Endovascular treatment of aortic stump blow-out after extra-anatomical repair of aortoduodenal fistula: a case report and review of literature

Abstract

Background: An aortoduodenal fistula (ADF) is an unusual, but serious complication following surgical or endovascular aortic repair. The optimal treatment for ADF consists of removal of the infected graft with in situ or extra-anatomical repair and is associated with high mortality. Part of this mortality is caused by re-bleeding or aortic stump ruptures. Classical treatment of an aortic stump rupture involves immediate re-laparotomy, removal of infected tissue, aortic stump formation and reinforcement with soft tissue flaps. However, this invasive treatment is often difficult to perform and the condition of the patient frequently requires a more rapid response. We describe a case in which an aortic stump rupture was treated endovascularly by using an Amplatzer® Vascular Plug, which successfully stopped the bleeding. Case presentation: This report describes a 67-year-old man who was presented with persistent duodenal leakage (due to secondary duodenal perforation) after resection and open in-situ repair of an infected aorto-bi-femoral prosthetic graft. An extra-anatomical reconstruction was performed with an axillo-bi-femoral bypass, followed by excision of the prosthesis, aortic stump formation, partial duodenal resection and duodenojejunal reconstruction. Twelve weeks later, sudden severe hematemesis with severe hemodynamic instability occurred. Computed tomography angiography showed extravasation of blood from the aortic stump into the duodenal loop. Endovascular treatment of the aortic stump blow-out with an Amplatzer® Vascular Plug was performed, which successfully stopped the bleeding and stabilized the patient. The duodenal fistula was treated conservatively. Three months later, the patient was discharged to a rehabilitation clinic in a good clinical condition. The patient was still alive after a follow-up of 4 years. Conclusions: Rapid treatment is requested in cases of aortic stump rupture. Re-laparotomy is practically never the most suitable solution and most of these aortic stump ruptures are fatal. Endovascular treatment could be a suitable alternative. Whether the endovascular treatment of aortic stump rupture is a definitive treatment or a bridge to surgery remains to be elucidated.

Endovascular Management of Aortic Stump Blowout by Parallel Grafting and Coil Embolization of Visceral Aorta

“…The traditional treatment of an aortic stump rupture includes immediate-laparotomy, debridement of infected tissue, over sewing the aortic stump again, and reinforcement of the repair with a tissue flap. 3 However, as demonstrated by the case herein, this is not suitable for all patients, necessitating an endovascular approach.…”

Treatment of Post-Evar Aortoduodenal Fistula Without Endograft Excision

“…15 This complex operation carries a high risk of morbidity, mortality and recurrence including an alarming incidence of "blowout" of the defunctionalized aortic stump. 17 Several alternative operative approaches have been suggested, most notably in situ replacement of the aortic prosthesis with antibiotic-soaked prosthetic or a tissue conduit such as autogenous superficial femoral vein or cryopreserved aortic homograft. 1,18,19 This latter approach appears to yield improved outcomes and, when technically feasible, has become the treatment-of-choice.…”

Endovascular Treatment of Aortic Stump Rupture After Extra-anatomic Aortoduodenal Fistula Repair is not a Definitive Treatment: A Case Report and Literature Review

“…Twelve weeks later, massive haematemesis and haemodynamic instability occurred due to an aortic stump bleeding into the duodenum. 5 The patient was admitted to the intensive care unit (ICU) and was considered unsuitable for open surgery due to severe haemodynamic instability and multiple previous abdominal operations ( Supplementary figure 1 ). He was brought to the angiosuite and a 16 mm Amplatzer® Vascular Plug (AVP) was implanted into the defect via upper arm access.…”

“…Previously successful endovascular treatment with placement of an Amplatzer® Vascular Plug (AVP) was described. 5 An endovascular approach was chosen because of the acute setting with severe haemodynamic shock combined with extensive previous abdominal surgery. Initially it was hoped that this endovascular treatment could be a definitive solution.…”