Vascular-enteric fistula is an uncommon complication following surgery on the aorta. Diagnosis requires a high index of suspicion. Iliac-enteric fistula formation is an uncommon complication following the creation of an aortoiliac bypass with prosthetic graft.
Iliac-Enteric Fistula: A Case Series
Christopher J Micallef, D.O.1, Jason Pasley, D.O.1, Jonathan M Saxe, M.D.1, Philip C. Williams, M.D.2, Cameron Wick, MS-IV1
1. Wright State University Boonshoft School of Medicine, One Wyoming St., CHE 6813, Dayton, OH 45409, Dept Ph 937.208.2485. 2. Dayton Surgeons Inc., One Elizabeth Place, Suite 10A, Dayton, OH 45417, Dept. Ph 937.228.4126.
Contact: Christopher J. Micallef, D.O., Wright State University Boonshoft School of Medicine, One Wyoming St., CHE 6813, Dayton, OH 45409, Dept Ph 937.208.2485, E-mail
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Citation: Micallef CJ, Pasley J, Saxe JM, Williams PC, and Wick C. Iliac-Enteric Fistula: A Case Series. J Surg Radiol. 2010 Jul 1;1(1).
Received: April 13, 2010; Accepted: May 1, 2010; Published: May 1, 2010 Copyright: © 2010 Surgisphere Corporation. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
Contents - Introduction- Discussion - References |
Introduction
Overall prosthetic-related complications after surgery on the abdominal aorta and associated vasculature can be as high as 9%.1 Aortoenteric fistulas (AEF) remains a rare, but potentially catastrophic complication. Iliac-enteric fistula (IEF) is an uncommon variant of AEF. The diagnosis of vasculo-enteric (VE) requires a high-index of suspicion that may be confounded by negative or equivocal endoscopic and CT imaging studies. Secondary VE is more common than primary VE and occurs at a rate of 0.3% to 1.6%.1-4 Regardless of the surgical technique used to repair the defects, perioperative morbidity and mortality of VE remains significantly elevated.4,5
Secondary AEF and its inherent complications are well described in the surgical literature, while IEF and its related complications are not. The following case presentations describe two IEF’s from our institution, one following bilateral aortoiliac bypass and the second after stent grafting of the right iliac artery.
Case Report 1
An 86 year-old Caucasian male with a history significant for aortoiliac bypass with graft repair for abdominal aortic aneurysm in 1999 presented to an outside institution with hematochezia. He underwent upper and lower endoscopy that failed to localize a bleeding source. The patient continued to have hematochezia, requiring transfusions and was subsequently transferred to our institution. Upper endoscopy and enteroscopy to the proximal jejunum did not reveal a source of bleeding. Colonoscopy revealed moderate pan-diverticulosis with scattered blood in the colon and transverse ileum.
A CT angiogram was performed, revealing a right internal iliac aneurysm with an adjacent loop of small bowel filling with contrast, consistent with iliac-enteric fistula. The patient became hemodynamically unstable and was resuscitated and taken to the OR. Operatively, an iliac-enteric fistula was noted, consistent with the preoperative imaging. The patient underwent an axillofemoral bypass with excision of the fistula with primary anastomosis of the bowel. Unfortunately, the patient eventually expired from intractable bleeding and a coagulopathy.
Figure 1: CT angiogram of the abdomen / pelvis demonstrating an iliac-enteric fistula. Extravasation of contrast from the right external iliac artery into adjacent small bowel is seen.
Case Report 2
A 53 year-old African American female with a history end stage renal disease with multiple prior kidney transplants, and right iliac stent graft for atherosclerotic peripheral vascular disease presented with abdominal pain, hematochezia and hematemesis of several days duration. Laboratory studies revealed significant anemia with a hemoglobin of 8.0 mg/dl. A nasogastric tube was placed without return of bloody aspirate. The patient was resuscitated and transfused.
Emergent upper endoscopy revealed no pathology to explain her symptoms. During a nuclear medicine tagged red blood cell scan, the patient became hypotensive and bradycardic leading to the study being aborted. The patient was transferred to the ICU for resuscitation. Her limited tagged RBC scan revealed abnormal accumulation of tracer in the pelvis just right of the midline. Capsule endoscopy was performed but failed to identify a source of bleeding. After an additional episode of bleeding requiring transfusion, the patient was taken to the operating room for exploration.
During our exploration, the small bowel was carefully dissected from the right lower quadrant and the vascular stent visualized in connection with a portion of the distal ileum. She underwent a small bowel resection, end ileostomy, and ligation of the right common iliac artery. On the first postoperative day, the patient developed a symptomatic anemia that required transfusion. This was complicated by right lower extremity ischemia. A femoral-femoral bypass was attempted, but poor inflow prevented this extra-anatomic bypass from functioning successfully. Alternative options for bypass, including axillofemoral and aortobifemoral bypass were discussed but declined by the patient and her family. Due to unresolved ischemia, the patient eventually required an above knee amputation. She recovered from this operation and was ultimately transferred to an inpatient rehabilitation center in stable condition.
Figure 2: CT abdomen / pelvis demonstrating an iliac-enteric fistula between the ileum and right iliac stent graft.
Discussion
Vascular-enteric fistulas remain a rare and potentially catastrophic complication with significant morbidity and mortality. Fistulas are classified as either primary or secondary. Primary fistulas occur most commonly in patients with intestinal disease and abdominal aortic aneurysms.5 Secondary fistulas occur following vascular reconstruction with prosthetic grafts and subsequent erosion into surrounding bowel.
Typical presenting signs range from intermittent gastrointestinal bleeding, frank hematemesis, hematochezia and sepsis.1 Gastrointestinal bleeding is the most common presenting sign of AEF and may be a hallmark of pending exsanguination.6 Accordingly, the absence of active bleeding does not necessarily rule out the presence of vasculo-enteric fistulas. Appropriate management of prosthetic graft infection should also be taken into account. Graft infection is present in nearly all instances of vascular-enteric fistulas and contributes to sepsis and bleeding.7
The successful diagnosis and therapeutic management of the iliac-enteric fistula is of vital significance. Upper and lower endoscopy, CT scan, angiography, and tagged RBC scans are of great importance in the successful diagnosis of vascular-enteric fistulas.8,9 These studies may all be negative or equivocal; therefore, a high index of suspicion is necessary. Occasionally, definitive diagnosis may only be established upon surgical exploration.
Multiple treatment strategies have been described, including graft excision alone, graft excision with in-situ repair using new prosthesis, and extra-anatomic bypass. The most traditional approach is prosthetic excision, stump closure, and immediate extra-anatomic bypass.1 Endovascular stabilization can provide a bridge to more definitive therapeutic options.4
Iliac-enteric fistulas are a rare subgroup of vascular enteric fistulas with a high rate of morbidity and mortality. A high index suspicion, aggressive resuscitation, and prompt surgical management are keys for survival of these patients. Multiple modalities of treatment remain available for stabilization and definitive therapy.
References
- Leon LR, Mills JL, Psalms SB, Kasher J, Kim J, Ihnat DM. Aortic paraprosthetic-colonic fistulae: A review of the literature. Eur J Vasc Endovasc Surg 2007;34:682-92. | CrossRef | PubMed |
- Elliott JP, Smith RF, Szilagyi DE. Aortoenteric and paraprosthetic-enteric fistulas. Arch Surg 1974;108:479-90. | PubMed |
- Peck JJ, Eidemiler LR. Aortoenteric fistulas. Arch Surg 1992; 127:1191-4. | PubMed |
- Burks JA, Faries PL, Gravereaux EC, Hollier LH, Marin ML. Endovascular repair of bleeding aortoenteric fistulas: A 5-year experience. J Vasc Surg 2001;34:1055-9. | CrossRef | PubMed |
- Lawlor DK, DeRose G, Harris KA, Forbes TL. Primary aorto/iliac-enteric fistula-report of 6 new cases. Vasc Endovascular Surg. 2004 May-Jun;38(3):281-6. | CrossRef | PubMed |
- Doney MK, Vilke GM. Case Report: Aortoenteric fistula presenting as repeated hematochezia. J Emerg Med. 2010 Jan 23.
- Dean RH, Allen TR, Foster JH: Aortoduodenal fistula: An uncommon but correctable cause of upper gastrointestinal bleeding. Am Surg 44:37, 1978. | PubMed |
- Hamdani R, Summers R. Vascular-enteric fistula: diagnosis by colonoscopy. Gastrointest Endosc. 1995 Jul;42(1):80-1. | CrossRef |
- Dobbs SM, Jordan PH, Cain GD, Schwartz JT, Graham DY. Vascular-enteric fistula: diagnosis by colonoscopy. Gastrointest Endosc. 1982 Feb;28(1):22-3. | CrossRef |
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