Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak

Abstract

An 84-year-old female was lost to follow-up after endovascular aneurysm repair at another hospital with known type II endoleak. She later presented with presyncope and hematemesis. A referral center esophagogastroduodenoscopy showed possible duodenal diverticulum. She had recurrent symptoms and repeat computed tomography scan showed air within the aortic sac. At our center, she underwent stent graft explantation and axillofemoral reconstruction for a primary aortoenteric fistula. She was discharged and is doing well 5 months postoperatively. A high degree of suspicion for aortoenteric fistula is imperative in any patient with upper gastrointestinal hemorrhage after open or endovascular abdominal aortic aneurysm repair.

Aortoduodenal Fistula After Endovascular Abdominal Aortic Aneurysm Repair

“…Persistent endoleak leading to sac enlargement and sustained pressure to the duodenal wall may result in development of ADF. 1,13,14 Aortoduodenal fistula formation in patients 1 and 4 in our series may be related to the type II endoleak, although the size of the aneurysm was not increased compared to that before EVAR in both cases. On the other hand, several reports have described post-EVAR ADF without endoleak, device migration, or sac enlargement.…”

“…Clinical symptoms of ADF after EVAR are usually nonspecific, and include gastrointestinal bleeding, chronic fever, abdominal or back pain, and nausea; hemorrhagic shock is less common in cases without a major endoleak. 1,3,6,13,14 Computed tomography is useful in making the diagnosis, as we experienced in our patients. Typical signs indicative of ADF include air bubbles and fluid collection around the stent graft and a dense connection between the aneurysm and duodenum, whereas extravasation of the contrast media is rarely observed.…”

“…Typical signs indicative of ADF include air bubbles and fluid collection around the stent graft and a dense connection between the aneurysm and duodenum, whereas extravasation of the contrast media is rarely observed. 1,3,[13][14][15] Endoscopy can confirm the diagnosis of ADF even in cases with negative CT findings, and is also recommended to rule out other pathology in the upper gastrointestinal tract. 6,13 Surgical treatment of ADF after EVAR includes explantation of stent graft, arterial reconstruction, and repair of the duodenal defect.…”

Aortoenteric Fistula after Endovascular Aneurysm Repair

“…Some authors have considered fistulae occurring by this mechanism as primary AEF. [6] Our patient had the communication between 3 rd part of the duodenum and his native aorta which was not covered by the stent graft so theoretically, we can consider this as a primary AEF due to type II endoleak.…”

Coexisting Aortoenteric and Aortovesical Fistulae after Endovascular Aortic Repair of Abdominal Aortic Aneurysm: A Case Report

“…Co-existing AEF and AVF secondary to EVAR had never been reported. The etiology of fistulae formation after EVAR is usually abrasion and erosion of adjacent iliac loop, ureter, or bladder caused by transluminal aortic coils [7], type I or II endoleaks with persistent AAA sac expansion [3,5,10], and graft kinking or erosion [4],which theoretically share much in common with AVF formation. The specific risk factors which contribute to primary AVF formation are pelvic surgery, ureteral stenting, and previous radiation therapy [11], and these factors also increase the risk of post-EVAR AVF formation.…”