Radiologia Brasileira - Publicação Científica Oficial do Colégio Brasileiro de Radiologia

Dear Editor,

A 63-year-old man was referred to our hospital with abdominal pain, left varicocele, hematuria, and acute kidney injury. Multislice computed tomography (CT) revealed a 7.8 cm infrarenal abdominal aortic aneurysm and no contrast enhancement of the left kidney (Figure 1A), as well as a retroaortic left renal vein and dilatation of the left gonadic vein (Figure 1B), together with simultaneous contrast enhancement of the aneurysm, inferior vena cava, and left renal vein, suggesting the presence of a fistula between the abdominal aortic aneurysm and the aberrant left renal vein (Figures 1C and 1D). Given the suitability of the aneurysm, we decided to perform endovascular repair. Exclusion of the aneurysm and the aorto-left renal vein fistula was achieved after successful deployment of a 26–14 × 165 mm bifurcated endoprosthesis with a 16–16 × 95 contralateral limb (Gore Excluder; W.L. Gore and Associates, Flagstaff, AZ, USA). After endovascular management, renal function initially improved. The patient presented intraoperative hypotension, and the postoperative course was complicated by brain ischemia. Unfortunately, the patient died 65 days after surgery due to multiorgan failure.




Abdominal aortic aneurysm with spontaneous aorto-left renal vein fistula is a rare but well-described clinical entity, usually accompanied by abdominal pain, hematuria, and a nonfunctioning left kidney⁽¹⁾. In male patients, left varicocele may result from venous overload in the pampiniform plexus via the left gonadal vein⁽²⁾. A review of the literature revealed only approximately 30 other reported cases^(3–6). Aorto-left renal vein fistula is often seen in patients with a retroaortic left renal vein, an anatomical variant present in 1.0% to 2.4% of the population⁽⁷⁾. It has been postulated that the vein is compressed between the pulsating aneurysm and the vertebral bodies, leading to erosion of the vessel wall and fistula formation. Open repair is the recognized method of treating rupture of an abdominal aortic aneurysm into a retroaortic left renal vein. Endovascular treatment is an attractive modality because it is minimally invasive, given its capacity for rapid percutaneous arterial access and graft deployment, as well as, if necessary, balloon occlusion for vascular control, thus minimizing blood loss in comparison with open surgery⁽⁸⁾. To our knowledge, this is the sixth reported case in which endovascular repair of this type of fistula has been attempted.


REFERENCES

1. Mansour MA, Rutherford RB, Metcalf RK, et al. Spontaneous aorta-left renal vein fistula: the "abdominal pain, hematuria, silent left kidney" syndrome. Surgery. 1991;109:101–6.

2. Meyerson SL, Haider SA, Gupta N, et al. Abdominal aortic aneurysm with aorta-left renal vein fistula with left varicocele. J Vasc Surg. 2000;31:802–5.

3. Kamali D, Dobson G, Stannard A, et al. Complete endovascular management of a spontaneous aorto-left renal vein fistula caused by ruptured abdominal aortic aneurysm under local anaesthetic: a case report. Eur J Vasc Endovasc Surg. 2014;47:455–6.

4. Yagdi T, Atay Y, Engin C, et al. Aorta-left renal vein fistula in a woman. Tex Heart Inst J. 2004;31:435–8.

5. Faucherre M, Haftgoli-Bakhtiari N, Menth M, et al. Aorto-venous fistula between an abdominal aortic aneurysm and an aberrant renal vein: a case report. J Med Case Rep. 2010;4:255.

6. Dragas M, Davidovic L, Pejkic S, et al. Aorto-left renal vein fistula is a rare complication of abdominal aortic aneurysm with unique clinical presentation. J Vasc Surg. 2010;52:1658–61.

7. Yesildag A, Adanir E, Köroglu M, et al. Incidence of left renal vein anomalies in routine abdominal CT scans. Tani Girisim Radyol. 2004;10:140–3.

8. Ferrari M, Berchiolli R, Sardella SG, et al. Endovascular repair of an aorto-left renal vein fistula due to a ruptured abdominal aortic aneurysm after EVAR. J Endovasc Ther. 2005;12:512–5.










1. Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
2. CEDIRP – Central de Diagnóstico Ribeirão Preto, Ribeirão Preto, SP, Brazil

Mailing address:
Dra. Leonor Garbin Savarese
FMRP-USP
Avenida Bandeirantes, 3900, Monte Alegre
Ribeirão Preto, SP, Brazil, 14049-900
E-mail: leonorsavarese@hotmail.com