Bilateral Leg Swelling
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Bilateral Leg Swelling
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History
CC: Bilateral leg swellingHPI: This 67 year old white male
complained of bilateral leg edema beginning several weeks prior to admission. He has never had limb edema, lymphedema, or deep venous thrombosis. He has had no injury or other change in his health status.
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History
PMH: cataractsROS: Positive only for long-standing pain in
both lower legs when walking two blocks or more.
PSH: lives at home with his wife, smoked cigarettes (90 pack-years)
MED: eye drops
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Physical Exam
Rales at both bases on auscultation of the chest. ~ 5 cm pulsatile abdominal mass just to left of midline, no tenderness
LABS: WNL
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CT Scan
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Diagnosis?
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CT Scan
5+ cm AAAEarly visualization of contrast within IVCConsistent with fistula
Next steps?
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Aortogram
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Aortogram
Infrarenal AAA extending into both common iliacs
Iliac calcification and stenosisEarly appearance of contrast within IVC
Next steps?
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Operative Findings
Large AAA with bulge to left at bifurcation, distended IVC, bilateral CIA aneurysms.
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Operative Findings
HEADFOOT
AORTA
IVC
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Operative Findings
HEADFOOT
AORTA
IVC
Left CIV
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Procedure
AAA resection with aortobifemoral graft placement through a midline incision
Repair of aortocaval fistula from within aneurysm sac
Ligation of left renal Vein for difficult proximal exposure
HOSPITAL COURSE: Patient developed acute renal failure requiring dialysis. Discharged to home on POD #13.
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Aortocaval Fistula Discussion
Aneurysm erodes (or ruptures) into vena cava or left iliac vein
Sx: syncope, typical rupture pain, swollen legs, venous thrombosis, CHF
Diagnosis: arteriographyTreatment: Repair AAA, close fistula from
within aneurysmMortality: 20-50%