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Endovascular and Endoscopic Treatment for Primary Aortoduodenal Fistula: A Case Report.

ABSTRACT: Primary aortoduodenal fistula (ADF) is a relatively rare and morbid diagnosis. A 91-year-old man who developed hematemesis and melena was transferred from a community hospital with the diagnosis of a ruptured abdominal aortic aneurysm (AAA). Computed tomography revealed an irregular-shaped AAA with cavities enhanced near the duodenum, with suspected ADF. The patient was initially treated with emergency endovascular aneurysm repair. Duodenoscopy showed defects of the mucosa. ADF was diagnosed, and fistulas were closed with endoscopic clipping. This case highlights the success of ADF endovascular repair.

SUBMITTER: Noda K

PROVIDER: S-EPMC9257393 | biostudies-literature | 2022 Jun

REPOSITORIES: biostudies-literature

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Endovascular and Endoscopic Treatment for Primary Aortoduodenal Fistula: A Case Report.

Noda Kazuki K Yokawa Koki K Dan Naoki N Matsuda Hitoshi H

Annals of vascular diseases 20220601 2

Primary aortoduodenal fistula (ADF) is a relatively rare and morbid diagnosis. A 91-year-old man who developed hematemesis and melena was transferred from a community hospital with the diagnosis of a ruptured abdominal aortic aneurysm (AAA). Computed tomography revealed an irregular-shaped AAA with cavities enhanced near the duodenum, with suspected ADF. The patient was initially treated with emergency endovascular aneurysm repair. Duodenoscopy showed defects of the mucosa. ADF was diagnosed, an ...[more]

PMID: 35860827

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Project description:BACKGROUND:Ureteroarterial fistula is a rare life-threatening complication of indwelling ureteral stents. The mechanism has not yet been fully evaluated using intravascular imaging. CASE PRESENTATION:An-84-year-old female was referred to our unit because of large volume pulsatile bleeding from the left ureter during routine stent exchange in the urology department. The hematuria was initially managed by rapidly exchanging for a new stent; however, the patient went into hypovolemic shock due to acute blood loss. The patient underwent implantation of the bilateral ureteral stents due to urinary retention caused by retroperitoneal fibrosis 2 years ago. To prevent ureteral infection, occlusion of the stents and stone formation, the stents were exchanged every 6 months. Computed tomography revealed contact between the left ureter and the common iliac artery. Therefore, ureteroarterial fistula was suspected and endovascular therapy was performed. Although angiography did not show definite blood flow into the ureter, a soft guidewire was advanced from the subintima of the external iliac artery to the left ureter. The diagnosis of ureteroarterial fistula was confirmed. Intravascular ultrasound identified the stent in the ureter and its connection to the subintima of the external iliac artery. The ureter did not contact directly to the inner lumen of the iliac arteries according to the ultrasound findings; therefore, we considered that the risk of stent-graft infection might not be high. After coil embolization of the ipsilateral internal iliac artery, a covered stent was implanted in the external iliac artery to seal the subintimal entry. The patient had no further episodes of any gross hematuria on dual anti-platelet therapy, when the ureteral stent was exchanged three time during 1 year after the endovascular therapy. CONCLUSIONS:We demonstrated a case of ureteroarterial fistula, in which intravascular ultrasound allowed to visualize the communication between the ureter and the subintimal lumen in the external iliac artery.

Project description:BACKGROUND:An aortoduodenal fistula (ADF) is an unusual, but serious complication following surgical or endovascular aortic repair. The optimal treatment for ADF consists of removal of the infected graft with in situ or extra-anatomical repair and is associated with high mortality. Part of this mortality is caused by re-bleeding or aortic stump ruptures. Classical treatment of an aortic stump rupture involves immediate re-laparotomy, removal of infected tissue, aortic stump formation and reinforcement with soft tissue flaps. However, this invasive treatment is often difficult to perform and the condition of the patient frequently requires a more rapid response. We describe a case in which an aortic stump rupture was treated endovascularly by using an Amplatzer® Vascular Plug, which successfully stopped the bleeding. CASE PRESENTATION:This report describes a 67-year-old man who was presented with persistent duodenal leakage (due to secondary duodenal perforation) after resection and open in-situ repair of an infected aorto-bi-femoral prosthetic graft. An extra-anatomical reconstruction was performed with an axillo-bi-femoral bypass, followed by excision of the prosthesis, aortic stump formation, partial duodenal resection and duodenojejunal reconstruction. Twelve weeks later, sudden severe hematemesis with severe hemodynamic instability occurred. Computed tomography angiography showed extravasation of blood from the aortic stump into the duodenal loop. Endovascular treatment of the aortic stump blow-out with an Amplatzer® Vascular Plug was performed, which successfully stopped the bleeding and stabilized the patient. The duodenal fistula was treated conservatively. Three months later, the patient was discharged to a rehabilitation clinic in a good clinical condition. The patient was still alive after a follow-up of 4?years. CONCLUSIONS:Rapid treatment is requested in cases of aortic stump rupture. Re-laparotomy is practically never the most suitable solution and most of these aortic stump ruptures are fatal. Endovascular treatment could be a suitable alternative. Whether the endovascular treatment of aortic stump rupture is a definitive treatment or a bridge to surgery remains to be elucidated.

Dataset Information

Endovascular and Endoscopic Treatment for Primary Aortoduodenal Fistula: A Case Report.

Publications

Endovascular and Endoscopic Treatment for Primary Aortoduodenal Fistula: A Case Report.

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