234 SURGERY INFLAMMATORY ABDOMINAL AORTIC ANEURYSMS ( IAAA) represent 3% to 10% of aortic aneurysms encoun- tered in clinical practice. 1 Their rupture into the inferior vena cava (IVC), developing an aortocaval fistula, is extremely rare. 2 Surgical management of aortocaval fistula is usually performed with endo- aneurysmal running suture and rarely with IVC lig- ation. Prosthetic repair of unsuspected aortocaval fistula associated with IAAA, through a left flank retroperitoneal approach, has never been described and was adopted in the reported case. CASE REPORT A 64-year-old man was transferred to our institution with a 2-week history of mottled and edematous scrotum and legs, abdominal distention, and constipation. His medical history was positive for arterial hypertension and previous cerebral stroke leading to hemiplegia of the right side. At admission, the patient was hemodynamically sta- ble; his blood pressure was 110/ 70 mm Hg, and his heart rate was 88 beats/ min. The abdomen was distended, hyperresonant, and mildly tender; prominent superficial venous circulation was evident; a large pulsatile mass was palpable, but no abdominal bruit was audible. There were no signs of high output congestive heart failure. The patient was oliguric and his blood profile revealed the fol- lowing values: serum creatinine, 4.8 mg/ dL; serum urea, 105 mg/ dL; serum potassium and sodium, 5.5 mEq/ L and 126 mEq/ L, respectively. Contrast-enhanced spiral com- puted tomography (CT) showed a 10-cm juxtarenal aortic aneurysm, extending to the bifurcation and surrounded by fibrotic tissue, incorporating the IVC and ureters and causing collateral venous engorgement and bilateral hydroureteronephrosis. Compression exerted by the large aneurysm was responsible for complete occlusion of the IVC in the proximity of the bifurcation (Fig 1, A). In the absence of hemodynamic failure and in con- sideration of the renal impairment, we decided to per- form hemofiltration, to treat uremia and refractory hyperkalemia, and bilateral cystoscopic ureteral stent- ing, to treat obstructive uropathy. Six days later, a left anterolateral flank incision in the 11th intercostal space with extraperitoneal access was per- formed. The abdominal wall was thick, edematous, and rich in collateral venous circulation. A large juxtarenal IAAA was found. All the structures among the thick, desmoplastic process and the collateral venous circulation affecting the retroperitoneum were almost impossible to identify. No palpable thrill was present. The left kidney was displaced anteriorly, and after minimal dissection, proxi- mal suprarenal control of the aorta was obtained, the left common iliac artery was clamped, and, on opening the aneurysm, back-bleeding from the right iliac artery was controlled with insertion of a ballon catheter. On removal of mural thrombus, at the posteromedial aspect of the aneurysmal sac and adjacent to the bifurcation, a wide communication of 6 × 3 cm with the IVC was identified. Decompression of the aneurysm and digital divulsion of residual luminal stenosis allowed the IVC to resume its patency, as demonstrated by venous bleeding from the aor- tocaval fistula. Direct suture from within the aorta was impossible. After distal control with intraluminal balloon catheters inserted into the iliac veins, a venous reconstruc- tion—taking special care to leave a patent lumen—was per- formed with a large polytetrafluoroethylene (PTFE) pros- thetic patch, sutured with continuous 3-0 polypropylene to the edges of the fistula (Fig 2). A bifurcated Dacron poly- ester fiber graft (Clean Room Products, Inc; Ronkonkoma, NY) was inserted and anastomosed just below the renal arteries according to the usual technique. Surgical management of inflammatory abdominal aortic aneurysm associated with occult aortocaval fistula Mauro Ferrari, MD, Gianluca Bonanomi, MD, Nicoletta Fossati, MD, Ugo Boggi, MD, Emanuele Neri, MD, and Franco Mosca, MD, FACS, Pisa, Italy From the Divisions of General and Vascular Surgery and Radiology, Department of Oncology, University of Pisa, Italy Accepted for publication September 2, 1999. Surgery 2000;127:234-6. Reprint requests: Mauro Ferrari, MD, Division of General and Vascular Surgery, University of Pisa, Via Paradisa, 2, Cisanello, 56100 Pisa, Italy. Copyright © 2000 by Mosby, Inc. 0039-6060/ 2000/ $12.00 + 0 11/ 57/ 102755