Emergent Chimney Endovascular Repair of an Aortoenteric Fistula in the Setting of a Solitary Kidney

Abstract

Open surgery remains the definitive therapy for secondary aortoenteric fistula, but mortality is as high as 40%. Endovascular repair has emerged as a viable option, particularly in the critically ill. We present a case of an emergent chimney endovascular repair of a juxtarenal secondary aortocolonic fistula complicated by septic and hemorrhagic shock in a patient with a solitary kidney. A 68-year-old morbidly obese man with a history of myocardial infarction, peripheral artery disease, and a solitary kidney (prior kidney donation to wife) underwent an open tube graft repair of a ruptured abdominal aortic aneurysm at an outside facility. His recovery was complicated by a large proximal anastomotic pseudoaneurysm with an aortocolonic fistula. On postoperative day 30, he was transferred to our institution for worsening hemodynamic status and evolving sepsis. Shortly after arrival, superimposed hemorrhagic shock developed after 1 L of lower gastrointestinal bleed. Imaging had demonstrated a fistula at the level of the left renal artery ostium with a broad-based communication with the mid-transverse colon (Fig, A). Given the patient’s acutely deteriorating clinical status and hostile anatomy, we decided to pursue the least invasive treatment option. A left renal artery chimney stent graft was delivered through the left brachial artery while an Endurant II (Medtronic, Santa Rosa, Calif) proximal aortic cuff was deployed to promptly seal the fistula. To exclude the entire tube graft from the systemic circulation, to avoid the need for contralateral gate cannulation, and to concomitantly address bilateral iliac occlusive disease, the AFX platform (Endologix, Irvine, Calif) was deployed with adequate overlap with the proximal cuff (Fig, B and C). The patient then underwent laparotomy for an extended left hemicolectomy and transverse colostomy. We noted prompt postoperative improvement in sepsis and hemodynamic status. Serial postoperative imaging up to 9 months has shown near-resolution of periaortic inflammatory changes and widely patent aortic and left renal artery repairs. Suppressive oral antibiotics are maintained. Chimney endovascular aortic repair is a viable option for emergent repair of secondary aortoenteric fistula in a select group of high-risk patients.