Endovascular Management of Acute Bleeding Arterioenteric Fistulas

Abstract

The objective of this study was to review the outcome of endovascular transcatheter repair of emergent arterioenteric fistulas. Cases of abdominal arterioenteric fistulas (defined as a fistula between a major artery and the small intestine or colon, thus not the esophagus or stomach), diagnosed over the 3-year period between December 2002 and December 2005 at our institution, were retrospectively reviewed. Five patients with severe enteric bleeding underwent angiography and endovascular repair. Four presented primary arterioenteric fistulas, and one presented a secondary aortoenteric fistula. All had massive persistent bleeding with hypotension despite volume substitution and transfusion by the time of endovascular management. Outcome after treatment of these patients was investigated for major procedure-related complications, recurrence, reintervention, morbidity, and mortality. Mean follow-up time was 3 months (range, 1-6 months). All massive bleeding was controlled by occlusive balloon catheters. Four fistulas were successfully sealed with stent-grafts, resulting in a technical success rate of 80%. One patient was circulatory stabilized by endovascular management but needed immediate further open surgery. There were no procedure-related major complications. Mean hospital stay after the initial endovascular intervention was 19 days. Rebleeding occurred in four patients (80%) after a free interval of 2 weeks or longer. During the follow-up period three patients needed reintervention. The in-hospital mortality was 20% and the 30-day mortality was 40%. The midterm outcome was poor, due to comorbidities or rebleeding, with a mortality of 80% within 6 months. In conclusion, endovascular repair is an efficient and safe method to stabilize patients with life-threatening bleeding arterioenteric fistulas in the emergent episode. However, in this group of patients with severe comorbidities, the risk of rebleeding is high and further intervention must be considered. Patients with cancer may only need treatment for the acute bleeding episode, and an endovascular approach has the advantage of low morbidity.

Quality Improvement Guidelines for Transcatheter Embolization for Acute Gastrointestinal Nonvariceal Hemorrhage

“…Other negative predictive factors include older age, cirrhosis, oncologic diseases, multiple organ failure, and current corticosteroid treatment [7,56]. Generally, the morbidity and mortality associated with endovascular intervention is lower or comparable than for surgical procedure [28,42,[57][58][59].…”

“…The most frequent etiology is diverticulosis and less frequent is bleeding in angiodysplasia, tumors, inflammatory disease, and bleeding from Meckel's diverticulum [4,5]. A separate group comprises hemorrhage from sources outside the digestive tract, such as the biliary tract, the pancreatic duct, and arterioenteric fistula, or visceral arteries aneurysms or pseudoaneurysms [6,7].…”

Endovascular Treatment for Common Iliac Artery Injury Complicating Lumbar Disc Surgery : Limited Usefulness of Temporary Balloon Occlusion

“…Intravascular balloon occlusion would be an effective first step management to control massive bleeding from arterial fistula 6) . However, interventional balloon occlusion and insertion of covered stent are possible only in about 100 hospitals which are about 10% of clinics performing lumbar disc surgery in South Korea according to the data from Health Insurance Review and Assessment Service of Korea.…”

Aortoduodenal fistula following aortic reconstruction of a pseudoaneurysm caused by stab wound 12 years ago

“…Early recognition of herald bleeding and urgent surgical intervention is essential to decrease the mortality rate of AEF. Some authors suggested to place an occlusive balloon at, or above, the level of the AEF, in order to gain time to consider different therapeutic options and even to transport the patient within the institution when needed (Leonhardt et al, 2008). Treatment typically entails removal of the graft and any infected tissue, revascularization, and closure of the bowel fistula.…”