Spontaneous Ilio-Iliac Arteriovenous Fistula from Rupture of an Iliac Aneurysm: A Systematic Review.

Background: Spontaneous arteriovenous fistulas (AVF) caused by iliac aneurysms are a rare condition with possible dramatic complications due to secondary hemodynamic changes. Diagnosis can be challenging because patients may present with progressive cardiac failure or even hemodynamic shock as primary symptom. Due to the rarity of the condition, data are scarce and treatment decisions are challenging. The aim of this systematic review is to give an overview of the symptoms, treatment possibilities, and patient outcomes.
Methods: Literature searches were performed in PubMed, Embase, Web of Science, and Scopus. Case reports and literature reviews were included in the review. The literature review was performed by 2 independent reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A third reviewer was available in case of disagreement. The study was registered in Prospero (ID CRD42022335318). All cases of isolated, iliac atherosclerotic aneurysms with spontaneous fistulization into an iliac vein were included.
Results: Fifty articles were included, resulting in 62 cases. A case from our own center was included, bringing the total up to 63 cases. Median age was 71 years, ranging from 41 to 87 years. 87.3% of patients were male, 6.3% were female, and in 6.3% sex was not reported. The duration of symptoms until presentation ranged from less than an hour to 6 years. 73.0% was treated with open surgery and 17.5% was treated by endovascular way, with 4 reinterventions in the endovascular group. There was an overall mortality rate of 9.5%.
Conclusions: Although rare, iliac AVF might cause acute therapy-resistant heart failure and hemodynamic instability. In patients with acute heart failure, especially when combined with a pulsating mass with accompanying bruit or thrill and unilateral swollen leg, an AVF should be suspected. Surgical treatment of AVF has an excellent outcome, provided that the condition had been diagnosed preoperatively.
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