract. He had no history of hypertension, hyperlipidemia or smoking.
The patient suddenly experienced pain andswelling of the left leg. The patient also complainedof abdominal discomfort. Gastric endoscopic examination and abdominal ultrasonography revealed
abdominal venous dilatation. Chest radiography
revealed congestive heart failure, and computed
tomography confirmed bilateral common iliac
aneurysms and right common iliac arteiovenous fistula（Fig. 1）. The patient was then referred to ourdepartment.
On admission, the patient complained of dyspnea, and pain and swelling of the left leg. Bloodpressure was 100/76 mmHg, and heart rate was
90/min, with normal sinus rhythm. A continuous
murmur was also audible in the abdominal region.
Chest radiography confirmed cardiac dilatation,
pulmonary congestion and pleural effusion（Fig.
2）. Electrocardiography confirmed normal sinus
rhythm and complete right bundle branch block.
Echocardiography showed normal left ventricularwall movement, mildly elevated pulmonary arterypressure, and markedly enlarged inferior vena cava.
Diuretic therapy was initiated to treat congestive
heart failure, and although the symptoms improved
transiently, heart failure again exacerbated, despite
increased dose of diuretic agents, and ascites wasseen. Hence, the heart failure became difficult tocontrol with drug therapy.
The results of cardiac catheterization and contrast-enhanced aortography were as follows : common iliac arteriovenous shunt rate was 80.6%,
Qp/Qs was 5.0, and O 2 step-up was seen in thecommon iliac vein（Table 1）. Shunt flows wereconfirmed at the right common iliac vein and rightcommon iliac aneurysm（Fig. 3）. Based on theFig. 1 Abdominal three-dimensional computed tomography scanrt.＝ right; IVC ＝ inferior vena cava.

Fig. 2 Chest radiographclinical course, the diagnosis was congestive heart
failure. He then underwent Y-graft replacement andcommon iliac arteriovenous fistula ligation（Fig.
4）. Postoperative right cardiac catheterization
revealed marked improvements in pressure data
J Cardiol 2007 Mar; 49（3）: 143 – 147

Congestive Heart Failure Due to Iliac Arteriovenous Fistula

Table 1145

Echocardiographic findings and hemodynamics before and after operation
Echocardiography
Before operation

After operation

Left ventricular end-diastolic diameter（mm）

5542

Left ventricular end-systolic diameter（mm）

3628

Inferior vena cava（mm）

259

Pulmonary arterial pressure（mmHg）

5420

Cardiac catheterization
Hemodynamics

Before operation

After operation

Pulmonary capillary wedge pressure（mp）（mmHg）

224

Pulmonary arterial pressure（sp/dp/mp）（mmHg）

60/30/40

22/6/12（mmHg）
Right ventricular pressure（sp/edp）

60/25

22/4

Right atrial pressure（mp）（mmHg）

223

Qp/Qs＝5.07
L→R shunt rate : 80.6%
mp＝mean pressure ; sp＝systolic pressure ; dp＝diastolic pressure ; edp＝end-diastolic pressure ; Qp/Qs＝ ratioof blood flow before and after common iliac arteriovenous fistula.

Fig. 3 Angiogram of the abdominal aorta（left anterior
oblique view 45 °）Abbreviations as in Fig. 1.

（Table 1）. Postoperative course was favorable, andthe patient recovered without complications. At
present（3 months after surgery）, the patient has
returned to work and is not taking any medication.
DISCUSSION
Arteriovenous shunt affects the heart, large vesJ Cardiol 2007 Mar; 49（3）: 143 – 147sels and small vessels, and arteriovenous shunt at
the common iliac level is not uncommon. Arteriovenous shunt can be caused by trauma or infection,5,6）but is often iatrogenic, and may occur as acomplication of orthopedic surgery, urologic
surgery or puncture. 7−9） Several studies havereported venous perforation of aneurysms, andthere have been 32 reported cases of common iliac
arteriovenous fistula, including complications fromheart failure.10）
The onset mechanism for venous perforation ofaneurysms may involve localized degeneration andulceration of the aortic wall due to arteriosclerosis
or infection. 11）Symptoms at the time of onset
include dyspnea associated with heart failure andswelling of the leg ipsilateral to the arteriovenous
fistula. The present patient had swelling of the leg
contralateral to arteriovenous fistula, but theswelling disappeared postoperatively, so may havebeen caused by venous compression or perfusion
disturbance due to the aneurysm. Even when an
aneurysm grows in size, it is often asymptomatic,
and leg swelling is an important diagnostic sign.
Although the symptoms associated with heart failure were transiently alleviated by drip infusion ofdiuretic agents, the present patient gradually worsened, and when ascites was confirmed, heart failure
could not be controlled with drug therapy.
The present patient had previously undergone
surgery for kidney stones ipsilateral to theaneurysm, so persistent arteriovenous fistula due to146

Sata, Hiramine, Horinouchi et al

Right common iliac
aneurysmal artery

Fig. 4 Intraoperative photographs

Arteriovenous fistula

surgical complications was suspected. However, theclinical course after onset of venous aneurysm perforation is rapid.12）In the present patient, left leg
swelling appeared suddenly, and the symptoms
exacerbated rapidly, thus suggesting acute-onset
venous perforation.
At surgery, ulceration of the arterial wall aroundthe perforation was confirmed. Hypotension may be
associated with a rapid decrease in intraventricular
要

Arteriovenous fistula is
10 mm in diameter.

blood immediately after surgery,13）but in the present patient, hemodynamics were stable immediately after surgery, and as frequently found, the patient
returned to a normal life without medication. Thus,
arteriovenous shunt at the leg level can cause heart
failure, and because the enlarged aneurysm andvenous perforation are often asymptomatic, it isnecessary to consider arteriovenous shunt as one of
the causes of heart failure.
約

総腸骨動静脈瘻の静脈穿破によりうっ血性心不全をきたした 1 例
佐多直幸

平峯聖久

堀之内尚志

網 谷滋

宮原健吉

木村知恵里

茂 原淳

森山由紀則

田中康博

坪内博仁

心不全の原因として，動静脈シャント疾患があるが，総腸骨動静脈瘻による心不全の例は比較的まれである．今回我々は総腸骨動脈瘤の静脈穿破による急性心不全を経験したので報告する．症例は 64 歳，男性．心不全，右総腸骨動静脈瘻，両側動脈瘤（径 58 mm）を指摘され当科に紹介入院した．入院時，呼吸苦と左下腿腫脹を訴え，心不全に対して利尿薬治療を開始した．心臓カテーテル検査で総腸骨静脈の動脈瘤前後でのシャント率 : 80.6%，Qp/Qs 比 : 5.0，総腸骨静脈の穿通部前後での O2 step-up を認めた．治療を継続するも，胸腹水は増加し心不全コントロールが困難となったため，手術を施行した．動脈瘤は，人工血管で置換し，瘻孔を直接縫合閉鎖した．以後，症状は消失し経過良好である．

J Cardiol 2007 Mar; 49（3）: 143−147

J Cardiol 2007 Mar; 49（3）: 143 – 147

Congestive Heart Failure Due to Iliac Arteriovenous Fistula

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