Secondary aortoenteric fistula possibly associated with continuous physical stimulation: a case report and review of the literature

Abstract

BackgroundSecondary aortoenteric fistula is a rare but fatal complication after reconstructive surgery for an aortic aneurysm characterized by abdominal pain, fever, hematochezia, and hematemesis, and the mortality rate is high. It has been suggested that it arises due to either continuous physical stimulation or prosthesis infection during primary surgery. We describe an aortoenteric fistula following reconstructive surgery for an abdominal aortic aneurysm together with postmortem pathological findings.Case presentationA 59-year-old Japanese man who had undergone reconstructive surgery for an abdominal aortic aneurysm 20 months earlier presented with the chief complaint of hematochezia and malaise. Esophagogastroduodenoscopy and total colonoscopy revealed only colon diverticula with no bleeding. Contrast-enhanced computed tomography revealed gas within the aneurysm sac and adhesion between the replaced aortic graft and intestinal tract, suggesting a graft infection. After 18 days of antibiotic treatment, he suddenly went into a state of shock, with massive fresh bloody stool and hematemesis, followed by cardiac arrest. An autopsy revealed communication between the artery and the ileum through an ulcerative fistula at the suture line between the left aortic graft branch and the left common iliac artery. Pathological analysis revealed tight adherence between the arterial and intestinal walls, but no marked sign of infection around the fistula, suggesting that the fistula had arisen due to physical stimuli.ConclusionsPathological analysis suggested that the present secondary aortoenteric fistula arose due to physical stimuli. This reaffirms the importance of keeping reconstructed aortas isolated from the intestine after abdominal aortic aneurysm surgery.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report

“…The fundamental process of fistula formation must be determined despite the significance of doing so. They are often diagnosed simply based on the clinical history or surgical findings; however, it has been proposed that either chronic infection of the graft, as in our case, or physical stimulation, such as from aortic pulsation pressure, contributes to their creation 15 . To our knowledge, only 32 case reports on SAEFs have been published (see Table 1 ).…”

A Novel Endovascular Treatment for Recurrent Secondary Aorto-Enteric Fistula in a Patient With Prior Infra-Renal Aortic Ligation

“…SAEF is a rare but lethal entity with limited literature and experience in managing this condition. SAEF is estimated to occur in 0.4-4.0% of patients with prior aortic intervention, which is expected to increase with increased detection of aortic disease and the use of aortic prosthetic grafts [3,4]. The gold standard for the treatment of SAEF is surgical repair which involves graft excision, bowel repair, and extra-anatomic bypass (EAB) or in-situ repair (ISR) either as a staged or single procedure [4].…”

Secondary aortoenteric fistula: a narrative review of the view of the surgeon

“…The main mechanism seems to be the gradual erosion of the aortic graft in the intestine, with or without the presence of inflammation from the intestinal contents. The constant irritation of the intestinal wall by the aortic pulsation seems to play an important role, which explains why most fistulas appear at the proximal anastomotic site of the third portion of the duodenum, which is pressed between the aorta and the superior mesenteric artery in the retroperitoneal space [3,[15][16][17]. Other hypotheses presuppose the presence of local inflammation and subsequent erosion of the intestinal wall due to infection of the aortic graft during the first operation [11,15,[18][19][20].…”