Secondary aortoenteric fistula possibly associated with continuous physical stimulation: a case report and review of the literature

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.

A Case of Problem-Free Survival Five Years After Abdominal Aortic Sigmoid Colon Fistula Surgery

An aortoenteric fistula (AEF) is a rare but life-threatening condition where an abnormal connection forms between the aorta and the gastrointestinal tract, most commonly the duodenum. It can be primary (arising spontaneously due to an aortic aneurysm or infection) or secondary (complicating prior vascular surgery). Immediate recognition and surgical intervention are critical to manage severe gastrointestinal bleeding and prevent fatal outcomes. A 71-year-old male developed an AEF following abdominal aortic graft surgery. Four months postoperatively, he presented with persistent lower gastrointestinal bleeding and was diagnosed with a secondary AEF. A staged surgical approach was employed, involving initial bowel resection, stoma creation, and graft cleaning, followed by subsequent aortic graft replacement with omental flap coverage. Postoperatively, a graft rupture at the proximal anastomosis required emergency endovascular stenting, which stabilized the patient. Antibiotic therapy successfully managed graft infection, including meropenem, linezolid, and later levofloxacin. The patient was discharged home on day 65 and has remained free of aortic events for five years. This case illustrates the complexity of AEF management, emphasizing the importance of a multidisciplinary, staged approach to achieve infection control, hemostasis, and long-term stability. He has been followed up in an outpatient clinic since then. He is now 76 years old, five years later, and is progressing without an aortic event.

The usefulness of gel immersion endoscopy in identifying herald bleeding from an infectious aortoenteric fistula: a case report

A 62-year-old male with a history of stent graft replacement for an infectious aortic aneurysm, followed by multiple interventions for postoperative complications, was admitted with melena and anemia. Enhanced computed tomography (eCT) demonstrated fluffing and hyperdensities surrounding the graft, despite no evidence of an aortoenteric fistula (AEF). Emergency esophagogastroduodenoscopy (EGD) showed a massive bleeding in the reconstructed tract and the protruding lesion of postoperative granulation tissue with clots at the end of the blind pouch. Thereafter, hemorrhage temporarily reoccurred several times; however, the source could not be identified using eCT or EGD. Finally, on the third attempt, we performed gel immersion endoscopy (GIE) with manual injection of VISCOCLEARⓇ, and it showed purulent blood flowing from one side of the protruding lesion in the pouch. Based on the eCT findings showing exudation of the contrast agent from the graft into the pouch, we made a diagnosis of an AEF. However, radical surgery was not performed because of the patient's poor general condition. During conservative management, he died of uncontrolled bleeding from the AEF on the 5th day of hospitalization. This is the first case in which the GIE might provide tips to identify herald bleeding from a lethal AEF.

Secondary aortoenteric fistula: a narrative review of the view of the surgeon

Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.

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.

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.

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.

Endovascular Treatment of Abdominal Infection-induced Aortoenteric Fistula

Primary aortoenteric fistulas is a rare clinical entity but with fatal outcome, usually arise from atherosclerotic aneurysm, but induced by abdominal infection is extremely rare. We present a case of 54-year-old man with history of Aortic arch replacement and elephant trunk stent implantation 6 years ago for Stanford type A aortic dissection. He underwent enteroscopy and had gastrointestinal perforation during enteroscopy 11 months ago. Since then he had episodes of syncope and Haemorrhage. Finally, a fistula was found on imaging. Endovascular treatment and digestive tract repair was accomplished. At 13-month follow-up, he did not have hematochezia and fever again.

Unclear Reason of Recurrent Graft Infections after Aortobifemoral Reconstruction

BACKGROUND: Aortic graft infection is one of the most serious complications of vascular reconstruction with the incidence of 1%. The clinical presentation can vary, which delays the diagnosis. CASE REPORTS: Infections in our patients affected iliac, inguinal region, and retroperitoneum, which are not relatively common sites of graft infection. We present clinical presentation, imaging procedures, and surgical treatment of three patients with unknown cause of late graft infection after 6, 7, and 9 years. CONCLUSION: In our presentations, the etiological factors of the infection are not known, but they suggest that events in the gastrointestinal tract may be related to them. Aggressive surgery should be taken into consideration as a first choice in the similar cases.

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.