Primary Aorto-enteric Fistula: an Exceedingly Rare Life-Threatening Complication!
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IMAGES IN SURGERY
Primary Aorto-enteric Fistula: an Exceedingly Rare Life-Threatening Complication! Amit Ajit Deshpande 1 & SH Chandrashekhara 1 & Rishabh Khurana 1 & Sanjeev Kumar 1 Received: 10 July 2020 / Accepted: 9 October 2020 # Association of Surgeons of India 2020
Abstract Aorto-enteric fistula (AEF) is a catastrophic complication of the abdominal aortic aneurysm with poor prognosis. It can develop after surgery or endovascular repair of the aneurysm (secondary AEF) or without any prior intervention (primary AEF). We present a case of primary AEF in a patient with an abdominal aortic aneurysm who presented with rectal bleed. Keywords Aorto-enteric fistula . Aortic Aneurysm . EVAR
A 62-year-old man, a known case of abdominal aortic aneurysm, presented with hematochezia, pain in abdomen, and fever for the last 7 days. Hematochezia was accentuated in the last 2 days. He was a smoker, non-diabetic, and non-hypertensive. Patient did not undergo corrective surgery or endovascular repair prior to this presentation. He was hemodynamically stable at presentation with blood pressure 90/ 60 mmHg, without evident pallor. The per-rectal examination was unremarkable. CT revealed peripherally thrombosed pseudoaneurysm of the infrarenal abdominal aorta, abutting the duodenum with few air foci in the thrombosed portion (Fig. 1a), without evidence of intravasation of IV contrast in the duodenum. There were peri-lesional fat stranding and lymph nodes (Fig. 1a) and normal opacification visceral arteries (Fig. 1b). Multiple centrilobular nodules were also seen in the lung (Fig. 1c) suggesting primary aorto-enteric fistula (AEF) with septicemia. The patient underwent emergent surgery within 2 days of admission with an in situ reconstruction of aorta and bowel. Resection of D3 and D4 segments of the duodenum was done with side to side duodenojejunal anastomosis, patch closure of
* Sanjeev Kumar [email protected] 1
Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi 110029, India
the rent in the aorta. However, the patient died on day 2 postoperatively. Primary AEF is rare with an incidence of less than 1%. The classic triad (bleeding per rectum, abdominal pain, and pulsatile abdominal mass) is rare. Hematochezia or melena is more common (32–78%) which can be minor (“Herald Bleed”) and followed by massive bleeding leading to exsanguination. The time interval between the two can be hours or days with a mortality rate of 100% if untreated [1]. Stable patients are treated with primary surgery and the type of surgery (in situ reconstruction or extra-anatomic bypass graft) depends on the anatomy and extent of retroperitoneal infection. The peri-operative mortality rate after in situ reconstruction is 27–30%, whereas after 25–90% after extraanatomic bypass graft [2]. In unstable patients, temporary balloon tamponade can be given to control the bleeding. If the patient cannot be taken for emergency surgery, endovascular treatment of abdominal aneurysm can be d
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