Endovascular Repair of an Aortoduodenal Fistula

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.

Endovascular management of arterioenteric fistulas: a systemic review and meta-analysis of the literature

PURPOSE

To present a systemic review and meta-analysis investigating the outcomes of endovascular management of arterioenteric fistula (AEF).

METHODS

Literature review on AEF management with endovascular surgery using MEDLINE search, including two cases managed by the authors.

RESULTS

Fifty-nine patients (50 men; mean age 68 years, range 23-90) were identified. AEF was successfully managed in 55 (93%) patients and 30-day mortality was 8.5% (5/59). During follow-up, 10 (19%) patients developed recurrent bleeding, which occurred more often in AEFs due to cancer. The freedom from recurrence rate at 12 and 24 months was 71.5%. Seventeen (32%) patients developed sepsis, which was managed conservatively in 8 (7 successful). Freedom from sepsis at 12 and 24 months was 64%, while the freedom from combined recurrence and sepsis at 12 and 24 months was 59%. Patients who did not have intestinal repair had a higher rate of combined recurrence and sepsis compared to patients who did; the freedom from combined recurrence and sepsis at 12 months was 52% for patients not having intestinal repair versus 100% in patients who did (p = 0.022). Total AEF-related mortality rates at 12 and 24 months were 15% and 19%, respectively, significantly worse when AEF recurred (p = 0.001). Overall survival rates at 12 and 24 months were 68% and 52%; prognosis was worse in patients with perioperative sepsis, large bowel fistulization, tube graft placement, no intestinal repair, and recurrent AEF.

CONCLUSION

Endovascular management of AEF can achieve satisfactory short and midterm results, better than those historically reported for open surgery, despite the high rate of recurrent bleeding and sepsis. Further investigation of the role played by intestinal repair is warranted.

Endovascular Repair of a Bleeding Secondary Aortoenteric Fistula with Acute Leg Ischemia: a Case Report and Review of the Literature

The endovascular approach seems very attractive for patients with bleeding secondary aortoenteric fistulas (SAEF) and limb ischemia, particularly when there is no associated sepsis. Aortic stent-grafting can rapidly seal the aortoenteric communication and ensure limb reperfusion. In the present case, a 53-year-old man with a bleeding SAEF and acute leg ischemia underwent aortic stent-grafting. Ten months later, CT and leukocyte scan (Tc-99m) showed no evidence of graft infection and the patient remains well 18 months postoperatively. In the typical patient with a bleeding SAEF, endoluminal treatment, if feasible anatomically, should be considered as first-choice treatment whether it represents a "bridging" step or a "definite" solution.