Aortoduodenal fistula after transperitoneal repair of an inflammatory abdominal aortic aneurysm: A case report

Introduction: An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Case Report: A 77-year-old Caucasian male who underwent a conventional repair of an inflammatory infrarenal aortic aneurysm, was readmitted with hematemesis only six weeks after surgery. Gastroscopy and computed tomography angiography indicated an aortoduodenal fistula and urgent aortic reconstruction was performed. An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Conclusion: An aortoduodenal fistula seldom occurs as early after conventional transperitoneal open aneurysm repair as in our case. The early occurrence of the aortoduodenal fistula can be explained by the inflammatory character of the aneurysm. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 5 No. 9, September 2014. ISSN – [0976-3198] Int J Case Rep Images 2014;5(9):619–624. www.ijcasereportsandimages.com Brunschot et al. 619 CASE REPORT OPEN ACCESS Aortoduodenal fistula after transperitoneal repair of an inflammatory abdominal aortic aneurysm: A case report Denise MD Özdemir-van Brunschot, Giel G Koning, J Adam van der Vliet


cAsE rEPort
A 77-year-old Caucasian male patient was admitted to the emergency department because of general discomfort, nausea and dark stained emesis. Medical history of the patient included diabetes mellitus type 2, a peritonitis after appendicitis and peripheral artery occlusive disease (PAOD) stage 2a. Six weeks earlier, he underwent a conventional transperitoneal repair of an inflammatory infrarenal aortic aneurysm measuring 7.6 cm in diameter. It was a difficult procedure because of dense adhesions between the duodenum and the aortic aneurysm wall, leading to a small serosal injury which was sutured peroperatively. Six days after surgery the patient was discharged after an uneventful postoperative recovery.
At readmission, the vital signs were stable and hemoglobin level was 6.1 g/dL. Shortly thereafter, the patient produced hematemesis. A gastroscopy was performed subsequently. This examination revealed a vulnerable, edematous mucous membrane with a trace of blood in the duodenum. A computed tomography www.ijcasereportsandimages.com Brunschot et al. 620 angiography (CTA) was performed ( Figure 1) because of the high suspicion of an aortoduodenal fistula. Although no clear contrast extravasation in the duodenum was seen on this scan, an aortoduodenal fistula was presumed because of the very close proximity of the duodenum to the aorta and the air bubbles in and around the aneurysm sac and the signs of local bowel wall thickening.
An urgent aortic reconstruction was performed with a graft constructed from the right superficial femoral vein according to Nevelsteen (Figure 2) [3]. Intraoperatively, no signs of a duodenal perforation were detected. An additional femoro-femoral crossover bypass was constructed using a Dacron prosthesis (8 mm Gelsoft) because of absent pulsations in the left leg.
Perioperative cultures of the removed aortic graft turned out positive for Streptococcus anginosus and Haemolytic streptococcus group B.
The fourth day after surgery, a sudden resuscitation setting occurred and hemoglobin level declined to 3.5 g/ dL. An emergency CTA was done, which showed no active blush. Despite all measures to resuscitate his condition worsened. Aortic stump blow-out was considered, but since no active blush was seen and it was considered unlikely. After careful discussion and consideration among all treating physicians and his family, it was agreed not to initiate any further surgical nor endovascular intervention and the patient deceased shortly afterwards. Permission for a postmortem examination was declined by the relatives.

dIscussIoN
Aortoduodenal fistulas are difficult to diagnose because patients often have non-specific complaints such as general discomfort, weakness and weight loss and imaging is seldom clear [2,4]. Classical signs are gastrointestinal bleeding, a pulsatile abdominal mass and abdominal pain. Gastrointestinal bleeding can present as melena (up to 50%) and/or hematemesis (up to twothirds). Typically, this bleeding is extensive but may be preceded by intermittent bleeding or herald bleeding. The sensitivity and specificity of computed tomography ranges from 40-90% and from 33-100%, respectively [4]. Signs include perigraft gas or fluid, soft tissue inflammation with edema, loss of continuous wrap of tissue around the graft and bowel wall thickening. Characteristics of other modalities, such as magnetic resonance imaging/ angiography (MRI/MRA), have not yet been sufficiently evaluated [4].
A secondary aortoduodenal fistula is fatal without surgical intervention [3]. Treatment should consist of resection of the aortoduodenal fistula and preferably also the aortic graft. Revascularization can be undertaken in a variety of ways, including primary aortic repair, aortic replacement with a new prosthetic or venous graft or an extra-anatomical bypass (for example, axillobifemoral bypass) [4]. Each procedure is associated with significant complications including lower extremity amputations, aortic stump blow out and mortality [3,5]. Like conventional aortic repair, recently more reports are published of patients treated with various percutaneous   [6,7]. Also, injection of embolic material in the fistula followed by endovascular stent graft has been described [8].
Despite the advancements in treatment of aortoduodenal fistulas and state-of-the-art intensive care, the prognosis remains poor, with an overall 30-days survival of 30-44% [4,5].
Due to the meticulous coverage of the aortic prosthesis after implantation by closing the aneurysm sac and closing the retroperitoneum, an aortoduodenal fistula usually presents as a late complication after transperitoneal open aneurysm repair with an incidence of 0.4-2.4%, mostly 3-5 years after surgery [4]. Mechanisms of secondary fistulas include direct mechanical erosion of the suture line into the bowel, proximal suture line disruption with pseudoaneurysm formation and fistulization, transient bacteremia and graft infection from perioperative contamination [4].
In this patient, the early occurrence of an aortoduodenal fistula may be explained by the perioperative duodenal serosal injury or by the inflammatory character of the aneurysm. On the preoperative computed tomography scan, it was not expected that an inflammatory aortic aneurysm was present in the patient. Best on based available evidence, if an inflammatory aneurysm had been expected, an open retroperitoneal approach may have been considered [26,27]. A search of literature according to the Patient Intervention Comparison Outcome (PICO) strategy and critical appraisal method in line with Guyatt [28] and the Cochrane Handbook for systematic reviews [29], showed that repair of an inflammatory aneurysm may have a higher risk of developing an aortoduodenal fistula [16,30]. In summary, an aortoduodenal fistula is a devastating condition, associated with high morbidity and mortality, generally, presenting years after the aneurysm repair. The presented case of an aortoduodenal fistula occurred only six weeks after conventional aneurysm repair. The early development of this aortoduodenal fistula may be explained by the inflammatory character of the abdominal aortic aneurysm. *********

Author contributions
Denise MD Özdemir-van Brunschot -Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published Giel G Koning -Substantial contributions to conception and design, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published J Adam van der Vliet -Substantial contributions to conception and design, Revising it critically for important intellectual content, Final approval of the version to be published

Guarantor
The corresponding author is the guarantor of submission.

conflict of Interest
Authors declare no conflict of interest.

Edorium Journals: An introduction
Edorium Journals Team

But why should you publish with Edorium Journals?
In less than 10 words -we give you what no one does.

Vision of being the best
We have the vision of making our journals the best and the most authoritative journals in their respective specialties. We are working towards this goal every day of every week of every month of every year.

Exceptional services
We care for you, your work and your time. Our efficient, personalized and courteous services are a testimony to this.

Editorial Review
All manuscripts submitted to Edorium Journals undergo pre-processing review, first editorial review, peer review, second editorial review and finally third editorial review.

Peer Review
All manuscripts submitted to Edorium Journals undergo anonymous, double-blind, external peer review.

Early View version
Early View version of your manuscript will be published in the journal within 72 hours of final acceptance.

Manuscript status
From submission to publication of your article you will get regular updates (minimum six times) about status of your manuscripts directly in your email.

Mentored Review Articles (MRA)
Our academic program "Mentored Review Article" (MRA) gives you a unique opportunity to publish papers under mentorship of international faculty. These articles are published free of charges.

Favored Author program
One email is all it takes to become our favored author. You will not only get fee waivers but also get information and insights about scholarly publishing.

Institutional Membership program
Join our Institutional Memberships program and help scholars from your institute make their research accessible to all and save thousands of dollars in fees make their research accessible to all.

Our presence
We have some of the best designed publication formats. Our websites are very user friendly and enable you to do your work very easily with no hassle. Something more...
We request you to have a look at our website to know more about us and our services.
We welcome you to interact with us, share with us, join us and of course publish with us.

Invitation for article submission
We sincerely invite you to submit your valuable research for publication to Edorium Journals.

Six weeks
You will get first decision on your manuscript within six weeks (42 days) of submission. If we fail to honor this by even one day, we will publish your manuscript free of charge.

Four weeks
After we receive page proofs, your manuscript will be published in the journal within four weeks (31 days). If we fail to honor this by even one day, we will publish your manuscript free of charge and refund you the full article publication charges you paid for your manuscript.