Primary aortoenteric fistula: a rare complication of an eroding duodenal stent

A 58-year-old female patient was admitted to our hospital with obstruction of the large intestine and she underwent an exploratory laparotomy. The findings of the laparotomy were peritoneal carcinomatosis and a large solid mass in the pelvis, probably arising from the sigmoid, causing intestinal obstruction. A colectomy was performed with removal of the mass. In the postoperative course, an enterocutaneous fistula with low output occurred, due to an injury to the third portion of the duodenum (Figure 1). The histological examination identified a neuroendocrine tumor of the large intestine, grade II, and the patient received treatment with somatostatin (Figures 2 A, B). The enterocutaneous fistula was treated conservatively and a covered self-expandable duodenal stent was placed in the third portion with progressive reduction of the output (Figure 3). The patient was safely discharged, but 62 days after she was admitted to the emergency department with hematemesis, hematochezia, and hemodynamic instability. The vital signs were blood pressure (BP) 70/45 mm Hg, bpm 120/min, SaO2 94%, a temperature of 38°C, and the patient was pale and disoriented. The laboratory studies revealed elevated white blood cells 17,800 and hemoglobin 5 g/dl. An esophagogastroduodenoscopy (EGD) was immediately performed, which revealed stent migration distally and active bleeding from the third portion. The diagnosis of primary aortoenteric fistula (PAEF) was confirmed with computed tomography (CT) angiography, where intravenous contrast extravasation to the lumen of the duodenum was recognized (Figures 4 A, B). The patient did not have a previous history of an abdominal aortic aneurysm. The endovascular approach was decided due to the hemodynamic instability of the patient and an aortic stent was placed by the interventional radiologists in the celiac aorta, behind the third portion of the duodenum with immediate cessation of bleeding and stabilization of the patient (Figures 5 A, B). Regarding the short-term outcomes, the patient did not present recurrence of the bleeding, the migrated duodenal stent was removed 20 days after the management of the PAEF and she was safely discharged with an enterocutaneous fistula without receiving home antibiotics. A close follow-up was maintained and ten months after the endovascular repair there were no signs of re-bleeding. During this period, the patient was admitted twice with fever and bacteremia, although without confirming the aortic...


View full text...