Aortoduodenal fistula and associated rupture of abdominal aortic aneurysm after endoluminal stent graft repair

The main complications of endovascular repair of abdominal aortic aneurysms are vascular leaks and rupture, although infection and aortoduodenal fistulas have also been reported rarely. We report a case of aortoduodenal fistula with separate retroperitoneal rupture of an abdominal aortic aneurysm after endovascular stent graft repair. The initial implantation was uneventful, without any leaks at 1 month. The patient underwent open repair and did well. To our knowledge, this is the first case report of aortoduodenal fistula and associated retroperitoneal rupture of the aneurysm after endovascular stent graft repair of an abdominal aortic aneurysm.     

Endovascular treatment of two aortoduodenal fistulae

We report the endovascular treatment of two patients presenting with aortoduodenal fistulae. The first patient was a 66-year-old man admitted with hematemesis. He was on clopidogrel and had received a cryopreserved aortic graft for a mycotic abdominal aortic aneurysm five years earlier. Computed tomography (CT) showed aortic pseudoaneurysms in close contact with the duodenum. Endovascular repair was carried out. Twenty-seven months after the procedure the patient remains asymptomatic. The second patient was a 78-year-old man admitted with abdominal pain and nausea. CT revealed an abdominal aortic pseudoaneurysm and aortoduodenal fistula. He suffered from severe chronic obstructive pulmonary disease that greatly increased his surgical morbidity and mortality. An endovascular repair was performed under epidural anesthesia. The patient died of a postoperative pneumonia 38 days after surgery. These two cases illustrate the importance of endovascular aortic repair especially when an open surgical procedure is either difficult or impossible.     

Aortoduodenal fistula occurring after type II endoleak treatment with coil embolization of the aortic sac

A bifurcated stent graft device was successfully deployed to exclude an asymptomatic abdominal aortic aneurysm (AAA) with adequate proximal aortic neck morphology. At 6 months, a type II endoleak was successfully embolized through a proximal perigraft channel with metallic coils. The patient was seen with upper gastrointestinal bleeding and a pulsatile abdominal mass 11 months later. Surgical exploration revealed an aortoduodenal fistula in the vicinity of the previous embolization. We discuss the possible causes of this complication and review the literature on the subject. We conclude that aortoduodenal fistula can occur after endovascular AAA repair despite the absence of endoleak or AAA diameter increase on follow-up computed tomographic scan.     

Endovascular treatment of abdominal aortic aneurysms

BACKGROUND: Endovascular treatment of abdominal aortic aneurysms is a rapidly evolving technique that has gained broad acceptance in the treatment of patients with abdominal aortic aneurysms. METHODS: A review of the English literature was done to determine the short- and long-term outcomes of endovascular repair of abdominal aortic aneurysms. Reports of complications such as endoleak, graft migration, graft limb occlusion, aneurysm rupture, and aneurysm enlargement were evaluated. RESULTS: Short-term results of endovascular repair of abdominal aortic aneurysms are excellent. The necessity for open conversions is less than 5%. The cumulative risk of aneurysm rupture is approximately 1% per year. The coverall incidence of graft limb occlusion was 2.8% in the follow-up period. The cumulative risk for a secondary procedure was 12% at 1 year, 24% at 2 years, and 35% at 3 years. Moderate and severe neck angulation was associated with an increased incidence of adverse events in the follow-up period. Endografts have the potential to become infected and develop aortoduodenal fistula. The treatment of ruptured aneurysms with endovascular grafts has been successful and a technique that is increasingly used. CONCLUSION: Endovascular treatment of abdominal aortic aneurysm is an effective technique with excellent short-term results. The long-term results remain to be determined. Ongoing surveillance is necessary to avoid late complications of aneurysm rupture.     

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.     

Repair of abdominal aortic aneurysm by transfemoral endovascular graft placement.

PURPOSE: The authors describe the initial clinical experience with a new device, approved by the FDA for investigation, for repair of abdominal aortic aneurysm by transfemoral endovascular insertion of an aortic graft. METHODS: Sixty-nine patients with abdominal aortic aneurysms were screened, and ten were found to be suitable for endovascular grafting. Repair was done in the operating room using general anesthesia. One femoral artery was surgically exposed, and the device, containing a premeasured graft with proximal and distal self-expanding fixation devices, was inserted with fluoroscopic control through an open arteriotomy. FINDINGS: Eight of ten patients underwent successful graft placement, and two patients required conversion to an open repair. On follow-up, six of eight patients who underwent graft placement functioned normally, with documented aneurysm thrombosis. Two patients who underwent graft placement functioned normally, with contrast computed tomography evidence of incomplete aneurysm thrombosis, but without further expansion. CONCLUSION: Transfemoral repair is safe and appears to be effective. Phase II study currently is appropriate, with need for long-term follow-up.     

Endovascular repair of a presumed aortoduodenal fistula.

This report describes the use of transluminal endovascular grafting for the treatment of a presumed aortoduodenal fistula. The patient was a 71-year-old man who had undergone resection and graft replacement for an abdominal aortic aneurysm. Three years after operation, melena was caused by perforation of the duodenal wall by a pseudoaneurysm at the proximal graft anastomosis. The pseudoaneurysm was treated by transluminal endovascular grafting. The pseudoaneurysm was subsequently thrombosed and absorbed. The ulcer-like lesions at the site of the duodenal wall perforated by the pseudoaneurysm also resolved. Endovascular stent-grafts may have a role to play in management of aortoduodenal fistula.     

Endovascular treatment of a primary aortoduodenal fistula: 2-year follow-up of a case report

The purpose is to evaluate the role of endovascular management for primary aortoduodenal fistula in poor surgical risk patients. A 70-year-old-man was admitted at the emergency room of our hospital with recurrent upper-gastrointestinal bleeding. A diagnostic workup was suggestive of a primary aortoduodenal fistula caused by erosion of an infrarenal abdominal aortic aneurysm. Intractable cardiac arrhythmia, recurrent hemorrhage, and poor patient condition were compatible with an exceedingly high surgical risk. The fistula was successfully treated, and gastrointestinal bleeding was eliminated with placement of a Lifepath endoluminal aortoiliac stent graft. At the 21-month follow-up, the patient was not presenting with symptoms and signs of graft infection, and radiologic studies confirmed decreasing aneurysm size without associated signs of local sepsis. Endovascular stent grafts can efficiently arrest massive exsanguination in critically ill patients with primary aortoenteric fistula. The risk of graft infection remains the most serious problem associated with this approach.     

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

INTRODUCTION

Aortoenteric 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 CASE

We 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.

DISCUSSION

This 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.

CONCLUSION

Aorto-enteric fistulas are associated with a grave prognosis. Early diagnosis is crucial and extra vigilance should be taken in cases of inflammatory AAA.     

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应用跨肾动脉支架人工血管腔内修复术治疗腹主动脉瘤,并探讨其手术适应证,操作要点及并发症的预防。方法对２例病人采用全麻,在动态数字减影血管造影监测下用跨肾动脉支架分叉型人工血管对腹主动脉瘤进行了腔内修复术,结果手术中ＤＳＡ提示动脉瘤消失,无内漏发生。术后１周及分别随访３和９个月,螺旋ＣＴ检查提示腔内人工血管无移位扭曲,血流通畅无内漏发生,结论腹主动脉瘤腔内修复术手术创伤小,病人恢复快,跨肾动支架人工     

Combining open and endovascular surgery for the treatment of infrarenal abdominal aortic aneurysm: a case report using a hybrid vascular graft

Migration and endoleaks after endovascular exclusion of an infrarenal abdominal aortic aneurysm may lead to long-term failure of the stent graft. We report a successful case of a novel technique that combined open and endovascular surgery to address the issues of migration and endoleak in the repair of an abdominal aortic aneurysm. The hybrid graft, consisting of a proximal, conventional Dacron graft and two distal endoprosthesis limbs, was designed to reduce aortic cross-clamp time in aortic procedures. This is the first reported clinical experience with this new hybrid vascular graft for the treatment of an abdominal aortic aneurysm.     

"Unpredictable" late rupture of an abdominal aortic aneurysm after bifurcated Ancure endograft repair

The goal of endovascular repair of an abdominal aortic aneurysm is to exclude the aneurysm from systemic arterial pressure, thereby preventing rupture. However, the long-term durability of endovascular repair continues to be in question, as aneurysm rupture after endovascular repair continues to be reported. We report the case of an 89-year-old patient who underwent endovascular repair of a 7.1-cm abdominal aortic aneurysm with an Ancure endograft 5 years earlier. Despite close follow-up and a shrinking aneurysm sac on annual contrast-enhanced computed tomography, he presented with aneurysm rupture and a new proximal type I endoleak. The endoleak and rupture were successfully repaired with endovascular placement of a main body extension.     

Migration of a bifurcated endovascular graft into an iliac aneurysm: endovascular salvage and future prevention--a case report

The FDA approval of endovascular grafts for the treatment of abdominal aortic aneurysms has been associated with a dramatic increase in the use of these devices. Major referral centers are reporting the treatment of 75% to 80% of their patients with infrarenal abdominal aortic aneurysms with endovascular devices. The large quantity of endovascular devices being used has produced a growing number of management issues that are often not predictable during the preoperative assessment. These issues require complex intraoperative decision making and innovative techniques for their management as reflected by the subsequent case report. An 82-year-old patient presented with a 7.8-cm abdominal aortic aneurysm. The aneurysm extended into the common iliac arteries bilaterally. The right common iliac artery was 6.5 cm and the left common iliac artery was 2.0 cm in maximal diameter. The preoperative work-up, including a computed tomography scan and arteriogram, suggested that he would be a potential candidate for endovascular repair. The plan was to extend the graft into the right external iliac artery after embolization of the right hypogastric artery and to seal the left limb in the ectatic left common iliac artery using an aortic extender cuff. During the endovascular repair of the aortoiliac aneurysms using the AneuRx bifurcated graft, the main device became dislodged from its infrarenal attachment site and migrated into the large right common iliac artery aneurysm with the iliac limb ending in the distal external iliac artery. A new bifurcated device was deployed from the left side to attempt an endovascular salvage of the difficult situation. The new graft was partially deployed down to the iliac limb. This allowed cannulation of the contralateral stump through the original endovascular graft that had migrated distally. The two grafts were connected with a long iliac limb. This allowed stabilization of the endovascular reconstruction by increasing its columnar strength. The deployment of the second bifurcated graft was completed and the central core with the runners removed safely without migration of the second bifurcated component. The reconstruction was completed with an aortic cuff in the left common iliac artery. The use of the aortic cuff was useful to preserve the left hypogastric artery. No intraoperative endoleak was noted. The patient did well and was discharged the day following the procedure. The follow-up computed tomography scan shows the abdominal aortic aneurysm excluded by the endovascular graft with a defunctionalized portion of one bifurcated graft within the right common iliac aneurysm. There is no evidence of endoleak and the abdominal aortic aneurysm had decreased in size at 6 months. This case demonstrates one of the unique management problems that may arise during endovascular graft placement. Events that initially would suggest failure of the endoluminal treatment may be corrected using advanced endovascular techniques by an experienced surgeon. However, there will be times that the prudent decision will be conversion to open repair. Only good clinical judgement and adequate training will prevent catastrophic outcomes.     

Postoperative imaging after endovascular AAA repair

Unlike open aortic aneurysm repair, follow-up is vital for endovascular aneurysm repair. If there is no perigraft flow or endoleak after endograft placement, the natural history is a decrease in aneurysm size. However, a significant number of aneurysms after endograft repair enlarge without apparent endoleak, and ruptures have occurred in this situation. Aneurysms so treated also can develop a late, secondary endoleak that leads to rupture. Late stent deformation has been noted in abdominal and thoracic applications, and deformation can ultimately lead to graft thrombosis, endoleak, and aneurysm rupture. For these reasons, regular postoperative imaging will likely be needed for the life of the patient after endovascular aortic aneurysm repair, and it must be capable of accurately detecting endoleak, aneurysm expansion, graft migration, and graft deformation. As with the entire field of endovascular surgery, imaging techniques and recommendations regarding their use are changing rapidly. However, a combination of examinations appears superior to any single test. Only long-term follow-up data can determine which methods will become standard, but physical examination, abdominal radiographs, and spiral computed tomography (CT) with specialized 3D reconstruction protocols are the current gold standard. In centers of excellence, color or power Doppler ultrasound is a useful adjunctive study and ultimately may decrease the required frequency of more expensive studies such as CT with specialized protocols.     

Hybrid endovascular repair with reconstruction of superior mesenteric and celiac arteries for thoracoabdominal and abdominal aortic aneurysms

A 79-year-old woman presented with sustained thoracolumbar back pain. Contrasted computed tomography (CT) showed a thoracoabdominal aortic aneurysm (TAAA: type I of Crawford classification) and an abdominal aortic aneurysm (AAA) that were not ruptured. Considering her age, the placement of an endovascular stent graft was performed for TAAA at the possible sacrifice of the celiac (CA) and superior mesenteric arteries (SMA). In order to prevent ischemic events, it was necessary that blood supply to the CA and SMA was maintained by placing a graft to each artery from the Y-shaped graft for replacement of AAA. Actually, only CA was sacrificed and coil embolization of CA was needed because of type 2 endoleak. The patient was discharged 17 days after surgery. A hybrid technique, endovascular repair with reconstruction of abdominal branches for TAAA and AAA, can be an alternative procedure for such high-risk operation with multiple aortic aneurysms including TAAA.     

Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair

We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.     

Endovascular treatment for secondary aortoduodenal fistula

Aortoenteric fistula (AEF) is an uncommon condition, but carries high mortality, with increasing incidence. Conventional treatment of AEF by open debridement and bypass grafting has high mortality and morbidity rates. In the present study, we report on a patient with a history of open repair of impending ruptured abdominal aortic aneurysm, who presented with aortoduodenal fistula 9 years after the index operation. The patient was treated with endovascular stenting and recovered well afterwards. We also reviewed previous reports on the use of endovascular stents for the treatment of secondary AEF.     

Late Infection of an Endovascular Stent Graft with Septic Embolization, Colonic Perforation, and Aortoduodenal Fistula

We report on a 52-year-old male who developed late stent graft infection resulting in infective aneurysm formation with systemic septic embolization and aortoduodenal fistulation 9 months following endoluminal repair of an abdominal aortic aneurysm. Although endoluminal stent graft infection and erosion into surrounding viscera is rare, we highlight the need for awareness of this potentially catastrophic complication.     

Aortic Wrap as a Novel Technique of Type I Endoleak Repair

Type I endoleak after endovascular abdominal repair is associated with a high risk of aneurysm expansion and rupture. Though type I endoleak can frequently be managed with endovascular techniques, in this report we describe a patient whose endoleak was refractory to multiple attempts at endovascular repair. The patient ultimately underwent a novel minimally invasive surgical repair with placement of an aortic wrap around the infrarenal aortic neck, successfully abolishing the endoleak.     

一体式覆膜支架在腹主动脉腔内修复中的应用

目的:总结一体式覆膜支架在腹主动脉以及髂动脉病变中的应用效果。方法:回顾性分析应用一体式腹主动脉覆膜支架腔内修复腹主动脉瘤15例、髂动脉瘤5例及腹主动脉或髂动脉夹层5例的临床资料。结果:平均时间42.4 min,手术成功率100%(25/25)。术后无I、III型内漏,发生髂动脉血栓形成1例,围术期无死亡病例。随访3~16个月复查无动脉瘤复发和II型内漏。结论:一体式覆膜支架是腹主动脉瘤和夹层动脉瘤腔内治疗方法的一种较好选择,具有快速、简单、有效的优点;其远期疗效需进一步观察。