Aortoesophageal fistula with hemorrhagic shock successfully treated with resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal hemorrhage. Despite diagnostic and therapeutic advances, the mortality rate in AEF patients remains high because of its fulminant course, even with maximal intensive care. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation technique to control life-threatening bleeding. It has become an important modality in the management of life-threatening, traumatic or non-traumatic, arterial bleeding. However, it's use in hemorrhagic shock caused by cancer has rarely been reported. CASE PRESENTATION: A 51-year-old woman with a history of esophageal cancer presented to our emergency department with hematemesis. Computed tomography was performed because of a strong suspicion of hemorrhagic shock. With a diagnosis of AEF due to esophageal cancer, emergency thoracic endovascular aortic repair was performed while the bleeding was controlled using REBOA. Staged elective esophageal reconstruction was successfully performed. CONCLUSIONS: Hemostasis is crucial in patients who present with suspected hemorrhagic shock attributable to AEF. The timely implementation of REBOA has shown promise and potential effectiveness in such cases.

Aortoenteric Fistula with Digestive Contrast Material Leaking in the Aneurysmal Sac.

Teaching point: Aortoenteric fistula, a major complication of aortic surgery, can be identified with certainty on CT scan with opacification of the intestinal tract.

Two Cases of Primary Aortoenteric Fistulas Diagnosed by Computed Tomography.

A primary aortoenteric fistula is a rare clinical entity that leads to severe upper gastrointestinal bleeding and carries a high risk of mortality, yet diagnosing aortoenteric fistulas remains challenging. Diagnosis is frequently delayed due to the uncommon and non-specific nature of the abdominal signs and symptoms. Rapid diagnosis and prompt surgical intervention are paramount to the successful management of this condition which is known for its profoundly poor prognosis. This report describes two cases of primary aortoenteric fistulas, one of which presented with melena and hematemesis, and the other presented with hematemesis and abdominal pain. In both cases, computed tomography angiography (CTA) demonstrated findings suggestive of an aortoenteric fistula, namely, locules of gas within the aortic lumen, which led to emergent surgical intervention. One patient underwent esophagogastroduodenoscopy while in the operating room before surgical intervention. One patient underwent repair with axillo-bifemoral bypass and the other with juxtarenal abdominal aortic aneurysm repair with a rifampin-soaked gelsoft dacron graft followed by primary bowel repair. Postoperative complications for one of the patients included duodenal repair breakdown as well as colonic ischemia. One patient made a meaningful recovery and remained without complications until the first postoperative visit two months after the repair. The other patient was discharged and then subsequently lost to follow-up. The two patients' successful outcomes of such a lethal condition were in large part due to rapid diagnosis with CTA and prompt surgical intervention.

The usefulness of gel immersion endoscopy in identifying herald bleeding from an infectious aortoenteric fistula: a case report.

A 62-year-old male with a history of stent graft replacement for an infectious aortic aneurysm, followed by multiple interventions for postoperative complications, was admitted with melena and anemia. Enhanced computed tomography (eCT) demonstrated fluffing and hyperdensities surrounding the graft, despite no evidence of an aortoenteric fistula (AEF). Emergency esophagogastroduodenoscopy (EGD) showed a massive bleeding in the reconstructed tract and the protruding lesion of postoperative granulation tissue with clots at the end of the blind pouch. Thereafter, hemorrhage temporarily reoccurred several times; however, the source could not be identified using eCT or EGD. Finally, on the third attempt, we performed gel immersion endoscopy (GIE) with manual injection of VISCOCLEARⓇ, and it showed purulent blood flowing from one side of the protruding lesion in the pouch. Based on the eCT findings showing exudation of the contrast agent from the graft into the pouch, we made a diagnosis of an AEF. However, radical surgery was not performed because of the patient's poor general condition. During conservative management, he died of uncontrolled bleeding from the AEF on the 5th day of hospitalization. This is the first case in which the GIE might provide tips to identify herald bleeding from a lethal AEF.

A complicated case of primary aortojejunal fistula: A case report.

BACKGROUND: Aortoenteric fistulas are rare and life-threatening pathology characterized by an abnormal connection between the aorta and the gastrointestinal tract. CASE PRESENTATION: The patient is a 61-year-old male who initially presented with hypogastric pain, hematemesis, and melena. Computed tomography angiography (CTA) revealed an abdominal aorta aneurysm but not a fistula. Imaging modalities were inconclusive in the diagnosis. The patient became unstable hemodynamically and was transferred to the operation room. The definitive diagnosis of aortoenteric fistula was confirmed during surgical exploration. Urgent surgery was performed; however, the patient experienced a cascade of complications, including rebleeding, intestinal leakage, and hemodynamic instability due to aortic bleeding. Despite rigorous interventions, the patient expired due to multiple organ failure 53 days after the first repair surgery. CLINICAL DISCUSSION: There is no definite imaging method due to the lack of guidelines, and the absence of exact findings has led to intraoperative diagnosis in up to 50 % of cases. This is one of the modalities of choice to examine suspected aortoenteric fistulas. Many authors prefer Computed tomography (CT) with intravenous contrast for suspected AEF despite its limitations in clarity. Others recommend CT angiography as the preferred modality. It is worth noting that, as reported in a comprehensive retrospective review, the mortality rate is approximately 46 % within 60 days after AEF repair surgery. CONCLUSION: This report adds to the limited data about primary aortojejunal fistulas, an extremely rare type of aortoenteric fistulas which has been reported in only a few cases. Understanding the importance of promptly suspecting, diagnosing, and intervening is crucial, emphasizing the importance of sharing such cases for medical guidance and better patient outcomes.

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

Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.

Misdiagnosis of Primary Iliac Aneurysmo-Colonic Fistula as a Submucosal Tumor Leading to Delayed Treatment: A Case Report.

An aortoenteric fistula (AEF) is an uncommon cause of gastrointestinal bleeding that requires prompt diagnosis and intervention owing to its high mortality rate. Moreover, iliac aneurysmo-colonic fistula is an exceptionally infrequent presentation. We report a unique case of a 71-year-old male presenting with hematochezia, later diagnosed with a primary fistula between a common iliac artery aneurysm and the sigmoid colon. Initially, the patient was misdiagnosed as having a gastrointestinal stromal tumor, leading to delayed and emergent surgical intervention due to massive bleeding 2 days later. This case is particularly notable for its rarity, misinterpretation of the initial diagnosis, complicated surgical procedures, and development of complications including ischemic myopathy. This case highlights the criticality of accurate diagnosis with a high index of suspicion, significance of consultation with a vascular surgeon for vascular abnormalities, and importance of considering ischemic time in the sequence of surgical treatments to ensure timely and appropriate management.

Primary aortoduodenal fistula: As a first presentation of brucellosis; a case report.

INTRODUCTION: The etiologies of primary aortoenteric fistula include aneurysm (most common), foreign body, tumor, radiation therapy, and infection (e.g., tuberculosis, syphilis). Brucellosis is a rare cause of primary aortoenteric fistula. PRESENTATION OF CASE: In this study, we reported the case ofa 55-years-old male with an aortoenteric fistula and a positive brucellosis test. DISCUSSION: In regions where brucellosis is endemic, the coexistence of aortitis and aneurysm should prompt consideration of brucella infection as a relatively uncommon cause of aortoenteric fistula. CONCLUSION: While aortitis due to brucellosis is rare, it can lead to life-threatening manifestations such as aortoduodenal fistula. Therefore, we recommend the use of Wright, Coombs Wright, and 2ME tests in similar cases.

Endovascular Management of Aortic Stump Blowout by Parallel Grafting and Coil Embolization of Visceral Aorta.

Aortic graft and endograft infections remain a significant source of morbidity and mortality after abdominal aortic aneurysm repair. With graft excision and extra-anatomic bypass, an infrarenal aortic stump remains which can have suture line dehiscence and catastrophic stump blowout. Treatment of this is extremely challenging, especially for severely co-morbid patients who cannot undergo major surgery, or in patients with a hostile abdomen. We present a case study of a 74-year-old male found to have an aortoenteric fistula (AEF). This case broadens operative options for this type of patient population by demonstrating an endovascular technique for addressing aortic stump blowout by parallel grafting and coil embolization of the visceral aorta.

Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula.

BACKGROUND: We report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach. CASE PRESENTATION: A 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications. CONCLUSIONS: A one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

Dialister pneumosintes and aortic graft infection - a case report.

BACKGROUND: Dialister pneumosintes is an anaerobic, Gram negative bacillus, found in the human oral cavity and associated with periodontitis. It has also been isolated from gastric mucosa and stool samples. Recent case reports implicate D. pneumosintes in local infection such as dental root canals, sinusitis, Lemierres syndrome and brain abscesses, as well as distal infections of the liver and lung through haematogenous spread. CASE PRESENTATION: We present a novel case of aortic graft infection and aortoenteric fistula (AEF) in a 75 year old Caucasian male, associated with D. pneumosintes bacteraemia. Microbiological evaluation of septic emboli in the lower limbs revealed other gastrointestinal flora. This suggests either AEF leading to graft infection and subsequent distal emboli and bacteraemia, or a dental origin of infection which seeded to the graft, resulting in AEF and systemic infection. To our knowledge this is the first report of D. pneumosintes associated aortic graft infection. The patient underwent surgical explantation, oversew of the aorta and placement of extra-anatomical bypass graft in conjunction with antimicrobial therapy, making a good recovery with discharge home after a 35-day hospital admission. CONCLUSION: We report a case of Dialister pneumosintes bacteraemia associated with aortic graft infection. To our knowledge, vascular graft-associated infection with D. pneumosintes has not been reported before.

Aortoenteric fistulae and their multidisciplinary approach.

Aortoenteric fistula is an uncommun life-threatening condition which remains associated with significant morbidity and mortality. It can be primary (aneurysm, neoplasms, radiation therapy, infection) or secondary to vascular prosthesis. Early diagnosis and aggressive surgical treatment are very important to achieve optimal outcomes in these patients. The aim of this article is to highlight the importance of early diagnosis and multidisciplinary approach of aortoenteric fistula through the presentation of a clinical case.

La fístula aortoentérica es una patología poco frecuente, pero de riesgo vital, asociada a alta morbimortalidad. Puede ser primaria (aneurisma, neoplasia, radioterapia, infección) o secundaria a prótesis vascular. El diagnóstico precoz y el tratamiento quirúrgico agresivo son los pilares fundamentales para lograr buenos resultados en estos pacientes. El objetivo de este trabajo es destacar la importancia del diagnóstico precoz de la fístula aortoentérica y su manejo multidisciplinar, mediante la presentación de un caso clínico.

Aortoenteric Fistula: A Differential Diagnosis of Anemia.

Aortoenteric fistulas (AEFs) are a rare and deadly cause of gastrointestinal bleeding that can be easily overlooked, leading to massive bleeding. Secondary AEFs are more common than primary AEFs. An example of a secondary cause of anemia is postoperative hemorrhage due to a surgically placed aortic graft or after endovascular aneurysm repair. This report aims to increase the awareness of AEF as a differential diagnosis when anemia is detected. The clinical report presents a case of anemia in a 79-year-old man due to a secondary AEF, which occurred in a patient who had undergone abdominal aortic aneurysm surgery 10 years before. Surgical repair is considered the gold standard for AEF treatment; however, in this case, the patient was managed with medical therapy and discharged after two months.

Aortoesophageal Fistula Occurring Due to Aortic Aneurysm.

Upper gastrointestinal bleeding is a rare presentation of the aortoesophageal fistula (AEF) and is usually caused by thoracic aortic aneurysms. We present the case of a 61-year-old male who presented with chest pain and hematemesis. A chest X-ray showed a widened mediastinum. The patient underwent computed tomography angiography (CTA), which showed the presence of a large aneurysm in the aorta, which caused compression of the trachea, esophagus, and left pulmonary artery. Additionally, there was evidence of an AEF. It was decided to perform an emergency surgical intervention on the patient. However, the patient had multiple episodes of hematemesis and expired.

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.

A double secondary aortoenteric fistula (AEF) occurs in a patient who has had significant aortic surgery and is characterized by a direct connection between the gastrointestinal (GI) tract and the aorta at two separate sites. Importance: During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. Case presentation: The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. Clinical discussion: Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. Conclusions: An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Cryopreserved arterial allografts vs rifampin-soaked Dacron for the treatment of infected aortic and iliac grafts.

OBJECTIVE: Aortic and iliac graft infections remain complex clinical problems with high mortality and morbidity. Cryopreserved arterial allografts (CAAs) and rifampin-soaked Dacron (RSD) are options for in situ reconstruction. This study aimed to compare the safety and effectiveness of CAA vs RSD in this setting. METHODS: Data from patients with aortic and iliac graft infections undergoing in situ reconstruction with either CAA or RSD from January 2002 through August 2022 were retrospectively analyzed. Our primary outcomes were freedom from graft-related reintervention and freedom from reinfection. Secondary outcomes included comparing trends in the use of CAA and RSD at our institution, overall survival, perioperative mortality, and major morbidity. RESULTS: A total of 149 patients (80 RSD, 69 CAA) with a mean age of 68.9 and 69.1 years, respectively, were included. Endovascular stent grafts were infected in 60 patients (41 CAA group and 19 RSD group; P ≤ .01). Graft-enteric fistulas were more common in the RSD group (48.8% RSD vs 29.0% CAA; P ≤ .01). Management included complete resection of the infected graft (85.5% CAA vs 57.5% RSD; P ≤ .01) and aortic reconstructions were covered in omentum in 57 (87.7%) and 63 (84.0%) patients in the CAA and RSD group, respectively (P = .55). Thirty-day/in-hospital mortality was similar between the groups (7.5% RSD vs 7.2% CAA; P = 1.00). One early graft-related death occurred on postoperative day 4 due to CAA rupture and hemorrhagic shock. Median follow-up was 20.5 and 21.5 months in the CAA and RSD groups, respectively. Overall post-discharge survival at 5 years was similar, at 59.2% in the RSD group and 59.0% in the CAA group (P = .80). Freedom from graft-related reintervention at 1 and 5 years was 81.3% and 66.2% (CAA) vs 95.6% and 92.5% (RSD; P = .02). Indications for reintervention in the CAA group included stenosis (n = 5), pseudoaneurysm (n = 2), reinfection (n = 2), occlusion (n = 2), rupture (n = 1), and graft-limb kinking (n = 1). In the RSD group, indications included reinfection (n = 3), occlusion (n = 1), endoleak (n = 1), omental coverage (n = 1), and rupture (n = 1). Freedom from reinfection at 1 and 5 years was 98.3% and 94.9% (CAA) vs 92.5% and 87.2% (RSD; P = .11). Two (2.9%) and three patients (3.8%) in the CAA and RSD group, respectively, required graft explantation due to reinfection. CONCLUSIONS: Aorto-iliac graft infections can be managed safely with either CAA or RSD in selected patients for in situ reconstruction. However, reintervention was more common with CAA use. Freedom from reinfection rates in the RSD group was lower, but this was not statistically significant. Conduit choice is associated with long-term surveillance needs and reinterventions.

Staged Repair of Primary Aortoesophageal Fistula.

Primary aortoenteric fistulas are rare with an incidence reported up to .07% at autopsy. Literature review yields few reported cases, and rarer still is a fistula between a normal thoracic aorta and the esophagus. Rather, 83% of cases are associated with an aneurysmal aorta and 54% involve the duodenum. Patients with aortoesophageal fistula (AEF) usually present with a triad of chest pain, dysphasia, and a herald bleed. Without treatment, AEFs will result in exsanguination and are universally fatal; even with traditional open surgical treatment, mortality is reported over 55%. The complex pathology of AEFs makes repair more challenging, given an infected field, friable tissue, and patients who are often hemodynamically unstable. Staged repair using endografts as initial treatment with the primary goal of controlling bleeding and preventing fatal exsanguination has been reported. We present a case where a descending thoracic aorta to esophageal fistula was repaired, and this strategy was utilized.

Primary aortoenteric fistula after intravesical instillation of Bacillus Calmette-Guérin for bladder cancer.

OBJECTIVE: Primary aortoenteric fistulas (PAEFs) are a rare entity with high morbidity, and their relationship with Bacillus Instillation of Calmette-Guérin is anecdotal. METHODS/RESULTS: We present a 68-year-old male with a primary aortoenteric fistula after instillation of Bacillus Calmette-Guérin (BCG) for a non-muscle-invasive bladder cancer. Diagnosis was made by CT angiography, subsequently confirmed by intraoperative findings and results of anatomopathological studies of aortic wall samples. We performed an in-situ reconstruction with a silver prosthesis impregnated in rifampicin with satisfactory evolution at one year. CONCLUSIONS: Primary aortoenteric fistula is an extremely rare complication, and although its relationship with intravesical BCG therapy is anecdotal, it should be considered in patients with gastrointestinal bleeding who have previously undergone this treatment. Its diagnosis requires clinical suspicion, and its treatment should be carried out without delay. Long-term targeted anti-biotherapeutic treatment is a fundamental pillar for its management. Reconstruction with an antibiotic-impregnated silver prosthesis is a valid option in cases of controlled infection.

Primary and secondary aortoenteric fistulas in a patient with abdominal aortic aneurysm.

INTRODUCTION: Aortoenteric fistulas (AEF) are infrequent malignant complications of abdominal aortic aneurysms (AAA). We present a unique case of a patient with recurring AAA fistulisations. PRESENTATION OF CASE: During oncologic treatment, a 63-year-old male was incidentally diagnosed with infrarenal AAA and assigned follow-up but was hospitalised with anaemia and elevated inflammation markers 14 months later. A CT-angiography scan detected an AAA enlargement, but no extravasation (negative FOBT). Another CTA-scan displayed a pseudoaneurysm and ruptured AAA 10 days later. During a total laparotomy, an enlarged pulsating inflammatory conglomerate without active leakage was detected, with a 2 cm duodenal defect (PAEF). The AAA was resected and replaced by a linear silver-coated Dacron graft. 3,5 years after PAEF, the patient was hospitalised with abdominal pain and haematemesis. He underwent gastroscopies, coloscopies, CT- and CTA-scans - all without significant findings. Only after the capsule-endoscopy detected a jejunal ulcer, the PET-scan visualized active regions in the jejunum and the aortic graft. A total laparotomy was performed; previous stapler-lined jejuno-jejunal anastomosis had adhered to the silver-coated Dacron graft (SAEF). The Dacron graft was removed and replaced with a linear xenograft from bovine pericardium. DISCUSSION: No evidence-based recommendations prefer endovascular aneurysm repair (EVAR) over open repair, leaving the strategy dependent on local preferences. Whether EVAR or initial xenograft usage would have shown surpassing results, is speculative, as no graft material/type has proved long-term pre-eminence. CONCLUSIONS: This case displays AEF's complex treatment and challenging diagnosis. Multimodal diagnostic and strategic approaches should be considered for best patient outcome.