Primary Aortoduodenal Fistula Supplied by Type II Endoleak

Primary Aortoduodenal Fistula: A Case Report and Current Literature Review

Primary aortoduodenal fistula is a rare, life-threatening pathology that is difficult to diagnose and manage. We present the case of a 64-year-old male with a primary aortoduodenal fistula. Our patient initially underwent an endovascular aneurysm repair at an outside institution before being transferred to our tertiary care center, where he ultimately had definitive management with an extra-anatomic bypass, aortic ligation, duodenal resection with primary anastomosis, and gastrojejunostomy tube placement. His surgical cultures grew Candida albicans, and he was discharged with a 6-week course of intravenous antibiotics with subsequent antibiotic suppression for 1 year. He died 14 months postoperatively from tongue squamous cell carcinoma. We also review the current literature regarding epidemiology, pathology, diagnostics, management, and case reports from 2015 to present. Overall, timely diagnosis and treatment is imperative for reducing mortality from primary aortoduodenal fistula, and although formal consensus is lacking regarding most clinical aspects, an increasing number of case reports has helped describe options for management.

Treatment of Post-Evar Aortoduodenal Fistula Without Endograft Excision

An 80 year-old gentleman presented with aortoduodenal fistula 2 months after uncomplicated endovascular aneurysm repair (EVAR). Upon laparotomy and fistula takedown, there was no active hemorrhage from the excluded aneurysm. It was theorized the fistula had originated from an occult type II endoleak which had since thrombosed. The duodenum was repaired primarily; the anterior defect in the aneurysm sac was packed and covered with omentum. The patient recovered uneventfully and remains well after 9 months. This is the first case, to our knowledge, of a post-EVAR aortoduodenal fistula successfully treated without endograft excision.

Secondary Aorto-enteric Fistula and Type II Endoleak Five Years after Endovascular Abdominal Aortic Aneurysm Repair

Introduction

Secondary aorto-enteric fistula (AEF) after endovascular abdominal aortic aneurysm repair (EVAR) is a rare but potentially fatal disease. The aetiology and mechanisms are unclear. This study presents a patient who developed secondary AEF and type II endoleak five years after EVAR.

Case

A 73 year old man underwent successful EVAR with a bifurcated aortic stent graft for a 5.5 cm infrarenal abdominal aortic aneurysm. The aneurysm sac showed no change in size for three years, then shrank 20 mm to 3.5 cm by five years. After five years and eight months, the patient presented with fever and back pain. Enhanced CT demonstrated enlargement of the aneurysm sac, type II endoleak from the third and fourth right lumbar arteries, and air around the stent graft. An emergency operation was performed. The infected stent graft was removed by pushing up the stent graft to release the hooks from the wall of the aorta. A small fistula resembling a fish mouth measuring 1×1 cm was observed in the third part of the duodenum. The fistula was closed by direct suture, and in situ reconstruction was performed with an 18×9 mm standard polyethylene terephthalate graft. Culture of the explanted stent graft grew enterobacter. Intravenous antibiotic therapy was continued for six weeks and was stopped after confirming no recurrence of infection with computed tomography and laboratory testing. Two years later, there has been no recurrence of infection.

Conclusion

Long term surveillance is critical because AEF can occur even after initially successful EVAR.

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Secondary aorto-enteric fistula post endovascular abdominal aortic aneurysm repair can occur in the late phase of follow up.

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Staged omentopexy may be beneficial for prevention of recurrent infection.

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Type II endoleak can affect the development of secondary aorto-enteric fistula.