Case Report

endovascular treatment of a bleeding secondary Aortoenteric fistula in a high-risk patient^?

Abstract

We report a patient with life-threatening gastrointestinal bleeding caused by a secondary aortoenteric fistula (AEF). Because the patient had severe medical comorbidities, an endovascular approach was chosen for Hemorrhage control. Endovascular treatment of aortoenteric fistula provides another treatment option that may be particularly valuable in patients whose comorbidities would preclude open repair.

Aortoenteric fistula (AEF) is an infrequent but disastrous complication of open abdominal Aortic repair. Traditional treatment of AEF has consisted of graft excision and extraanatomical bypass or in situ graft replacement and simple graft excision alone. Since its inception, Endovascular repair has offered a less invasive alternative for the management of aortic disease, including limited reports involving the placement of endografts into potentially infected fields, including the treatment of AEF. We describe the endovascular management of a nonsurgical candidate with a secondary AEF and review the literature.

A 79-year-old man was admitted for gastrointestinal bleeding. His medical history was remarkable for alcohol- induced Liver failure, chronic obstructive pulmonary disease, ischemic heart disease, a previous left above-knee amputa- tion, and right-sided aorta profunda graft. On admission, his laboratory tests revealed a hemoglobin level of 6.0 g/dL and an international normalized ratio of 1.8. Upper gastrointest- inal tract endoscopy demonstrated an AEF (Fig. 1). Abdominal computed tomographic angiography depicted an intact tubular surgical graft without perigraft air, contrast extravasation, or pseudoaneurysm (Fig. 2). However, there was close contact between the graft and the duodenum, which had no visible posterior wall (Fig. 3). In addition, ascites was present. Because of the patient’s comorbidities, an endovascular method was chosen. Our plan was to deploy an aortic stent graft inside the surgical graft, aiming to exclude the AEF from the arterial circulation. In the event that the viability of the patient’s left above-knee amputation

^? The authors have no financial or other conflicts of interest related to the submission.

stump was threatened, a cross-femoral bypass would be performed.

Intraoperative Digital subtraction angiography did not depict the AEF. After localization of the renal arteries, an occluder (Amplatzer Plug; AGA, Plymouth, MN) was placed in the distal aorta; and an aortouniiliac stent graft (Talent; Medtronic, Minneapolis, MN) was inserted via the graft in the right groin and deployed (Fig. 4). A completion angiogram revealed no evidence of a leak, and inspection of his amputation stump revealed it to be viable. On postoperative day 4, the patient was discharged on a lifelong course of daily oral antibiotics. At follow-up, he remains well.

The management of patients with vascular-enteric fistulas remains a challenging diagnostic and therapeutic problem. Aortoenteric fistulas are classified as primary [1] or secondary [2]. Primary AEFs commonly arise from athero- sclerotic or inflammatory Abdominal aneurysm, radiother- apy, or infections such as tuberculosis, whereas secondary AEFs follow previous arterial reconstructive surgery. Regardless of etiology, the traditional management goals of AEF have been to control hemorrhage and infection and to maintain adequate distal perfusion.

There are 2 time-honored approaches to the treatment of secondary AEF: removal of the aortic prosthesis with aortic

Fig. 1 Preoperative esophagogastroduodenoscopy showing AEF in the duodenum with no evidence of bleeding.

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Fig. 2 Coronal computed tomographic angiography demonstrat- ing an intact tubular surgical graft, without perigraft air, contrast extravasation, pseudoaneurysm, or fluid collection. It depicts the length of the right aortoiliac tube graft and the distance from the left renal artery to the AEF. Ascites is present.

stump closure accompanied by extraanatomical bypass or in situ replacement of infected prosthetic graft. Extraanatomical bypass with aortic stump closure is associated with considerable complications, including aortic stump rupture (17.1%-19%), limb loss resulting in amputation (5%-25%) [3-5], and a historical mortality of 36% to 48% [3-6]. recent developments such as wide debridement of infected tissue beds and diminished periods of lower body ischemia by staging of extraanatomical bypass and graft excision have led

to slightly reduced morbidity and mortality. In situ replace- ment of infected grafts with antibiotic-soaked prosthetic grafts, aortic homografts, or deep femoral venous reconstruc- tion has been suggested as an alternative technique. Never- theless, the mortality rate with this procedure is reported to be 21% to 59% [3-8]. Moreover, in situ graft replacement does not eradicate the possibility of aortic disruption and, indeed, is coupled with a considerable suture line disruption rate (7%-24.5%) [3-5].

Recently, the endovascular management of AEFs has been pioneered [9-13]. This method is promising despite justifiable concerns regarding the long-term outcome of the endograft because of the infected territory where it is placed. The merits of this approach entail the avoidance of operating in a hostile abdomen, and the relative straightforwardness and speed of the procedure compared with an open operation. Some have suggested it be used as a “bridge” to definitive surgery in hemodynamically unstable patients [14]. The limitations of Endovascular therapy include the anatomical constraints pertinent to Endovascular aneurysm repair, the immediate availability of suitable devices, and, most crucially, the fact that the infected surgical graft is not explanted but remains in situ and most probably will contaminate the endovascular device.

In this case, the patient had Severe comorbidities; and the endovascular approach allowed us to achieve expeditious control during his Hemodynamic deterioration. Other authors have reported single cases or small case series of secondary AEF treated with endovascular stent graft repair [10,11,15,16]. Because the original graft cannot be removed and there is no debridement of infected tissue, there is a concern for persistent Graft infection [15]. Therefore, close follow-up and lifelong antibiotic therapy are necessary. In summary, endovascular treatment provides another option for management of AEF when combined with appropriate long-term antibiotic treatment. It may be particularly

Fig. 3 A, Axial image depicts the close contact between the graft and the duodenum, which has no posterior wall. B, Coronal image demonstrating the same.

Case Report

Fig. 4 A, Postdeployment angiogram confirming exclusion of the fistula. B, Aortouniiliac graft.

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valuable in patients whose comorbidities would preclude open repair.

Graham Roche-Nagle MD

Department of Vascular and Endovascular Surgery

Toronto General Hospital

Toronto, Ontario Canada M5G 2C4

E-mail address: [email protected]

George Oreopolous MD

Department of Vascular and Endovascular Surgery

Toronto General Hospital

Toronto, Ontario Canada M5G 2C4

doi:10.1016/j.ajem.2008.07.029

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