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

Abstract

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.

Results from the Multicenter Study on Aortoenteric Fistulization After Stent Grafting of the Abdominal Aorta (MAEFISTO)

“…Even if most AEF reports are associated with open AAA repair, individual cases or small series of AEF after EVAR have been published recently, [4][5][6][7][8][9][10] with the only clear evidence that they represent a rare but life-threatening complication of EVAR as well. 11 Besides, relatively little is known about these sequelae because of their rarity, the fairly recent clinical introduction of endovascular techniques, and the lack of multicenter reports.…”

Aortoduodenal fistula after abdominal aortic aneurism resection: Two case reports

“…[4] AEF are rare (2%) but devastating complications of prosthetic arterial reconstruction with high operative mortality rate (30% to 75%) and morbidity (amputation) rate (30% to 50%). [5,6,7,8,2] About 70% patients previously have aortooclusive disease with some bypass, and 30% operated because of aneurismal disease. [4] The average interval between first and operation with aortoenteric fistula was 3-5 years with aperiod of 2 weeks to 14 years.…”

“…[5,19] Some recommended a staged procedure with an initial AxFF followed by ligation of theaorta and iliacarteries. [7,21] This can be done if it is no profuse bleeding and we have enough time for that comfort order of procedures.…”

“…[4] Someone debrided scar tissue near the fistula or graft, then suture the defects of the aorta and the hole of duodenum as the less effective way. [12,7] AxFF were reserved for patients with periaortic purulence and an in situ aortic reconstruction used in cases with minor purulence. [1] Harvesting of saphenous vein should perform prior to clamping of aorta, except in cases of profuse bleeding where clamping has priority.…”

Management of aortic graft infections – the present strategy and future perspectives

“…AEF causes one third of endograft infections and is the most challenging problem for vascular surgeons. The bleeding is usually the fi rst warning sign heralding the massive hemorrhage which follows after hours, days or even weeks (17,18). Laboratory markers such as leukocytosis, elevated CRP levels, and positive blood cultures may be helpful, but are neither sensitive nor specifi c. Fiorani reported the mean interval of 42 days (2-392 days) between the onset of symptoms and diagnosis of AGI (19).…”