Aortoduodenal Fistula Research Articles

Surgical strategy for aorta-related infection†

This report describes our experience with surgical management of aorta-related infections. From November 1999 to April 2013, 70 patients underwent surgical management for aorta-related infection, including aortobronchial fistula in 12 patients, aorto-oesophageal fistula in 14 and aortoduodenal fistula in 4. The location of infection was aortic root to arch in 22 patients, descending aorta in 29, thoraco-abdominal aorta in 12 and abdominal aorta in 7. Forty-seven patients had infections of the native aorta and 23 had postoperative graft infections. In situ replacement [bridge thoracic endovascular aortic repair (TEVAR); n = 1] was performed in 45 patients, endovascular aortic repair in 18 and extra-anatomical bypass (bridge TEVAR; n = 2) in 7. Omental flap was installed in 29 patients and a pedicled latissimus dorsi muscle flap was used in 3. Since 2008, we have been trying to resect not only the infected tissues, but also the surrounding aneurysmal wall as well. Hospital mortality was 17.1% (12/70). Late death occurred in 15 patients. Overall survival at 3 years was 60.1 ± 6.7%. Freedom from infection-related death of patients who had in situ graft replacement, endovascular repair or extra-anatomical bypass at 3 years was 88.5 ± 4.9, 75.2 ± 10.9 or 14.3 ± 13.2%, respectively (P < 0.01). In situ graft replacement provided a better freedom from aortic event (recurrent infection and reintervention) at 3 years compared with endovascular repair (85.6 ± 5.5 vs 61.8 ± 12.5%, P = 0.029). Freedom from infection-related death at 3 years improved significantly from 61.1 ± 9.7 (before 2008) to 84.7 ± 5.8% (since 2008) (P = 0.044). Surgical treatment for aorta-related infection is still associated with high mortality and morbidity. However, our current strategy, which is aggressive surgical management, including resection of infected tissues, extensive debridement, in situ graft replacement of the aorta and omental or muscle installation provided a better patient survival.

Aortoduodenal fistula after transperitoneal repair of an inflammatory abdominal aortic aneurysm: A case report

Introduction: An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Case Report: A 77-year-old Caucasian male who underwent a conventional repair of an inflammatory infrarenal aortic aneurysm, was readmitted with hematemesis only six weeks after surgery. Gastroscopy and computed tomography angiography indicated an aortoduodenal fistula and urgent aortic reconstruction was performed. An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Conclusion: An aortoduodenal fistula seldom occurs as early after conventional transperitoneal open aneurysm repair as in our case. The early occurrence of the aortoduodenal fistula can be explained by the inflammatory character of the aneurysm.

Fatal Gastrointestinal Bleeding Probably Caused by an Aortoduodenal Fistula Following Surgical Repair of an Inflammatory Abdominal Aortic Aneurysm during Postoperative Steroid Therapy

We describe a case of fatal gastrointestinal bleeding probably caused by an aortoduodenal fistula following open surgical repair of an inflammatory abdominal aortic aneurysm (AAA) during postoperative steroid therapy. A 71-year old man underwent a graft replacement for an inflammatory AAA. Prolonged elevated C-reactive protein and newly emerged ascites after surgery were improved by oral administration of predonine. The steroid therapy had been continued until 5 months after surgery, when he suffered from fatal gastrointestinal bleeding. We speculated that the gastrointestinal bleeding was caused by an aortoduodenal fistula and discuss the etiology of this condition.

Secondary aortoduodenal fistula following endovascular repair of inflammatory abdominal aortic aneurysm due to Streptococcus anginosus infection: A case report and literature review

INTRODUCTIONAortoenteric fistula is a rare but very serious complication of both surgical and endovascular abdominal aortic reconstruction. Since the advent of endovascular abdominal aortic aneurysm repair (EVAR), 20 cases of aortoduodenal fistula associated with aortic stent grafts have been reported.1 However, only a handful has been reported following inflammatory abdominal aortic aneurysm repair. It most commonly presents with bleeding, usually from the upper gastro-intestinal tract. With recent advances in the screening, diagnosis and management of abdominal aortic aneurysms either surgically or through an endovascular approach, the diagnosis of an aortoduodenal fistula in patients with gastro-intestinal bleeding must be suspected and excluded. PRESENTATION OF CASEWe describe a case of secondary aortoduodenal fistula that occurred two and a half years following endovascular stent graft repair of an inflammatory abdominal aortic aneurysm. We also outline the emergency correction plan and the attempts at repair. DISCUSSIONThis case defies the general concept that patients with inflammatory abdominal aortic aneurysms are relatively immune to rupture. Although the presence of a peri-aneurysm thick inflammatory membrane decreases the possibility of rupture, these patients are more susceptible to other related complications such as aorto-enteric and aorto-caval fistulas.2 This case also demonstrates the peculiar presence of Streptococcus anginosus as the pathological organism leading to graft infection and subsequent fistula, as opposed to enterococci which are often found in endograft infection. CONCLUSIONAorto-enteric fistulas are associated with a grave prognosis. Early diagnosis is crucial and extra vigilance should be taken in cases of inflammatory AAA.

Fístula aorto-entérica secundária - a propósito de um caso clínico

The authors present a case report of a patient with previous history of a left aorto-femoral bypass complicated by infection, then submitted to partial resection of the prosthesis and femoro-femoral bypass, with subsequent transversostomy for fistula between the descendent colon, the loca of the removed prosthesis and the abdominal wall. After a few episodes of gastrointestinal bleeding with no conclusive investigation, a secondary aorto-duodenal fistula was suspected in the last abdominopelvic CT performed. The patient was submitted to laparotomy for abdominal aorta closure suture and axilo-“cross over” bypass. This is followed by a literary review of aorto-enteric fistulae.

Primary aortoduodenal fistula and Q-fever

Patients with abdominal aortic aneurysm (AAA) are prone to vascular infection with chronic Q-fever. There is a rising incidence of up to 8% of chronic Q-fever in The Netherlands. Increased vascular aortic aneurysm infection with chronic Q-fever is reported. This report shows two rare cases of primary aortoduodenal fistulae in patients with chronic Q-fever and an AAA. We describe the clinical symptoms, diagnostic tools for detection of Coxiella burnetii infection and treatment.

ダメージコントロールが有効であった腹部大動脈－十二指腸瘻手術の1 例

ダメージコントロールが有効であった腹部大動脈－十二指腸瘻手術の1 例

Primary aortoenteric fistula.

Primary aortoenteric fistula is a rare complication of aortic aneurysms. This cause of gastrointestinal bleeding poses significant diagnostic challenges due to its nonspecific presentation. We report a case of an 80-year-old man with right flank pain and rectal bleeding. The patient had been admitted 2weeks before with the same symptoms. Upper and lower endoscopies were unremarkable, but abdominal computed tomography scan showed evidence of aortoduodenal fistula. An emergency laparotomy with aortic bypass and fistula closure was performed and the patient was able to recover in the following weeks. This case highlights the need for a high index of suspicion to avoid diagnostic delay that frequently has fatal results.

Aortoenteric Fistula in A 25-Year-Old Man

BackgroundAortoenteric fistula (AEF) is a rare diagnosis that is often considered only in older patients with histories of abdominal aortic aneurysm. ObjectivesTo remind emergency physicians that traumatic injury and repair put patients at risk for formation of AEF. Case ReportWe discuss the case of a 25-year-old man who developed an aortoduodenal fistula weeks after a stab wound to the abdomen. AEF can occur anywhere along the gastrointestinal tract and can therefore present as either upper or lower tract bleeding. The expected triad of pain, pulsatile mass, and gastrointestinal bleeding is unfortunately rarely present, making diagnosis difficult. Patients often present with a self-limited herald bleed that precedes the fatal exsanguination by hours to days. Diagnosing the fistula at the time of the herald bleed can be difficult but lifesaving. Imaging studies are often misleading and only delay definitive operative treatment. Even with prompt diagnosis and treatment, mortality is high; without repair, it is 100%. ConclusionThis case highlights the importance of suspecting and quickly recognizing AEF based on history and physical examination alone. After extensive preoperative imaging to confirm the diagnosis, this patient nearly died in the operating room as surgeons took down adhesions trying to reach the fistula to repair it.

Commentary on ‘Outcomes of Infected Abdominal Grafts Managed with Antimicrobial Therapy and Graft Retention in an Unselected Cohort’

In this paper, Maze et al. report a series of 18 patients treated for aortic graft infection over a period of 11 years. Only one of them, presenting with an aortoduodenal fistula, was treated surgically as a first intention, while the other 17 were treated conservatively, despite the fact that 11/18 (61%) showed signs of systemic infection. The only patient initially treated surgically with complete graft removal remained alive 128 months after treatment. Of the 17 patients treated with antimicrobial therapy and graft retention, there was a recurrence of infection in almost 60% (10/17). A quarter of these patients died as a result of the first relapse episode. Surgery was performed in 35% (6/17) of patients initially treated conservatively. Of note also is that for patients treated by non-operative management the overall survival rate was 1/9. Although this article aimed to investigate the assumption that conservative management may be an alternative to graft removal with or without revascularization, there are several issues to be considered before reaching a conclusion from the data presented.

Aortoduodenal Fistula: Not Always Bleeding

1Division of Gastroenterology, Department of Medicine; 2Division of Vascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Michael F Byrne, Division of Gastroenterology, Department of Medicine, University of British Columbia, 5153-2775 Laurel Street, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-5640, fax 604-875-5378, e-mail michael.byrne@vch.ca Received for publication March 17, 2013. Accepted May 12, 2013 Case Presentation A 73-year-old woman presented to a community hospital with three months of intermittent, followed by continuous epigastric pain. There was no gastrointestinal bleeding, nausea, vomiting or fever. A noncontrast abdominal computed tomography scan identified gas locules around an aortobifemoral bypass graft performed in 1992, with surrounding inflammatory fat stranding (Figure 1A). Graft infection was suspected. Metronidazole was prescribed with outpatient follow-up by a vascular surgeon who referred her for gastroscopy. At the third part of the duodenum, a wall defect 3 cm × 2 cm in size was replaced by a yellow-coloured foreign body suspected to be the external surface of an aortic Dacron graft (Figure 1B). The aortoduodenal fistula was treated with an axillofemoral graft, removal of the infected graft and a duodenal-jejunostomy, in which the lateral wall defect at the junction of the third and fourth parts of the duodenum was closed with a loop of proximal jejunum (Figure 1C). Cultures from the excised graft had growth of Candida lusitaniae and Streptococcus constellatus. Antimicrobials were commenced, with recovery in two months.

Primary aortoduodenal fistula: A case report

Primary abdominoaortic fistula is an extremely rare cause of upper gastrointestinal (GI) bleeding. The diagnosis is frequently delayed due to the rarity of the disease and low index of suspicion by physicians. A range of invasive and non-invasive diagnostic tools are available, but helical computer tomography (CT) remains the mainstay. Surgery offers the only hope for survival. This case report presents a 47-year-old male with massive upper GI bleeding. Various diagnostic tests and an exploratory laparotomy failed to identify the diagnosis. Later, a primary aortoduodenal fistula was confirmed by CT scan which necessitated surgical repair of the fistula and a Goretex graft for the abdominal aortic aneurysm. The patient made an uneventful recovery and remained well to the first postoperative visit in the clinic 2 wk after surgery.

Aortoduodenal fistula after endograft repair of abdominal aortic aneurysm secondary to a retained guidewire

Aortoduodenal fistula is a well-known complication of abdominal aortic aneurysm repair and has been described after endovascular repair. A unique complication of duodenal perforation by intentionally placed embolic material in the aneurysm sac is described. Intentional off-label use of material to promote aneurysm sac thrombosis should be avoided.

Unexpected double-primary aortoenteric fistula resulting in massive bleeding after induction of anesthesia

We report a case of a patient with a double-primary aortoenteric fistula with an abdominal aortic aneurysm. A 75-year-old man was taken to the operating room for the repair of an abdominal aortic aneurysm and a suspected aortoenteric fistula between the aorta and sigmoid colon. Sudden onset of massive bleeding through the nasogastric tube occurred after the induction of anesthesia. Surgical exploration confirmed an unexpected aortoduodenal fistula. Primary aortoenteric fistula is extremely rare and difficult to diagnose, and may cause fatal bleeding. The possibility of the presence of aortoenteric fistula, including multiple types, should be considered in the anesthetic management of abdominal aortic aneurysm.

Aorto-duodenal fistula on an aortic endograft: a rare cause of late conversion after endovascular aneurysm repair

The last few years have seen an increase in popularity of endovascular aneurysm repair because of the improvements made to the endografts design as well as experience gained by physicians, but the long-term results of this procedure are still uncertain. The majority of late complications after an endograft can be treated with an endovascular approach but, in some cases, it may need conversion to open surgery. In this paper, we discuss the case of a male patient who presented with an aorto-duodenal fistula on an endograft requiring explant. After two operations and 20 days in hospital, the patient was discharged and after 1 year he is doing well. In medical literature, there are very few reported cases of aortoenteric fistula complicating endovascular prosthesis, the diagnosis is quite difficult, surgical treatment is fairly complex consisting in endograft removal and we refer to our experience on this difficult and life-threatening operation.

Secondary aortoduodenal fistula in the duodenal bulb: role of side-viewing endoscopy

Secondary aortoduodenal fistula is an uncommon but life-threatening complication of aortic reconstructive surgery [1]. Here we report on the diagnosis of an aortoduodenal fistula using an atypical endoscopic method.

An aortoduodenal fistula as a complication of immunoglobulin G4-related disease

Most primary aortoduodenal fistulas occur in the presence of an aortic aneurysm, which can be part of immunoglobulin G4 (IgG4)-related sclerosing disease. We present a case who underwent endovascular grafting of an aortoduodenal fistula associated with a high serum IgG4 level. A 56-year-old male underwent urgent endovascular reconstruction of an aortoduodenal fistula. The patient received antibiotics and other supportive therapy, and the postoperative course was uneventful, however, elevated levels of serum IgG, IgG4 and C-reactive protein were noted, which normalized after the introduction of steroid therapy. Control computed tomography angiography showed no endoleaks. The primary aortoduodenal fistula may have been associated with IgG4-related sclerosing disease as a possible complication of IgG4-related inflammatory aortic aneurysm. Endovascular grafting of a primary aortoduodenal fistula is an effective and minimally invasive alternative to standard surgical repair.

Herald Bleeding: A Diagnosis of Aorto-Duodenal Fistula Treated with Graft Within a Graft Repair

Purpose: Introduction: An aortoenteric fistula is a communication between the aorta and an adjacent loop of the bowel. Secondary aortoenteric fistula is an uncommon but very important complication of abdominal aortic reconstruction. Herald bleeding sometimes precedes a catastrophic bleed. We report a case with this rare complication with typical herald bleeding treated with endovascular graft repair. Case report: An 80-year-old Caucasian male with a history of abdominal aortic aneurysm repair 18 years ago with a tube graft, presented with back pain, and vomiting “bloody slime.” He was on aspirin, but denied taking non-steroidal anti-inflammatory drugs or blood thinners. On examination, he was afebrile, his heart rate was 108/min and blood pressure was 101/53 mm Hg. His hemoglobin was 6.4 g/dL. He received packed red cells transfusion. An endoscopy was performed which revealed a large adherent clot in the third portion of the duodenum. This was not removed as there was a concern for aorto-enteric fistula. A review of previous CT scan revealed a closely adherent tube graft to the duodenum. Patient was deemed to be a poor surgical candidate and an endovascular graft repair was performed using a stent graft with CO2 angiography. A repeat upper endoscopy after removal of the adherent clot showed the previous aortic graft eroding through the duodenal wall, but there was no active bleeding. Patient had no further episodes of bleeding and was discharged with a close follow up. Discussion: Aorto-duodenal fistulas (ADF) after endovascular abdominal aneurysm repair are rare. Secondary ADF is an uncommon (0.3-2%) and life-threatening, long-term complication of aortic reconstructive surgery. The classic presentation of an aortoduodenal fistula is that of a “herald bleed” (brief, with spontaneous resolution), followed anywhere from hours to weeks later by a massive upper gastrointestinal bleed. Untreated cases have a mortality rate of up to 100%. In our patient, intermittent hematemesis was a warning symptom. Though laparotomy with repair is the treatment of choice, our patient was treated with graft within a graft repair in view of the comorbidities. In summary we report a rare case of aorto-duodenal fistula treated with endovascular graft repair.Figure: Visible aortic graft in the duodenum.

Granulomatous hepatitis, choroiditis and aortoduodenal fistula complicating intravesical Bacillus Calmette-Guérin therapy: Case report

BackgroundIntravesical instillation of Bacillus Calmette-Guérin (BCG) is the treatment of choice for superficial bladder carcinoma. Complications of BCG therapy include local infections and disseminated BCG infection with multiple endorgan complications.Case PresentationWe report a case of disseminated, post-treatment BCG infection that initially presented with granulomatous hepatitis and choroiditis. After successful anti-mycobacterial therapy and resolution of the hepatic and ocular abnormalities, the patient developed an acute upper gastrointestinal hemorrhage from an aortoduodenal fistula that required emergency surgery. The resection specimen revealed multifocal, non-caseating granulomas, indicating mycobacterial involvement.ConclusionsThis case highlights the varied end organ complications of disseminated BCG infection, and the need for vigilance even in immuno-competent patients with a history of intravesical BCG treatment.

Endovascular treatment of two aortoduodenal fistulae

We report the endovascular treatment of two patients presenting with aortoduodenal fistulae. The first patient was a 66-year-old man admitted with hematemesis. He was on clopidogrel and had received a cryopreserved aortic graft for a mycotic abdominal aortic aneurysm five years earlier. Computed tomography (CT) showed aortic pseudoaneurysms in close contact with the duodenum. Endovascular repair was carried out. Twenty-seven months after the procedure the patient remains asymptomatic. The second patient was a 78-year-old man admitted with abdominal pain and nausea. CT revealed an abdominal aortic pseudoaneurysm and aortoduodenal fistula. He suffered from severe chronic obstructive pulmonary disease that greatly increased his surgical morbidity and mortality. An endovascular repair was performed under epidural anesthesia. The patient died of a postoperative pneumonia 38 days after surgery. These two cases illustrate the importance of endovascular aortic repair especially when an open surgical procedure is either difficult or impossible.