Aortoduodenal fistula 2 years after elective endovascular repair of an abdominal aortic aneurysm

Abstract

Aortoduodenal fistula 2 years after elective endovascular repair of an abdominal aortic aneurysm Aortoenteric fistula (AEF) is a rare complication after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). 1 An AEF is a pathological connection between the aorta and gastrointestinal tract that is invariably life-threatening. Primary AEFs occur de novo due to mechanical factors, aortic inflammation or infection. Secondary AEFs commonly involve a previously placed aortic graft. Almost all secondary AEF occur after open AAA repair but cases following EVAR are reported. 1-6 We present our experience with this rare complication, which is unique because it was only identified at time of operation. An 85-year-old female with a history of chronic lymphocytic leukaemia on ibrutinib and atrial fibrillation on rivaroxaban was referred to a vascular surgeon with a 38 × 30 mm incidental saccular infrarenal aortic aneurysm. There was no clinical evidence that the aneurysm was mycotic. She underwent an uncomplicated endovascular graft repair using a Gore Excluder AAA Endograft (W. L. Gore & Associates, Inc.; Newark, Delaware, US). Follow-up duplex ultrasound at 24 months post-operatively demonstrated a patent stent graft with no evidence of endoleak. Twenty-five months post-operatively, the patient developed left lower quadrant abdominal pain, night sweats and constipation. She denied any gastrointestinal bleeding. Investigation of her abdominal pain including a colonoscopy did not identify a cause. She

Treatment of Post-Evar Aortoduodenal Fistula Without Endograft Excision

“…Although millions of aneurysms have been repaired using endovascular techniques, 21 only about 30 cases of post-EVAR aortoduodenal fistula have been reported. 2,[4][5][6][7][8][9][10][11] They have resulted from either distal migration of the aortic prosthesis, secondary infection, or ongoing endoleak (type I) which served to erode then disintegrate the barrier separating the duodenum from the bloodstream. To date, all cases reported in the surgical literature have been treated with graft excision, duodenal repair and either extra-anatomic bypass or in situ aortic replacement.…”

“…To date, all cases reported in the surgical literature have been treated with graft excision, duodenal repair and either extra-anatomic bypass or in situ aortic replacement. [4][5][6][8][9][10][11] Attempts at nonoperative treatment by leaving the endograft in place have proven uniformly fatal. 13 The elderly patient presented herein underwent successful EVAR then re-presented 2 months later with concern for development of a secondary aortoduodenal fistula.…”

“…[1][2][3] Aortoenteric fistula formation following endovascular aneurysm repair (EVAR) is less likely as the aortic endoprosthesis resides inside an excluded aneurysm sac so is anatomically separated from the bowel. 2,[4][5][6][7][8][9][10][11] In general, the reported cases of aortoenteric fistula following EVAR have been treated in a similar fashion as fistula formation following open aortic repair, namely by duodenal exclusion, graft excision and either extra-anatomic bypass or in situ aortic graft replacement. [4][5][6]8,9,12 The operation is curative but also highly morbid and mortal.…”

Aorto-digestive fistula: a rare cause of gastrointestinal bleeding

“…до 25 лет [15]. Развитию способствуют такие факторы, как миграция и изгиб трансплантата, эндолики, местная инфекция [16], которые приводят к несостоятельности анастомоза и образованию ложной аневризмы аорты [17]. Еще одна причина -близкое расположение трансплантата и органа желудочно-кишечного тракта [18].…”

“…Важное преимущество перед эндоскопическими и ангиографическими методами -отсутствие риска рецидива или усугубления имеющегося кровотечения [7]. К основным признакам аорто-дигестивной фистулы по данным МСКТ относятся: газ в забрюшинном пространстве или стенке аорты (чувствительность 40 %, специфичность 100 %) [16]; сдавление и сморщивание кишечной стенки по направлению к аневризматически измененной аорте [30], исчезновение между ними жировой прослойки (чувствительность 90 %, специфичность 33 %) [15]; разрушение стенки аорты (чувствительность 89 %, специфичность 75 %), экстравазация контраста в полый орган [7]; ложная аневризма анастомоза протеза аорты рядом со стенкой полого органа со скоплением жидкости (чувствительность 90 %, специфичность 92 %), отеком и утолщением более 5 мм мягких тканей в области трансплантата [6]. Если аорто-дигестивная фистула изначально установлена по данным МСКТ, следует без диагностических и лечебных эндоскопических манипуляций направлять пациента на экстренную операцию, задержка которой может привести к летальному исходу.…”