Double primary aortoenteric fistula

Emergent Endovascular Treatment in Primary Ilio-enteric Fistula

Aortoenteric fistula (AEF) is a rare cause of gastrointestinal (GI) bleeding. If not promptly diagnosed and treated, the associated mortality is very high. The role of endovascular treatment is not yet defined. In this article, we report a clinical case of a 94-year-old male patient admitted in the emergency department with rectal bleeding. Owing to the detection of a pulsatile abdominal mass, a computed tomography angiography (CTA) scan was performed, which established the diagnosis of aorto-enteric fistula due to a left common iliac artery aneurysm (CIAA) ruptured to the sigmoid colon and also revealed an abdominal aortic aneurysm (AAA) and an internal iliac artery aneurysm (IIAA). Given the age of the patient, general condition and technical difficulty inherent to the treatment of the IIAA by conventional surgery, we chose endovascular treatment. However, we wanted to avoid contact between the endograft and the colon orifice because of the risk of infection. The patient was treated emergently with an aorto-right uni-iliac graft and a femoro-femoral bypass, IIAA embolization and 2 left iliac excluders (at the origin of the common iliac and distally in the external iliac artery). It was decided to treat colon lesion conservatively. In this case, the aorto-uni-iliac graft excluded the aortic inline flow, the distal occluder prevented retrograde flow from the external iliac, and the embolization prevented retrograde flow and treated the IIAA. This way, no arterial pressure and no prosthetic material existed inside the ruptured artery, hopefully allowing the spontaneous closing of the orifice leading the sigmoid colon to heal. The postoperative period was uneventful, and the patient was discharged at the 8^th postoperative day. The patient outcome is a strong argument on the merit of the treatment strategy.

Double primary aortoenteric fistulae: a case report of two simultaneous primary aortoenteric fistulae in one patient

Aortoenteric fistula is a rare but potentially fatal condition causing massive gastrointestinal bleeding. In particular, double primary aortoenteric fistulae are vanishingly rare. We encountered a 75-year-old male patient suffering from abdominal pain, hematochezia, hematemesis, and hypotension. His computed tomography images showed abdominal aortic aneurysm and suspected aortoenteric fistulae. During surgery, we found two primary aortoenteric fistulae. The one fistula was detected between the abdominal aorta and the third portion of the duodenum, and the other fistula was detected between the abdominal aorta and the sigmoid colon. We conducted the closure of the fistulae, the exclusion of the aneurysm, and axillo-bifemoral bypass with a polytetrafluoroethylene graft. The patient was discharged with no complications on the 21st postoperative day.

Unexpected double-primary aortoenteric fistula resulting in massive bleeding after induction of anesthesia

We report a case of a patient with a double-primary aortoenteric fistula with an abdominal aortic aneurysm. A 75-year-old man was taken to the operating room for the repair of an abdominal aortic aneurysm and a suspected aortoenteric fistula between the aorta and sigmoid colon. Sudden onset of massive bleeding through the nasogastric tube occurred after the induction of anesthesia. Surgical exploration confirmed an unexpected aortoduodenal fistula. Primary aortoenteric fistula is extremely rare and difficult to diagnose, and may cause fatal bleeding. The possibility of the presence of aortoenteric fistula, including multiple types, should be considered in the anesthetic management of abdominal aortic aneurysm.

Unusual forms of ruptured abdominal aortic aneurysms

Over 95% of abdominal aortic aneurysms (AAAs) rupture into the retroperitoneal space. Rare types of AAA ruptures comprise ruptures into the inferior vena cava with aortocaval fistula formation (ACF), ruptures into the duodenum with formation of a primary aortoduodenal fistula (ADF), and chronic contained ruptures (CCRs). This article presents a study of 41 cases with unusual forms of ruptured AAA of a series of 506 patients with AAA rupture treated within a 14-year period. There were 11 cases of CCR, 5 cases with ADF, and 25 cases with ACF. The correct preoperative diagnosis was established in 6 (of 11) cases of CCR, in 2 (of 5) cases of primary ADF, and in 13 (of 25) cases of ACF. AAA replacement was performed in 8 cases using a tube graft, whereas a bifurcated graft was used in 31 patients because of the distant extent of the atherosclerotic/aneurysmatic lesions engaging iliac arteries. Two patients had an axillobifemoral bypass. The overall 30-day mortality rate was 19% (8 of 41), with subgroup mortality rates of 0 (CCR), 60% (ADF), and 20% (ACF). Diagnosis and treatment are simplest in cases of CCR and the most complicated in cases of ADF.

Primary aortoenteric fistula

BACKGROUND

A primary aortoenteric fistula (PAEF) is a rare clinical entity that results in fatal exsanguination if undiagnosed. The present study investigates whether management and survival have altered over time.

METHODS

A Medline search was conducted for the period from January 1994 to December 2003. Data were categorized and compared with reviews of PAEF published before this interval.

RESULTS

The classical triad (gastrointestinal bleeding, pain and a pulsating mass) was present in only 11 per cent of 81 patients. Most PAEFs were caused by an aneurysmal aorta and were almost always (94 per cent) heralded by repetitive gastrointestinal bleeds. Computed tomography (CT) provides images superior to those of other diagnostic modalities, such as gastroduodenoscopy or conventional angiography. Operative mortality rates were lower in later years possibly owing to improvements in perioperative care and the advent of endovascular techniques.

CONCLUSION

Gastrointestinal bleeding combined with a negative endoscopy in the presence of an aneurysmal aorta suggests PAEF and requires urgent evaluation by CT. Endovascular operation is an attractive treatment option.