Aortoenteric fistulas: CT features and potential mimics

Aortoenteric Fistulas Following Endovascular Aortic Aneurysm Repair: A Review

BackgroundSecondary aortoenteric fistulas (SAEF) following endovascular aortic repair (EVAR) is an extremely rare event but life threatening. Our review offers comprehensive knowledge on pathophysiology, clinical presentation, diagnosis, and treatment options.AimTo summarize the current literature regarding pathophysiology, clinical, diagnostic and therapeutic approach of aortoenteric fistulas secondary to EVAR.MethodsWe performed a literature search in Pubmed/MEDLINE to identify the literature published about SAEF after EVAR. Cases were summarized in a table and prevalences. Other relevant literature was included in the results sections.ResultsA total of 35 reports (single cases and small series) with 45 patients were included. SAEF after EVAR can result from infection, inflammation, or mechanical factors. Clinical presentation is often non-specific, ranging from a gastrointestinal herald bleed to hemorrhagic shock, or malaise and general infection-related symptoms. Cross-sectional imaging plays a critical role in diagnosing SAEF. The treatment approach involves a multidisciplinary team approach and requires broad-spectrum intravenous antibiotics, endovascular intervention for urgent hemorrhage control, and open surgical intervention for definitive repair. Long-term antimicrobial therapy is essential to avoid reinfection.ConclusionsSAEF following EVAR represents a complex, life-threatening condition with limited evidence-based management strategies. Given the growing prevalence of endovascular procedures, comprehensive knowledge of SAEF is crucial for all health care providers to improve early diagnosis and outcomes.

CT of the esophagus in the ER: what you need to know and what you need to remember

Computed tomography (CT) imaging is a crucial diagnostic tool in the emergency department (ED) for evaluating non-traumatic esophageal conditions. Advanced imaging techniques such as multidetector CT (MDCT) quickly provide detailed 3D images with high spatial resolution, making it ideal for rapid assessment of a variety of esophageal pathologies. This pictorial essay presents 10 illustrative cases to highlight the clinical applications of MDCT and its critical role in diagnosing conditions like perforation, foreign body impaction, inflammatory or infectious esophagitis, achalasia, fistulae, and neoplasms. Optimized CT protocols, such as contrast-enhanced imaging and advanced postprocessing techniques like maximum intensity projection (MIP) images and volumetric rendering technique (VRT), in addition to 3D cinematic rendering, are crucial in improving diagnostic accuracy and enhancing visualization of anatomical structures. The cases presented emphasize the importance of early detection and timely management of esophageal conditions, as small delays can lead to significantly increased morbidity and mortality. Ultimately, a multidisciplinary approach that coordinates clinical, radiological, and pathological evaluations ensures appropriate management and improved patient outcomes in esophageal emergencies.

Diagnosis of an Occult Aortoenteric Fistula and Treatment of a Silent Threat

An aortoenteric fistula (AEF) is an abnormal communication between the aorta and the gastrointestinal tract, which can lead to severe gastrointestinal bleeding, sepsis, and high mortality if not promptly diagnosed and surgically managed. Its occurrence, particularly in patients with prior aortic surgery, presents considerable diagnostic and therapeutic challenges. This case report describes an iatrogenic aorto-duodenal fistula following surgical intervention at the aortoiliac bifurcation, highlighting the complexity and rarity of this entity. The clinical presentation of AEF is often insidious, delaying diagnosis. While no imaging modality provides definitive confirmation, computed tomography (CT) remains the most effective and widely utilized tool for detection. Key imaging findings in patients presenting with gastrointestinal bleeding include contrast extravasation from the aorta into the intestinal lumen, as well as the presence of enteric material or gas within the periprosthetic space. Early recognition of these radiologic indicators is critical to timely intervention. Surgical repair remains the mainstay of treatment, with the primary objectives being hemostasis, aortic reconstruction, and infection control. The choice of surgical approach is dictated by the location and extent of the fistula, as well as the patient's overall clinical status. Despite advancements in imaging and surgical techniques, AEF continues to pose a major diagnostic and therapeutic challenge. A high index of suspicion and familiarity with its clinical and radiologic presentation are essential for early recognition and optimal management.

Aortoesophageal Fistula-Induced Rare Life-Threatening Hematemesis in the Emergency Department: A Case Series and Literature Review

Background and objective Aortoesophageal fistula (AEF) is a rare but life-threatening condition. It is often challenging to promptly diagnose AEF given the diversity of chief complaints and clinical presentations at the time of initial treatment. In some cases, upper gastrointestinal endoscopy is performed, and emergency surgery is delayed, or the disease is judged to be mild and rapidly worsens, ultimately resulting in the patient's death. In this study, we aimed to investigate the clinical characteristics of AEF in patients at the time of emergency department visits, which were only partially described in previous studies. Methods We retrospectively reviewed the medical records of patients diagnosed with AEF from May 2013 to May 2023 at a tertiary medical center in Japan. Results Six patients were diagnosed with AEF during the study period. The median age of the patients was 75.5 years, and four were females. All six patients had the chief complaint of hematemesis; three (50%) had bright red hematemesis and four (67%) had a relatively small amount of hematemesis. Two (33%) experienced syncope. Three (50%) were clinically diagnosed with shock upon arrival at the hospital. Four (67%) had a history of post-aortic surgery, aortic aneurysm, or esophageal cancer. Conclusions AEF should be considered in patients with hematemesis, especially those with distinctive underlying diseases, shock, or syncope, even if hematemesis only involves a small amount of blood or is bright red.

Recurrent Hematochezia Due to a Rectal Fistula Caused by a Left Internal Iliac Artery Aneurysm

Arterio-enteric fistulas (AEFs) are a rare cause of gastrointestinal bleeding involving direct communication between an artery and the intestinal tract. The duodenum is the most common fistula site for AEFs, but none of the rectal cases are known. We present the case of an elderly man with hematochezia due to a rectal fistula caused by a left internal iliac artery aneurysm, which was detected on contrast-enhanced computed tomography (CT), showing typical fistula formation and ectopic gas images. This case highlights the importance of considering the occurrence of rare but potentially fatal AEFs in elderly patients with hematochezia and that the timely performance of contrast-enhanced CT is critical for an accurate diagnosis.

Successful management of secondary aorto-enteric fistula: a case report from Nepal

Introduction

Aorto-enteric fistulas (AEFs) are rare but serious causes of gastrointestinal bleeding, classified into primary and secondary types. This report describes the first documented case of a secondary AEF from Nepal, emphasizing the need for prompt diagnosis and surgical intervention.

Case presentation

A 36-year-old male presented with black tarry stools and abdominal pain, 7 years after aorto-right common femoral artery and aorto-left common iliac artery bypass surgery for common iliac artery occlusive disease. He had a history of recurrent graft infections. Examination revealed hypotension, tachycardia, and melena. Upper gastrointestinal endoscopy showed the aortic graft in the duodenum, with CECT confirming an aortic graft inside the bowel lumen, leading to a diagnosis of secondary aorto-enteric fistulas (SAEF).

Discussion

SAEFs often arise from graft infection and mechanical erosion by the pulsatile graft. Patients typically present with gastrointestinal bleeding, and early diagnosis is crucial, as untreated SAEFs have a mortality rate approaching 100%. The combined use of upper gastrointestinal endoscopy and CECT is essential for identifying and guiding the surgical intervention of SAEFs. This case underscores the importance of early diagnosis and early surgical intervention for successful management of SAEF.

Conclusion

This case highlights the importance of suspecting secondary AEFs in patients with aortic graft presenting with gastrointestinal bleeding. Early diagnosis and timely surgical intervention are essential for improving patient outcomes.

Aorto-esophageal Fistula Management

Aorto-esophageal fistula is a rare but life-threatening source of massive upper gastrointestinal bleeding. Prompt diagnosis and intervention are key for patient survival. Treatments consist of aortic resection, thoracic endovascular aortic repair, esophagectomy with diversion, and primary esophageal repair. The appropriate treatment is dependent on patient hemodynamics and fitness and familiarity with operative approaches by the treating team.

Diagnosis and clinical presentation of iliac graft-enteric fistula: A case report

INTRODUCTION

Aorto-enteric fistula (AEF) is a life-threatening complication arising from abnormal connections between the gastrointestinal tract and major arteries. One uncommon type, iliac artery-enteric fistula (IEF), can occur following vascular interventions such as arterial stent-graft placement.

CASE PRESENTATION

We report the case of a 47-year-old male presenting with hematemesis and abdominal pain, who was diagnosed with an iliac graft-enteric fistula. Timely recognition and management were crucial for a favorable outcome.

CLINICAL DISCUSSION

Diagnosing AEFs remains challenging, requiring a multidisciplinary approach and high clinical suspicion. While computed tomography angiography (CTA) is commonly used for diagnosis, its sensitivity may be limited, emphasizing the importance of integrating clinical history and findings. Management strategies vary based on etiology and patient status, with surgery being pivotal.

CONCLUSION

Aorto-enteric fistula, which can arise from a thrombosed graft, presents diagnostic challenges due to its rare formation. In patients with a history of vascular interventions and gastrointestinal bleeding, AEF should be considered. This case underscores the need for heightened awareness among healthcare professionals regarding AEF diagnosis and management to reduce severe morbidity, mortality, and prolonged hospital stays.

Aortoenteric Fistula with Digestive Contrast Material Leaking in the Aneurysmal Sac

Teaching point: Aortoenteric fistula, a major complication of aortic surgery, can be identified with certainty on CT scan with opacification of the intestinal tract.

A complicated case of primary aortojejunal fistula: A case report

BACKGROUND

Aortoenteric fistulas are rare and life-threatening pathology characterized by an abnormal connection between the aorta and the gastrointestinal tract.

CASE PRESENTATION

The patient is a 61-year-old male who initially presented with hypogastric pain, hematemesis, and melena. Computed tomography angiography (CTA) revealed an abdominal aorta aneurysm but not a fistula. Imaging modalities were inconclusive in the diagnosis. The patient became unstable hemodynamically and was transferred to the operation room. The definitive diagnosis of aortoenteric fistula was confirmed during surgical exploration. Urgent surgery was performed; however, the patient experienced a cascade of complications, including rebleeding, intestinal leakage, and hemodynamic instability due to aortic bleeding. Despite rigorous interventions, the patient expired due to multiple organ failure 53 days after the first repair surgery.

CLINICAL DISCUSSION

There is no definite imaging method due to the lack of guidelines, and the absence of exact findings has led to intraoperative diagnosis in up to 50 % of cases. This is one of the modalities of choice to examine suspected aortoenteric fistulas. Many authors prefer Computed tomography (CT) with intravenous contrast for suspected AEF despite its limitations in clarity. Others recommend CT angiography as the preferred modality. It is worth noting that, as reported in a comprehensive retrospective review, the mortality rate is approximately 46 % within 60 days after AEF repair surgery.

CONCLUSION

This report adds to the limited data about primary aortojejunal fistulas, an extremely rare type of aortoenteric fistulas which has been reported in only a few cases. Understanding the importance of promptly suspecting, diagnosing, and intervening is crucial, emphasizing the importance of sharing such cases for medical guidance and better patient outcomes.

Two Cases of Primary Aortoenteric Fistulas Diagnosed by Computed Tomography

A primary aortoenteric fistula is a rare clinical entity that leads to severe upper gastrointestinal bleeding and carries a high risk of mortality, yet diagnosing aortoenteric fistulas remains challenging. Diagnosis is frequently delayed due to the uncommon and non-specific nature of the abdominal signs and symptoms. Rapid diagnosis and prompt surgical intervention are paramount to the successful management of this condition which is known for its profoundly poor prognosis. This report describes two cases of primary aortoenteric fistulas, one of which presented with melena and hematemesis, and the other presented with hematemesis and abdominal pain. In both cases, computed tomography angiography (CTA) demonstrated findings suggestive of an aortoenteric fistula, namely, locules of gas within the aortic lumen, which led to emergent surgical intervention. One patient underwent esophagogastroduodenoscopy while in the operating room before surgical intervention. One patient underwent repair with axillo-bifemoral bypass and the other with juxtarenal abdominal aortic aneurysm repair with a rifampin-soaked gelsoft dacron graft followed by primary bowel repair. Postoperative complications for one of the patients included duodenal repair breakdown as well as colonic ischemia. One patient made a meaningful recovery and remained without complications until the first postoperative visit two months after the repair. The other patient was discharged and then subsequently lost to follow-up. The two patients' successful outcomes of such a lethal condition were in large part due to rapid diagnosis with CTA and prompt surgical intervention.

Case report - Computed tomography diagnosis of an abdominal aortic aneurysm complicated with primary aortoduodenal fistula

Abdominal aortic aneurysm has been described as a rare condition touching 1% of the population over the age of 50 years with a high percentage of mortality. Aneurysms progress in size, causing deadly complications such as ruptures and fistulas. Computed tomography angiography is considered the gold standard imaging exam for the evaluation of abdominal aortic aneurysms and their complications. We report the case of an elderly patient admitted to the emergency room due to recurrent gastrointestinal bleeding. The computed tomography imaging findings were in favor of an abdominal aortic aneurysm complicated with a primary aortoduodenal fistula.

Vascular covered stent and video-assisted thoracoscopic surgery for Aortoesophageal fistula caused by esophageal fishbone: a case report

BACKGROUND

Aortoesophageal fistula (AEF) is a rare condition characterized by communication between the aorta and esophagus. AEF caused by an esophageal foreign body is even rare, and there is currently no recommended standard treatment protocol. We report a case of delayed aortic rupture after the endoscopic removal of a fish bone, which was successfully treated with a combined approach of vascular stenting and thoracic surgery.

CASE PRESENTATION

A 33-year-old man presented to the hospital after experiencing chest discomfort for 3 days following the accidental ingestion of a fish bone. Under endoscopic guidance, the fish bone was successfully removed, and the patient was subsequently admitted for medical therapy. On the fourth postoperative day, the patient suddenly developed hematemesis, and chest computed tomography angiography revealed the presence of an AEF. This necessitated urgent intervention; hence, thoracic surgery was performed and a vascular-covered stent was placed. Following the surgical procedure, the patient received active medical treatment, recovered well, and was successfully discharged from the hospital.

CONCLUSIONS

In patients with esophageal perforation caused by foreign bodies, hospitalization for observation, computed tomography angiography examination, early use of antibiotics, and careful assessment of aortic damage are advised. Thoracic endovascular aortic repair and esophageal rupture repair may have benefits for the treatment of AEF.

Massive gastrointestinal bleed due to a primary aortoenteric fistula

A man in his 60s attended emergency for acute-onset abdominal pain and haematemesis. Requiring resuscitation, a CT abdomen/pelvis revealed a primary aortoenteric fistula actively bleeding into the duodenum. His background included a previous severe Q-fever infection and a heavy smoking history. Despite attempts at resuscitation and an emergent surgical attempt at haemostasis, the patient did not survive the massive gastrointestinal haemorrhage.Even in less severe cases, management of aortoenteric fistulas is tricky. Blood cultures and angiographic imaging are important investigations in guiding surgical approach. The pathology tends to have a significant rate of mortality even at tertiary-level vascular surgical centres.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report

A double secondary aortoenteric fistula (AEF) occurs in a patient who has had significant aortic surgery and is characterized by a direct connection between the gastrointestinal (GI) tract and the aorta at two separate sites.

IMPORTANCE

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula.

CASE PRESENTATION

The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged.

CLINICAL DISCUSSION

Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel.

CONCLUSIONS

An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.

Aortoesophageal Fistula Occurring Due to Aortic Aneurysm

Upper gastrointestinal bleeding is a rare presentation of the aortoesophageal fistula (AEF) and is usually caused by thoracic aortic aneurysms. We present the case of a 61-year-old male who presented with chest pain and hematemesis. A chest X-ray showed a widened mediastinum. The patient underwent computed tomography angiography (CTA), which showed the presence of a large aneurysm in the aorta, which caused compression of the trachea, esophagus, and left pulmonary artery. Additionally, there was evidence of an AEF. It was decided to perform an emergency surgical intervention on the patient. However, the patient had multiple episodes of hematemesis and expired.

Primary and secondary aortoenteric fistulas in a patient with abdominal aortic aneurysm

INTRODUCTION

Aortoenteric fistulas (AEF) are infrequent malignant complications of abdominal aortic aneurysms (AAA). We present a unique case of a patient with recurring AAA fistulisations.

PRESENTATION OF CASE

During oncologic treatment, a 63-year-old male was incidentally diagnosed with infrarenal AAA and assigned follow-up but was hospitalised with anaemia and elevated inflammation markers 14 months later. A CT-angiography scan detected an AAA enlargement, but no extravasation (negative FOBT). Another CTA-scan displayed a pseudoaneurysm and ruptured AAA 10 days later. During a total laparotomy, an enlarged pulsating inflammatory conglomerate without active leakage was detected, with a 2 cm duodenal defect (PAEF). The AAA was resected and replaced by a linear silver-coated Dacron graft. 3,5 years after PAEF, the patient was hospitalised with abdominal pain and haematemesis. He underwent gastroscopies, coloscopies, CT- and CTA-scans - all without significant findings. Only after the capsule-endoscopy detected a jejunal ulcer, the PET-scan visualized active regions in the jejunum and the aortic graft. A total laparotomy was performed; previous stapler-lined jejuno-jejunal anastomosis had adhered to the silver-coated Dacron graft (SAEF). The Dacron graft was removed and replaced with a linear xenograft from bovine pericardium.

DISCUSSION

No evidence-based recommendations prefer endovascular aneurysm repair (EVAR) over open repair, leaving the strategy dependent on local preferences. Whether EVAR or initial xenograft usage would have shown surpassing results, is speculative, as no graft material/type has proved long-term pre-eminence.

CONCLUSIONS

This case displays AEF's complex treatment and challenging diagnosis. Multimodal diagnostic and strategic approaches should be considered for best patient outcome.

Predicting Infection Related Complications After Endovascular Repair of Infective Native Aortic Aneurysms

OBJECTIVE

Endovascular aortic repair (EVAR) as surgical treatment for infective native aortic aneurysm (INAA) is associated with superior survival compared with open surgery, but with the risk of infection related complications (IRCs). This study aimed to assess the association between baseline clinical and computed tomography (CT) features and the risk of post-operative IRCs in patients treated with EVAR for INAA. It also sought to develop a model to predict long term IRCs in patients with abdominal INAA treated with EVAR.

METHODS

All initial clinical details and CT examinations of INAAs between 2005 and 2020 at a major referral hospital were reviewed retrospectively. The images were scrutinised according to aneurysm features, as well as peri-aortic and surrounding organ involvement. Data on post-operative IRCs were found in the patient records. Cox regression analysis was used to derive predictors for IRCs and develop a model to predict five year IRCs after EVAR in abdominal INAA.

RESULTS

Of 3 780 patients with the diagnosis of aortic aneurysm or aortitis, 98 (3%) patients were treated with EVAR for abdominal INAAs and were thus included. The mean follow up time was 52 months (range 0 ‒ 163). The mean transaxial diameter was 6.5 ± 2.4 cm (range 2.1 ‒14.7). In the enrolled patients, 38 (39%) presented with rupture. The five year IRC rate in abdominal INAAs was 26%. Female sex, renal insufficiency, positive blood culture, aneurysm diameter, and psoas muscle involvement were predictive of five year IRC in abdominal INAA after EVAR. The model had a C-index of 0.76 (95% CI 0.66 - 0.87).

CONCLUSION

Pre-operative clinical and CT features have the potential to predict IRC after endovascular aortic repair in INAA patients. These findings stress the importance of rigorous clinical, laboratory, and radiological follow up in these patients.

A Novel Endovascular Treatment for Recurrent Secondary Aorto-Enteric Fistula in a Patient With Prior Infra-Renal Aortic Ligation

This report highlights the use of novel endovascular techniques in a 68-year-old male patient with massive hematemesis from a recurrent secondary aorto-enteric fistula (SAEF). With a prior history of infrarenal aortic ligation and the location of the SAEF being at the aortic sac, we explain the considerations for the techniques used and how we were able to stop the bleeding using percutaneous transarterial embolotherapy.

Chicken Bone Ingestion Leads to Aortoesophageal Fistula With Catastrophic Bleeding

Aortoesophageal fistula (AEF) is an uncommon, but potentially fatal cause of upper gastrointestinal bleeding. Aortoesophageal fistulas caused by foreign body ingestion are rare but devastating. The classic clinical triad of AEF consists of mid-thoracic pain or dysphagia, a herald episode of hematemesis, followed by fatal exsanguination after a symptom-free period (Chiari's triad). Computed tomography angiography (CTA) is the preferred diagnostic tool for identifying AEF and is substantially more sensitive than upper endoscopy for detecting AEF. Endoscopy can detect AEF as it might show pulsatile blood, pulsatile mass, hematoma, or adherent blood clot in the esophagus, or a deep esophageal tear. However, endoscopy has a low sensitivity and may delay definitive treatment. Several management options for AEF have been suggested; however, the definitive treatment is surgery performed on the thoracic aorta and esophagus, including esophagectomy, surgical replacement of the thoracic aorta, thoracic endovascular aortic repair, or omental flap. We report a case of a 63-year-old man who presented with hematemesis 2 weeks after chicken bone ingestion.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms

BACKGROUND

Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood.

METHODS

We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival.

RESULTS

Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72 years; range, 18-94 years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5 years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P = 0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P = 0.034) and preoperative serum albumin level <3 g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P = 0.033) were preoperative parameter that predicted persistent infection. A C-reactive protein level more than 5 mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P < 0.001) was observed in patients with persistent infection.

CONCLUSIONS

EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3 g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Primary Aortoesophageal Fistula Presenting as Upper Gastrointestinal Bleed

Aortoenteric fistula is a rare condition that can be primary or secondary. The primary type is less common than the secondary. The secondary aortoenteric fistula is an uncommon fatal complication after reconstructive surgery for an aortic aneurysm or other aortic diseases. Here we present a case of a 59-year-old man who presented to our emergency department with sudden onset of massive hematemesis. Imaging studies were done and the patient was diagnosed to have aortoesophageal fistula. Upper gastrointestinal endoscopy showed an intraluminal bulge in the posterior wall of the esophagus with an ulcer and hematoma. The patient was planned for emergency surgical intervention, but the patient had recurrent bouts of hematemesis and, unfortunately, expired. Hence patients presenting with massive hematemesis, aortoenteric fistula can be the underlying cause, and all surgeons should be aware of such conditions and the need for emergent surgical intervention.

Primary and secondary aorto-digestive fistulas in Behçet's disease: A case report and review of the literature

Behçet's disease (BD) is a multisystem chronic autoimmune inflammatory disorder that involves multiple organs. Arterial involvements in BD are rare. One of severe manifestation is the aortic aneurysm which can lead to a rupture. Aorto-duodenal fistulas (ADFs) are the most frequent aorto-digestive fistulas. In this article we will describe and discuss primary and secondary ADFs which occurred in a same patient.

Mycotic Aneurysm with Iliac Artery-Colonic Fistula

Although mycotic (infected) aneurysms are uncommon, they can affect any artery. The most frequently involved vessel is the aorta as well as femoral and cerebral arteries. A vascular-colonic fistula from infected aneurysms is even rarer, which remains a challenge for diagnosis and treatment. In this case report, we aimed to illustrate an 89-year-old man presenting initially with an aneurysm of the right common iliac artery. Forty days later, this lesion was infected and produced fresh blood in the rectum and sigmoid colon observed by colonoscopy. The final diagnosis of this case was a right common iliac artery aneurysm-colonic fistula due to infection. The patient was successfully diagnosed and treated with surgery at our hospital.

Features of infective native aortic aneurysms on computed tomography

Background

Infective native aortic aneurysm (INAA) is a rare clinical diagnosis. The purpose of this study was to describe the CT findings of INAAs in detail.

Methods

This was a retrospective single-center study of INAA patients at a major referral hospital between 2005 and 2020. All images were reviewed according to a protocol consisting of aneurysm features, periaortic findings, and associated surrounding structures.

Results

One hundred and fourteen patients (mean age, 66 years [standard deviation, 11 years]; 91 men) with 132 aneurysms were included. The most common locations were infrarenal (50.8%), aortoiliac (15.2%), and juxtarenal (12.9%). The mean transaxial diameter was 6.2 cm. Most INAAs were saccular (87.9%) and multilobulated (91.7%). Calcified aortic plaque was present in 93.2% and within the aneurysm in 51.5%. INAA instability was classified as contained rupture (27.3%), impending rupture (26.5%), and free rupture (3.8%). Rapid expansion was demonstrated in 13 of 14 (92.9%) aneurysms with sequential CT studies. Periaortic inflammation was demonstrated as periaortic enhancement (94.7%), fat stranding (93.9%), soft-tissue mass (92.4%), and lymphadenopathy (62.1%). Surrounding involvement included psoas muscle (17.8%), spondylitis (11.4%), and perinephric region (2.8%). Twelve patients demonstrated thoracic and abdominal INAA complications: fistulas to the esophagus (20%), bronchus (16%), bowel (1.9%), and inferior vena cava (IVC) (0.9%).

Conclusion

The most common CT features of INAA were saccular aneurysm, multilobulation, and calcified plaques. The most frequent periaortic findings were enhancement, fat stranding, and soft-tissue mass. Surrounding involvement, including psoas muscle, IVC, gastrointestinal tract, and bronchi, was infrequent but may develop as critical INAA complications.

Periaortic air in native and post-operative aorta on computed tomography

Periaortic air can be seen in various conditions which can be a benign imaging finding or harbinger of a catastrophic event. The causes vary in native aorta and post-operative aorta. A radiologist has an important part in the management process of these patients, as the treatment varies from conservative to radical surgery based on the aetiology. The presence of periaortic air seen in the light of various clinical, laboratory and radiological findings can guide the radiologist towards a particular aetiology. Cross-sectional imaging, mainly computed tomography, is an indispensable tool in recognising ectopic periaortic air and to identify the associated findings and eventually make an accurate diagnosis. We present a pictorial review of various causes of the periaortic air in native and postoperative aorta, the salient features and management of the described conditions.

Life‐saving case of cardiopulmonary arrest by secondary aortoenteric fistula formed in the anastomotic site between the inferior mesenteric artery and aortic graft

Background

Secondary aortoenteric fistula is a fatal cause of gastrointestinal bleeding after aortic reconstructive surgery with a prosthesis. In most cases, the proximal suture line is involved. We herein report a rare case in which the fistula formed between the suture line of inferior mesenteric artery reimplantation and the jejunum.

Case Presentation

An 82‐year‐old man was transferred to our hospital due to hematemesis with severe hypovolemic shock. Although he fell into cardiopulmonary arrest, immediate resuscitation achieved return of spontaneous circulation. As his surgical history of aortic reconstruction and computed tomography findings suggested potential secondary aortoenteric fistula, emergency surgery was carried out. The anastomosis between the inferior mesenteric artery and aortic graft was communicating with the jejunum. Partial jejunal resection was undertaken, and the aortic graft was replaced.

Conclusion

The anastomosis between the inferior mesenteric artery and aortic graft in the previous aortic replacement can become the site of secondary aortoenteric fistula.

A Rare Case of Aortoenteric Graft Erosion Presenting as Candida glabrata Fungemia

Background

An aortoenteric fistula (AEF) describes a communication of the aorta or aortic graft with an adjacent loop of the bowel. Aortic graft erosion is a rare complication of abdominal aortic aneurysm repair. We describe a case of a patient presenting with sepsis from Candida glabrata fungemia secondary to aortoenteric erosion without any symptoms or signs of gastrointestinal bleeding. This is a unique case of Candida glabrata fungemia from aortoenteric graft erosion. Case Summary. This patient is a 75-year-old male with a history of a prior aortobifemoral bypass graft in 2005. He presented with complaints of right paraspinal pain and chills. He had no symptoms of gastrointestinal bleeding or abdominal pain. His white blood cell count was 25,600/mcl (4,000–11,000/mcL) with left shift. The erythrocyte sedimentation rate was 11 mm/hr (0-38 mm/hr), and C-reactive protein was 95.5 mg/L (<=10.0 mg/L). Blood cultures were obtained and eventually grew Candida glabrata. A computed tomography angiogram (CTA) of abdomen and pelvis demonstrated inflammation surrounding the graft concerning for graft infection with additional inflammatory changes tracking down both femoral limbs. He underwent staged bilateral femoralaxillary bypass followed by the excision of aortobifemoral bypass.

Conclusion

Patients with aortoenteric erosion can present with sepsis in absence of gastrointestinal bleeding. Emergent computed tomography angiogram (CTA) of abdomen and pelvis should be performed to assess for aortic graft erosion or fistula. Empiric treatment with antibiotics should include antifungal agent like micafungin until the final culture is reported. The definite management is an extra anatomic bypass, followed by graft excision.

Primary aortoenteric fistula: A case report and brief review of the literature

Aortoenteric fistula is a life-threatening emergency and is associated with high morbidity and mortality. Prompt surgical intervention before the aneurysm ruptures lowers the mortality rate to about 50%. Potential imaging mimics for aortoenteric fistula include retroperitoneal fibrosis, mycotic aortic aneurysm, and infectious aortitis. Secondary aortoenteric fistula has relative higher incidence compared to primary and is more common with open aortic repair versus endovascular stent graft repair. Ectopic gas in the aneurysm sac and extravasation of enteric contrast into the aneurysm sac is diagnostic for aortoenteric fistula. However, enteric contrast is not recommended for routine evaluation of aortoenteric because the aforementioned finding is extremely rare. More common imaging findings include bowel loop appearing adherent to aneurysm sac with associated inflammatory stranding and foci or ectopic gas within the aneurysm sac or interposed between the bowel and aneurysm sac. Here we present a case of 52-year-old male who presents with incidental primary aortoenteric fistula.

Aortic Fistulas: Pathophysiologic Features, Imaging Findings, and Diagnostic Pitfalls

Fistulas between the aorta and surrounding organs are extremely rare but can be fatal if they are not identified and treated promptly. Most of these fistulas are associated with a history of trauma or vascular intervention. However, spontaneous aortic fistulas (AoFs) can develop in patients with weakened vasculature, which can be due to advanced atherosclerotic disease, collagen-vascular disease, vasculitides, and/or hematogenous infections. The clinical features of AoFs are often nonspecific, with patients presenting with bleeding manifestations, back or abdominal pain, fever, and shock. Confirmation with invasive endoscopy is often impractical in the acute setting. Imaging plays an important role in the management of AoFs, and multiphasic multidetector CT angiography is the initial imaging examination of choice. Obvious signs of AoF include intravenous contrast material extravasation into the fistulizing hollow organ, tract visualization, and aortic graft migration into the adjacent structure. However, nonspecific indirect signs such as loss of fat planes and ectopic foci of gas are seen more commonly. These indirect signs can be confused with other entities such as infection and postoperative changes. Management may involve complex and staged surgical procedures, depending on the patient's clinical status, site of the fistula, presence of infection, and anticipated tissue friability. As endovascular interventions become more common, radiologists will need to have a high index of suspicion for this entity in patients who have a history of aneurysms, vascular repair, or trauma and present with bleeding. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ^©RSNA, 2021.

Imaging Spectrum of Duodenal Emergencies

The duodenum, the first portion of the small bowel, is divided into four segments and extends to both retro- and intraperitoneal spaces. Some conditions arise primarily from the duodenum, but it can be secondarily affected by processes that involve neighboring structures. When duodenal emergencies are not identified and treated promptly, they may result in high morbidity and mortality. Imaging plays an important role in the diagnosis of duodenal conditions in the acute setting. However, the radiologic findings can be subtle, and awareness of relevant patient history and clinical presentation is important as it may increase the index of suspicion and one's ability to diagnose these conditions. Duodenal peptic disease is common and can be complicated by bleeding and perforation. The duodenum can be secondarily involved by pancreatitis and gallbladder pathologic conditions and may be affected by iatrogenic complications following endoscopic procedures. Traumatic injuries to the duodenum are generally uncommon, with penetrating traumatic injury being the most frequent mechanism of injury. Duodenal vascular pathologic conditions such as aortoduodenal fistula are uncommon but can be life threatening. The knowledge of which pathologic condition can involve which duodenal segment can help the radiologist establish a differential diagnosis and achieve a more targeted imaging approach. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Stent graft treatment of an ilioenteric fistula secondary to radiotherapy

Fistulas between the arteries and the gastrointestinal tract are rare but can be fatal. We present a case of an ilioenteric fistula between the left external iliac artery and sigmoid colon caused by radiotherapy for cervical cancer, which was treated with endovascular management using a stent graft. A 38-year-old woman underwent concurrent chemoradiotherapy for cervical cancer recurrence. Approximately 9 months later, the patient suddenly developed hematochezia. On her first visit to the emergency room of our hospital, computed tomography (CT) images did not reveal extravasation of contrast media. However, 8 hours later, she revisited the emergency room because of massive hematochezia with a blood pressure of 40/20 mmHg and a heart rate of 150 beats per minute. At that time, CT images showed the presence of contrast media in almost the entire colon. The patient was referred to the angiography room at our hospital for emergency angiography. Inferior mesenteric arteriography did not reveal any source of bleeding. Pelvic arteriography showed contrast media extravasation from the left external iliac artery to the sigmoid colon; this was diagnosed as an ilioenteric fistula and treated with a stent graft. When the bleeding focus is not detected on visceral angiography despite massive arterial bleeding, pelvic arteriography is recommended, especially in patients with a history of pelvic surgery or radiotherapy.

Endoscopic treatment of primary aorto-enteric fistulas: A case report and review of literature

BACKGROUND

Primary aorto-enteric fistula (PAEF) is a rare condition, traditionally treated in the acute, bleeding phase with open surgery or endovascular repair. However, these approaches have high morbidity and mortality, indicating a need for new methods. With advances in endoscopic techniques and equipment, haemoclipping of fistulas has now become feasible. Therefore, we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping.

CASE SUMMARY

A 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools. An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum. Afterward, a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm. Based on the clinical presentation and the combined endoscopic and radiographic findings, we argue that this is a case of a PAEF.

CONCLUSION

Endoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF, serving as a bridge to final therapy.

Concurrent Ilio-Enteric and Ilio-Vesical Fistula From Large Aorto-Iliac Aneurysm

Iliac artery aneurysms (IAA) are associated frequently with abdominal aortic (AAA) and other degenerative large-vessel aneurysms. Concurrent fistulization of the aortoiliac tree into the gastrointestinal tract (GIT) and bladder is exceptionally rare. We herewith report a unique case of concurrent ilio-enteric and ilio-vesical fistula arising from a large aorto-iliac aneurysm.

Femoral Vein Reconstruction for Aortic Infections

While rare, abdominal aortic infections remain one of the most technically and emotionally challenging cases that a vascular surgeon may face. Secondary infections of either endovascular, or open aortic reconstructions range from 0.2% to 8%. Primary aortic infections are much more rare. Diagnosis can be elusive, depending upon the virulence of the causative microbes, and extent of the infection. Patients are often brittle, with immunocompromise and malnutrition prevalent in this patient population. The gold standard diagnostic test remains a computed tomographic angiogram. The mainstay of management requires vascular control, and wide debridement of all infected materials and revascularization. Multiple methods exist to reconstruct the vascular supply. The neo-aortoiliac system (NAIS) is attractive as it utilizes the patient’s own femoral veins to reconstruct the vascular supply after the infection has been extirpated. The procedure is demanding upon the patient and surgeons alike. Also, the rarity of aortic infections limit experiences the literature to centers of excellence. However, the NAIS resists infection well, leaving the patient without any remaining foreign bodies. No further costs for conduit are incurred. Moreover, multiple experiences show excellent durability. While comparative effectiveness literature remains sparse, we believe the NAIS to be the optimal method of revascularization for select patients. In this article, we will review the use of NAIS for primary and secondary aortic infections. In particular, we will emphasize procedural details to help enable the reader to apply this procedure most effectively to their own patients.

Case series of aortoenteric fistulas: a rare cause of gastrointestinal bleeding

BACKGROUND

Aortoenteric fistula (AEF) is a rare cause of gastrointestinal bleeding and is often misdiagnosed in clinical practice. Herein, a case series of AEFs are presented and the clinical characteristics, diagnosis, and management strategies are summarized.

METHODS

A retrospective analysis was performed on consecutive hospitalized patients with a final diagnosis of AEF at Beijing Friendship Hospital, Capital Medical University, between January 1, 2007 and March 31, 2020. The clinical data including diagnostic and management procedures as well as outcomes were collected and summarized.

RESULTS

A total of nine patients were included in this study, five with primary AEF and four with secondary AEF. Eight of the patients were male, and the median age was 63 years. The fistulas were located in both the small intestine and the colon. All patients presented with gastrointestinal bleeding and pain, followed by weight loss, anorexia, and fever. A typical abdominal triad was found in only two cases. Seven patients experienced complications with preoperative abdominal infections and sepsis, and multiple organ failure occurred in four of these patients. All patients were assessed by computed tomography and five underwent abdominal and/or iliac aorta angiography. Two of these patients showed contrast agent leakage from the abdominal aorta into the intestine. Two cases were diagnosed with AEF by endoscopy before the operation. Eight patients received surgery and six patients survived.

CONCLUSIONS

AEF is a rare cause of gastrointestinal bleeding that is associated with high mortality. Gastrointestinal bleeding and pain are the most common presentations. Timely diagnosis and multidisciplinary management are crucial to achieve a positive outcome.

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

Fatal secondary aortoduodenal fistula diagnosed with postmortem computed tomography angiography

Secondary aortoduodenal fistula (AEF), although less rare than its primary form, is an uncommon and frequently lethal cause of gastrointestinal (GI) bleeding. We report a case of fatal GI hemorrhage in a woman with a remote history of endovascular graft repair of an abdominal aortic aneurysm. Postmortem examination included computed tomography (PMCT) and CT angiography (PMCTA), which revealed air in the aorta, loss of the fat plane between the aorta and duodenum, and direct extravasation of contrast from the aorta into the duodenum. To our knowledge, this is the first published report of secondary AEF diagnosed by PMCT and confirmed with PMCTA. We propose a set of imaging criteria by which PMCTA can be used to supplant traditional anatomical dissection in the medicolegal investigation of deaths due to AEF.

Aortoenteric fistulas: spectrum of MDCT findings

An aortoenteric fistula is an abnormal communication between the aorta and the gastrointestinal tract wall. The high mortality associated with this rare entity means it requires early accurate diagnosis. Aortoenteric fistulas are classified as primary when they develop on a native aorta that has not undergone an intervention and as secondary when they develop after vascular repair surgery. All radiologists need to be able to recognize the direct and indirect signs that might suggest the presence of an aortoenteric fistula. This article reviews the types of aortoenteric fistulas and their clinical and pathophysiological correlation, as well as the diagnostic algorithm, illustrating the most characteristic findings on multidetector computed tomography.

Aortoenteric fistula secondary to an Inflammatory Abdominal Aortic Aneurysm

Primary aortoenteric fistulas are rare, with the annual incidence of such fistulas estimated to be 0.007 per million. The most common predisposing conditions for primary aortoenteric fistulas are atherosclerotic abdominal aortic aneurysms or penetrating atherosclerotic ulcers. We illustrate a rare case of an inflammatory aortic aneurysm causing a primary aortic fistula, with a direct fistulous jet from the aorta to the bowel with resultant catastrophic bleeding. In contrast to atherosclerotic aneurysms, most inflammatory aneurysms are symptomatic and show dense perianeurysmal fibrosis and periaortic wall thickening. A direct jet of contrast extravasation from the aorta into a bowel loop, while rarely seen, remains the most specific sign of a primary aorta-enteric fistula. A comprehensive literature review of the clinical presentation, imaging features, and differential diagnosis of a primary aortoenteric fistula are also discussed.

Aortoenteric fistula: a rare but critical cause of small bowel bleeding discovered on capsule endoscopy

A 78-year-old man attended for outpatient capsule endoscopy, to investigate a recent history of unexplained small bowel bleeding. His previous medical history included an abdominal aortic aneurysm repair 6 years ago. Soon after capsule ingestion, he experienced sudden onset abdominal pain and collapsed on hospital grounds. He was rapidly transferred to the emergency department as he was haemodynamically unstable, and a significant per rectum (PR) bleed was found on examination. The patient was quickly stabilised following fluid resuscitation. CT angiography was performed which did not show active bleeding. However, use of the real-time capsule viewer indicated a profuse active jejunal bleed originating from the aortic graft, suggestive of an aortoenteric fistula. The patient underwent emergency endovascular cuff placement, and subsequent endovascular abdominal aortic stent grafting, to good effect.

Aortic Bulge: A Possible Predictive Sign of Impending Aortoenteric Fistula

Purpose

The purpose of this study is to introduce the aortic bulge sign, a finding observed retrospectively on computed tomography prior to the acute presentation of aortoenteric fistula, and to determine its interobserver reliability.

Methods

Following research ethics board approval, all cases of aortoenteric fistula at our institution occurring from 2011–2015 were identified retrospectively. All previous computed tomography images of patients who eventually developed aortoenteric fistula were reviewed by a single observer for the presence of a potentially predictive finding of fistulization, the aortic bulge sign. These previous images were then combined with age and sex matched controls into a case bank. Eight radiology residents and staff were instructed in observing the aortic bulge sign. These observers then reviewed the case bank in a blinded analysis to determine the interobserver reliability of this finding.

Results

Fourteen cases of aortoenteric were identified. The average patient age was 70.71 years with a male-to-female ratio of 11:3. Eleven patients had previous computed tomography images available for review. With blinded analysis by multiple observers, the aortic bulge sign was identified with greater than 80% agreement in six of 11 cases (66.67%). Fleiss' kappa was calculated at k = 0.60 (95% confidence interval 0.50–0.69), corresponding to moderate-to-substantial interobserver agreement.

Conclusions

The aortic bulge sign has been retrospectively identified as a promising computed tomography finding of eventual aortoenteric fistula prior to acute presentation. Further study is required to determine the diagnostic value of this sign.

An iliac-appendiceal fistula causing gastrointestinal bleeding

Aortoenteric fistulas are an uncommon cause of gastrointestinal bleeding, and iliac-appendiceal fistulas are an even rarer cause. We describe a case of an iliac-appendiceal fistula in a patient who presented several months after aortic reconstruction with gastrointestinal bleeding. An extensive workup revealed that the source of bleeding was localized to the appendiceal orifice. The patient underwent an appendectomy with a two-stage procedure involving the iliac graft for definitive repair and ultimately recovered well. Despite the rarity of aortoenteric and iliac-appendiceal fistulas causing gastrointestinal bleeding, keeping a high index of suspicion in patients with a prior vascular repair can prevent death.

Upper Gastrointestinal Bleeding: Etiologies and Management

Upper gastrointestinal bleeding is a medical condition routinely encountered in clinical practice. Overt upper gastrointestinal bleeding usually presents as melena or hematemesis but can also present as hematochezia in cases of brisk bleeding. The initial evaluation of a patient with suspected upper gastrointestinal bleeding begins with assessment of hemodynamic status, identification of potential risk factors, and appropriate triage of level of care. After resuscitation measures, endoscopic evaluation can be performed to diagnose and potentially treat the source of bleeding. Risk factors that increase the propensity for recurrent bleeding should be identified and addressed.