Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 67-69

Endovascular Management of Primary Aortoenteric Fistulae


Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Web Publication8-Jun-2016

Correspondence Address:
Albert Abhinay Kota
Department of Vascular Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.183640

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  Abstract 


Primary aortoenteric fistula (AEF) is a rare clinical entity which is life-threatening. Early diagnosis and prompt treatment play a crucial role in the management. Minimally invasive approaches such as endovascular treatment are newer options in treatment. We describe three patients with primary AEF successfully managed with endovascular treatment. The presentation of primary AEF may be acute, with an exsanguinating unstable patient who would be unfit to undergo a major laparotomy. In such instances, endovascular treatment can be used as the initial option to control the bleeding. Endovascular treatment is a valuable treatment option to control bleeding when the morbidity of open repair is high.

Keywords: Aortoenteric fistula, endovascular, primary


How to cite this article:
Kota AA, Selvaraj AD, Premkumar P, Ponraj S, Agarwal S. Endovascular Management of Primary Aortoenteric Fistulae. Indian J Vasc Endovasc Surg 2016;3:67-9

How to cite this URL:
Kota AA, Selvaraj AD, Premkumar P, Ponraj S, Agarwal S. Endovascular Management of Primary Aortoenteric Fistulae. Indian J Vasc Endovasc Surg [serial online] 2016 [cited 2019 Nov 14];3:67-9. Available from: http://www.indjvascsurg.org/text.asp?2016/3/2/67/183640




  Introduction Top


Aortoenteric fistula (AEF) is a rare clinical entity presenting as gastrointestinal (GI) bleeding. It can occur primarily with atherosclerotic aneurysms but often seen secondarily after aortic operations using prosthetic grafts. The first AEF was described by Sir Astley Cooper in 1829.[1] The clinical diagnosis is often made based on the history and evaluation. Management options are limited and can be surgical or endovascular, the latter being used more often in moribund patients not fit for open surgical repair.


  Case Reports Top


Case 1

A 63-year-old male presented with recurrent hematemesis and melena for 3 weeks requiring multiple blood transfusions. He was a diabetic and hypertensive. Clinical examination was normal. Upper GI (UGI) scopy was normal. The computed tomography (CT) angiogram revealed atherosclerotic infrarenal aortic aneurysm [Figure 1] adherent to the third part of the duodenum. He underwent endovascular covered stent (Advanta V12 16 mm × 61 mm) placement. His postprocedure hospital stay was uneventful.
Figure 1: Aorto-duodenal fistula

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Case 2

A 48-year-old male presented with two episodes of fresh bleeding per rectum for 1 week. He did not have any comorbidities. Clinical examination was normal. Lower GI scopy revealed pulsatile lesion with active bleeding from sigmoid colon 38 cm from the anal verge [Figure 2]. Further evaluation with CT angiogram revealed AEF with communication between the right proximal iliac artery and sigmoid colon [Figure 2]. He underwent endovascular stent placement (right – Jomed 6–12 mm × 48 mm and left – Jomed 6–12 mm × 38 mm). He did not have any further episodes of bleeding and was doing well at 3 months follow-up [Figure 2].
Figure 2: Right CIA to sigmoid

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Case 3

A 57-year-old presented with acute episode of large volume hematemesis. He had recurrent hematemesis for the past 4 months. He was a diabetic. He underwent a UGI scopy which was normal. Clinical examination revealed tachycardia and hypotension requiring multiple blood transfusions. CT angiogram revealed a thoracoabdominal aneurysm with contrast extravasation into the distal esophagus [Figure 3]. He underwent endovascular thoracic aortic repair with a stent graft (cook zenith flex 30 mm × 80 mm). His postprocedure stay was uneventful.
Figure 3: Aorto-esophageal fistula colic fistula

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  Discussion Top


An AEF is defined as an abnormal communication between the aorta and GI tract. Most commonly it involves the third and fourth part of the duodenum due to its proximity to the infrarenal aorta. It has also been described to involve esophagus, jejunum, ileum, colon, and appendix.[2]

AEF have been classified as primary and secondary. Primary AEF occurs when the communication occurs due to the presence of abdominal aortic aneurysms (most common), peptic ulcer disease, aortitis, mycotic aneurysm, inflammatory bowel disease, trauma, foreign body, radiotherapy, malignancy, tuberculosis, and pancreatic pseudocyst. Secondary AEF occurs after prior aortic operations requiring prosthetic graft placement. The incidence of primary and secondary AEF varies from 0.02–0.07% and 0.5–1%, respectively. Vollman and Kogel have also described AEF as Type 1 (A and B) – primary with or without pseudoaneurysm and Type 2 – secondary fistulae with graft-enteric erosion.[2],[3]

The pathophysiological factors involved in the development of AEF can be described based on the inciting events. Primary AEF is due to the pulsatile force within the aorta. Secondary AEF occurs due to factors such as anastomotic suture breakdown secondary to an infection, expanding constant pulsatile forces within the grafts, duodenal injuries, and also due to paraprosthetic infections/graft-enteric erosions.[2],[3],[4]

Clinical features include the history of “herald bleed” - the first episode of bleed is minor and often self-limiting due to the thrombus plug. However, the subsequent episodes can be severe and recurrent. The classic triad of GI bleed, abdominal pain, and pulsating abdominal mass seldom occur.[2],[3],[4],[5]

Evaluation mainly involves the identification of the site of AEF. This can be achieved with luminal scopy (both esophagogastroduodenoscopy and colonoscopy) which can be operator dependent followed by contrast imaging series such as CT angiogram which is sensitive to arrive at a diagnosis. The CT findings such as the contrast in the bowel lumen, air within the bowel wall at the site of AEF are pathognomonic features. Newer modalities of evaluation include magnetic resonance abdomen, digital subtraction, and three-dimensional rotational angiography. Ultrasound abdomen has a limited diagnostic role.[2],[3],[5],[6],[7]

The operative management of AEF is associated with high morbidity and mortality. Open surgical repairs with in vivo reconstruction using grafts along with excision of the fistulous tract, debridement of the infected tissue, or bowel resection have been mentioned.[3],[4],[5],[8]

Most often they present in an acute setting when a definitive open operative repair is hazardous. Therefore, endovascular treatment has revolutionized the management of AEFs. This modality of treatment has also been advocated as a bridge to a definitive procedure for unstable patients. This is, in addition, useful to temporarily tamponade the bleeding by endovascular balloon occlusion.[4],[6],[9],[10]

There is paucity in literature for the benefits of endovascular management of AEF and most have been described by case reports or case series. There have been no randomized controlled trials comparing open versus endovascular management options due to the critical nature of the presentation.

Recent reviews have noted that endovascular treatment of AEF with bleeding has a beneficial effect on the outcome. The presence of infection at presentation was a predictor for worse outcome.[4],[5] There was also some concern that the introduction of the prosthesis in the presence of infection could flare up sepsis.[3]

The three patients whom we managed had AEF communicating with duodenum, sigmoid colon, and esophagus. They were not fit for any operative intervention but had successful placement of endovascular stents with no recurrence of symptoms. They were discharged on long-term antibiotics. The 30-day mortality was nil. At 3 and 6 months follow-up, they did not have any further bleeding episodes.


  Conclusion Top


Endovascular treatment is a feasible alternative option to open repair in the management of primary AEF.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cooper A. The Lectures of Sir Astley Cooper on the Principles and Practise of Surgery with Additional Notes and Cases by F. Tyrell. 5th ed. Philadelphia: Barrington and Haswell; 1939.  Back to cited text no. 1
    
2.
Kashyap VS, O'Hara PJ. Local complications: Aortoenteric fistulae. In: Rutherford's Vascular Surgery. 7th ed. USA: Saunders Elsevier; 2010. p. 663-74.  Back to cited text no. 2
    
3.
Saers SJ, Scheltinga MR. Primary aortoenteric fistula. Br J Surg 2005;92:143-52.  Back to cited text no. 3
    
4.
Lonn L, Dias N, Veith Schroeder T, Resch T. Is EVAR the treatment of choice for aortoenteric fistula? J Cardiovasc Surg (Torino) 2010;51:319-27.  Back to cited text no. 4
    
5.
Antoniou GA, Koutsias S, Antoniou SA, Georgiakakis A, Lazarides MK, Giannoukas AD. Outcome after endovascular stent graft repair of aortoenteric fistula: A systematic review. J Vasc Surg 2009;49:782-9.  Back to cited text no. 5
    
6.
Burks JA Jr., Faries PL, Gravereaux EC, Hollier LH, Marin ML. Endovascular repair of bleeding aortoenteric fistulas: A 5-year experience. J Vasc Surg 2001;34:1055-9.  Back to cited text no. 6
    
7.
Hagspiel KD, Turba UC, Bozlar U, Harthun NL, Cherry KJ, Ahmed H, et al. Diagnosis of aortoenteric fistulas with CT angiography. J Vasc Interv Radiol 2007;18:497-504.  Back to cited text no. 7
    
8.
Song Y, Liu Q, Shen H, Jia X, Zhang H, Qiao L. Diagnosis and management of primary aortoenteric fistulas – Experience learned from eighteen patients. Surgery 2008;143:43-50.  Back to cited text no. 8
    
9.
Jayarajan S, Napolitano LM, Rectenwald JE, Upchurch GR Jr. Primary aortoenteric fistula and endovascular repair. Vasc Endovascular Surg 2009;43:592-6.  Back to cited text no. 9
    
10.
Thomson VS, Gopinath KG, Joseph E, Joseph G. Primary aorto-enteric fistula: A rare complication of abdominal aortic aneurysm. J Postgrad Med 2009;55:267-9.  Back to cited text no. 10
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