Management of aortoenteric fistula advances in surgery. Endovascular repair of bleeding aortoenteric fistulas. Maefisto study highlights the characteristics of late. The optimal revascularization modality in secondary abdominal aortoenteric fistula saef is debated, although in situ bypass isb has increasingly been used. A blinded retrospective study was performed to determine the sensitivity and specificity of computed tomography ct in detecting perigraft infection pgi and aortoenteric fistula aef, rare but devastating complications of aortic reconstructive surgery. The fistula opening was surrounded by edematous duodenal mucosal. Aortoenteric fistulas are an uncommon cause of gastrointestinal bleeding, and iliacappendiceal fistulas are an even rarer cause. Aortoenteric fistula aef is a rare but lifethreatening condition with an annual incidence of 0. Pestanas surgery notes fits perfectly in your lab coat so you can refresh your knowledge in between cases. Is evar the treatment of choice for aortoenteric fistula.
Fistula formed between aorta and intestines can be primary or secondary often due to aaa repair can form fistula anytime within life of aaa graft repair higher risk with recent graft placement. Endovascular repair of aortoenteric fistulae as a definitive. While secondary aortoenteric fistulas saefs are more common and arise after aortic reconstruction, primary aortoenteric fistulas paefs are generally caused by abdominal aortic aneurysms aaas. Secondary aortoenteric fistula saef is an infrequent complication following any aortic reconstruction surgery. Aortoenteric fistula a 7 year urban experience steven moulton, md, seattle, washington mark adams, md, seattle, washington kaj johansen, md, phd, seattle, washington the most feared complication of aortic reconstruc sition of living tissue between these structures has tion is the development of a communication be been considered a crucial adjunct to aortic recon tween the aorta and the.
The high mortality associated with this condition and relatively low incidence make this a diagnostic and management challenge. Aortoenteric fistulae aef are a rare and potentially fatal cause of upper gi bleeding. Abdominal aortic aneurysm aaa is a very serious and rare communication between the lumen of the aorta and that of the duodenum. Secondary aortoenteric fistula, due to mechanical erosion or infection of a prosthetic graft, is a very rare cause of gastrointestinal bleeding and an uncommon complication of abdominal aortic aneurysm repair. The inferior mesenteric artery was absent from recent abdominal aortic surgery. It results from mechanical erosion of the prosthetic graft or suture material into the surrounding bowel and sometimes even stent graft infection itself predisposes to erosion of the adherent bowel wall. We describe a case of an iliacappendiceal fistula in a patient who presented several months after aortic reconstruction with gastrointestinal bleeding. This type of fistula is the most common and often initiates massive gastrointestinal hemorrhage.
Aortoenteric fistula aef is an uncommon but catastrophic complication that can occur either primarily or after aortic reconstruction. Early diagnosis is difficult and depends on a heightened clinical suspicion. A definite aortoenteric fistula was seen arising in the native aorta. American journal of interventional radiology partially. Aortoenteric fistulae aef represent the most lethal subset of aortic infections. Although the reported incidence of aef is low, immediate recognition and management is essential for the patients survival. A 70yearold patient with aortoduodenal fistula 5 years after. Aortoenteric fistula aortoenteric fistula aef is a rare, lifethreatening disease process. Diverse presentation of secondary aortoenteric fistulae. Aortoenteric fistula to the sigmoid coloncase report. When the connection is between the aorta and a loop of bowel that is near the aorta it is known as an aortoenteric fistula aef. Conventional surgical management is associated with a perioperative mortality rate of 25% to 90% and frequent major complications. Pdf a fistula between the aorta and the gastrointestinal gi tract is a relatively uncommon and often lethal cause of gi bleeding. These patients often present with a herald bleed, followed by massive gastrointestinal hemorrhage.
Unfortunately, despite early diagnosis with aggressive antibiotic and surgical treatment, overall aef mortality rate remains between 10% and 50% 4. It is rare, potentially fatal, and is difficult to diagnose and manage. Aortoenteric fistulas aefs are deadly, abnormal connections between the aorta and gastrointestinal gi tract. Aortoenteric fistulas are a rare cause of gastrointestinal gi bleeding. Endoscopic image showing the aortoenteric fistula opening on the posterior superior wall of the. The high mortality associated with this condition and relatively. Any patient presenting with gastrointestinal hemorrhage and a history of aortic reconstruction should be considered to have an aortoenteric fistula until proven otherwise. Aortoenteric fistula aef is defined as a communication between the aorta and the. Aortoenteric fistula aef remains a catastrophic complication with a high morbidity and mortality, despite numerous strategies for surgical treatment. The diagnosis of aortoenteric fistula can be as challenging as diagnosing an early graft infection. Most commonly a complication of repair of abdominal aortic aneurysms. Primary aortoduodenal fistula a rare clinical entity. The focus of surgical treatment will be to confirm the diagnosis, control bleeding, repair the damaged area of bowel, and remove the aneurysm or graft that is.
The patient could not have the entire graft removed at the time. Aortoenteric fistula aef is an uncommon but lifethreatening condition. Primary aortoenteric fistulas paef are rare entities associated. The clinical signs of aortoenteric fistula include hematemesis, melena, sepsis, and abdominal pain, but the condition also may be clinically occult. An insidious gastrointestinal bleeding from secondary. An aortoenteric fistula was highly suspected and the patient went to emergent laparotomy.
We report a case of a 70yearold man who presented to the. Aortoenteric fistula aef is a rare clinical entity that was first described in 1818 by sir ashley cooper. It is usually secondary to an abdominal aortic aneurysm repair. The clinical manifestation of the aortoenteric fistula is always upper gastrointestinal bleeding. Once the diagnosis of aortoenteric fistula is suspected, urgent surgical repair is indicated after urgent diagnostic evaluation with ct scan and egd has been conducted 12. A this patient suffered a recurrent aortoenteric fistula after attempted aortic stump ligation. A medline search was conducted for the period from january 1994 to december 2003. Aortoenteric fistula is an uncommon but lifethreatening cause of gastrointestinal blood loss. Computed tomography with contrast medium is often the preferred test in emergent cases, with sensitivity and specificity up to 94% and 85%, respectively.
The complication often occurs months to years after aortic surgery. There is contrast and air extending between the duodenum and aorta consistent with an aortoenteric fistula white arrow. An aortoenteric fistula is a connection between the aorta and the intestines, stomach, or esophageus. After 18 days of antibiotic treatment, he suddenly went into a state of shock, with massive fresh bloody stool and hematemesis, followed by. Patients with an aef are commonly encountered as a medical emergency associated with acute gi bleeding. Aef is defined as an abnormal connection between the aorta or aortoiliac tree and the gastrointestinal tract.
Saef is typically secondary to abdominal aortic aneurysm repair. Therefore, we aimed to quantify the association between extraanatomic bypass eab and isb mortality in saef. After 18 days of antibiotic treatment, he suddenly went into a state of shock, with massive fresh bloody. Type 1, termed a true aortoenteric fistula or graft enteric fistula, with or without a pseudoaneurysm, develops between the proximal aortic suture line and the bowel. A fistula is an abnormal, tubelike connection between two structures inside the body. The data came from a study presented at the annual meeting of the european society for vascular surgery esvs. Celebrated by medical students for over a decade, kaplans pocketsized dr.
An aortoenteric fistula aef is a rare but lifethreatening cause of gastrointestinal gi bleeding. Technical challenges include scarring from the infection and often. The patient originally underwent aortobifemoral bypass with a side branch to the left renal artery yellow arrow. In situ bypass and extraanatomic bypass procedures result. When such a fistula occurs in the absence of previous aortic aneurysm surgery, it is called a primary aortoduodenal fistula padf, a condition much less frequent than a secondary aortoduodenal fistula which occurs as a result of previous aortic. Contrast enhanced arterial phase axial computed tomography demonstrates tumor encasing the inferior vena cava and aorta. Treatment of the disease is early surgical intervention. Secondary aortoenteric fistulas are an uncommon and lifethreatening condition that develop in the setting of a predisposing etiology, such as a prior aortic graft. We present a case of aortoenteric fistula with direct contrast extravasation from the abdominal aorta into an ileal loop during. Aortoenteric fistula is a communication between the aorta and adjacent bowel.
The pathogenesis of aef formation after endovascular abdominal aortic repair is related to mechanical failure of the stentgraft, to. Ct angiography was performed which did not show active bleeding. Although aortoenteric fistula following abdominal aortic aneurysm or aortoiliac reconstructive surgery has been reported by many investigators, 47 a vascular enteric fistula after a renal artery bypass graft has been reported only once. Successful treatment of secondary aortoenteric fistula with a. Proper treatment requires early diagnosis, which depends on a high rate of clinical suspicion. Pestanas surgery notes 5th edition pdf free download. Aef remain rare, despite the innumerable episodes of bacteremia that people experience in their lifetime. A case report of successful treatment of secondary. Pdf aortoenteric fistula aef is a communication between the aorta and an adjacent bowel loop.
Aortoduodenal fistula and associated rupture of abdominal aortic. Similarly, in the chest, when a large thoracic aortic aneurysm compresses the esophagus. Primary aortoenteric fistula saers 2005 bjs british. Prompt diagnosis of aortoenteric fistulas is imperative for patient survival. Resultsduring surgery, significant inflammation was noted surrounding the aorta with friable tissues of the aorta itself. A primary aortoenteric fistula paef is a rare clinical entity that results in fatal exsanguination if undiagnosed. Mechanical injury, infection, and adherence of a bowel segment to the aorta or aortic graft are major etiologic factors of aef after open aortic repair. Secondary aortoenteric fistula saf is an uncommon, but very important complication of abdominal aortic reconstruction. Aortoenteric fistula video journal and encyclopedia of. The disease is divided into two typesprimary and secondary aef. Patients presentation range from those with an occult anemia, to those with catastrophic gastrointestinal gi hemorrhage and sepsis. Aortoenteric fistula should be considered a subset of aortic graft infection. Late aortoenteric fistulae may occur in less than 1% of patients undergoing endovascular aneurysm repair evar, with an increased risk in cases of emergency evar or those performed for pseudoaneurysm following previous aortic surgery.
Secondary aortoenteric fistula saef is a rare yet lethal condition with a 45. Secondary aortoenteric fistula possibly associated with continuous. It is most often the result of primary compression of the aorta eg, abdominal aortic aneurysm against, or erosion of an aortic prosthetic graft into, the. Generally 2 types of secondary aortoenteric fistula have been described. A primary aortoenteric fistula forms when a large abdominal aortic aneurysm closely abuts bowel loops, usually the 3 rd or 4 th parts of the duodenum. An aortoenteric fistula was highly suspected and the patient underwent emergency laparotomy. Aortoenteric fistula in patient with infected aortic endovascular stent.
Definitive treatment includes primary duodenal repair and aortic. The patient was quickly stabilised following fluid resuscitation. Aortoenteric fistula an overview sciencedirect topics. Background secondary aortoenteric fistula is a rare but fatal complication after reconstructive. Early clinical and imaging diagnosis and prompt surgical intervention are crucial for patient survival. The present study investigates whether management and survival have altered over time. The fistula opening was surrounded by edematous duodenal mucosa. Successful surgical treatment of aortoenteric fistula. However, use of the realtime capsule viewer indicated a profuse active jejunal bleed originating from the aortic graft, suggestive of an aortoenteric fistula. Both mri and ct can fail to diagnose graft enteric fistulas. An iliacappendiceal fistula causing gastrointestinal. Prompt recognition and treatment of these complica tions is essential. B with the first presentation, the patient underwent axillobifemoral bypass, with ligation of the aortic graft. There can be significant blood loss into the intestines resulting in bloody stool and death.
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