Aortoenteric Fistula after Endovascular Aneurysm Repair
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A 73-year-old patient who was on follow-up for diverticulosis was incidentally detected to have an infrarenal abdominal aortic aneurysm with a maximum anteroposterior diameter of 5.5cm. He was on treatment for type 2 diabetes, hypertension, and hypercholesterolemia. In 2016 July, he underwent endovascular repair of the aneurysm using a bifurcated aortic stent graft system. His recovery was uneventful, and he was discharged 3 days after the procedure. Afterward, he was lost to follow-up.

The patient was readmitted to the hospital with severe malaena, the patient developed fever with chills and rigors and required another hospital admission. Blood investigations showed neutrophil leukocytosis with high CRP and ESR. An exhaustive search for the source of infection was done but all the investigations were negative. Despite broad-spectrum antibiotics, the fever persisted, and the inflammatory markers remained elevated. During the same hospital stay, he developed sudden onset pain and weakness of the left lower limb with absent popliteal and pedal pulses. Acute limb ischemia (ALI) was suspected, and a contrast CT of the abdomen and a CT angiogram of the lower limbs was done. There was a localized filling defect seen in the left popliteal artery with poor distal runoff. The CECT abdomen showed a 5.7cm size infrarenal abdominal aortic aneurysmswith an intraaortic stent graft. There were multiple gas loculi within the sac of the aneurysm. Contrast filling was noted in the posterior aspect of the sac suggestive of a type II endoleak due to a patent lumbar artery. Considering the history of upper GI bleeding and the imaging findings supportive of stent graft infection, a diagnosis of AEF was made. Initially, he underwent a left popliteal embolectomy to restore limb perfusion. The culture of the retrieved embolus yielded the growth of coliform organisms. This was indicative of septic embolism from the infected aneurysm sac.

After 1 week from the embolectomy, he was scheduled for the explanation of the infected endograft. First, an axillary-bifemoral bypass was done using the left axillary artery as the inflow vessel, using 6mm PTFE grafts. A midline laparotomy was done and the neck of the aneurysm defined. A fistulous connection was noted between the 3rd part of the duodenum and the infrarenal aorta. The track appeared to communicate with the true aortic lumen which was not covered by the endograft. Clamps were placed on bilateral common iliac arteries and the infrarenal aorta. A longitudinal aortotomy was made. The iliac limbs of the graft were pulled out. The hooks that anchor the proximal graft to the aortic wall were cut using scissors, and the proximal graft was pulled out. The aortic stump and the iliac artery stumps were oversewn. The defect in the duodenal wall was repaired using 3 0 polyglycolic acid suture. Intraoperative blood loss was 5L. The patient was transferred to the intensive care unit without extubation for postoperative care. During the ICU stay, he developed acute kidney injury which required continuous renal replacement therapy. It was difficult to wean him off from the ventilator, and he eventually succumbed to ventilator-associated pneumonia on a postoperative day 12.