A singular case of primary aorto-duodenal fistula without pre-existing abdominal aortic aneurism: why and when you should suspect it

Although gastrointestinal hemorrhage from aorto-enteric fistulae (AEF) secondary to previous aortic grafts are well known, a primary aorto-enteric fistula (PAEF) without aortic aneurysm is an extremely rare event resulting in poor prognosis and outcome. PAEF is a rare cause of gastro-intestinal (GI) bleeding that radiologists should consider because often its presence is not easily guessed by clinical features. It is difficult to detect at Computed Tomography (CT) examination therefore PAEF might be not diagnosed until a laparotomy. We report a case of a 74-year-old Italian male who presented to our Emergency Department (ED) with brightly red rectal bleeding that occurred from some hours and a pre-syncopal episode. There was no history of analgesic abuse, peptic ulceration, alcohol excess, weight loss. Standard resuscitation was commenced with the hope that common sources of bleeding such as peptic ulcers or varices would eventually be discovered by endoscopy and treated definitely. An upper GI endoscopy showed brightly red blood in the stomach and in the first portions of duodenum, but no source of active bleeding was found. Diagnosis of PAEF was made by Computed tomography (CT) and after confirmed during surgical intervention. Both the duodenum and the aorta were successfully repaired by direct suture and synthetic graft replacement respectively. Diagnosis of primary aortic duodenal fistula (ADF) has been very difficult in this case especially because our patient didn’t have abdominal aortic aneurism (AAA) history confirmed by CT examination. Radiologist should remember that upper GI bleeding could however be determined by primary ADF also if atherosclerotic damage is severe as in this case. A technically good and complete exam is mandatory to achieve this rare and complex diagnosis. Particularly, an ultra-tardive acquisition phase (5 min after contrast administration) could be helpful to suspect the presence of PADF: the appearance of contrast into the duodenal lumen is an evocative sign useful to increase clinical and radiological suspicious of ADF. Gl bleeding should be assumed to be caused from a PAEF unless another source can be identified without delay. A timely and accurate diagnosis of primary AEF may be challenging due to insidious episodes of GI bleeding, which are frequently under diagnosed until the occurrence of massive hemorrhage.

The Challenges of diagnosing and managing a ruptured abdominal aortic aneurysm with primary aortoduodenal fistula.

Primary aortoduodenal fistula is a rare and highly morbid complication of an abdominal aortic aneurism (AAA). Patient X presented with a ruptured AAA complicated by a primary aortoduodenal fistula in 2016 which was treated surgically but has since suffered from repeated admissions due to sepsis as a result of ongoing graft infections. The diagnosis of aortoduodenal fistula is complicated with no imaging technique providing a definitive diagnosis meaning that maintaining clinical suspicion is important. There is a paucity of evidence regarding how to surgically approach the repair of an aortoduodenal fistula, although there is a shift towards multiple-step procedures in elective repair.

Abstract 324: Use of Troponin Testing After Non-cardiac Surgery in Ontario

Background: Myocardial infarction after non-cardiac surgery is common and associated with worse patient outcomes. In 2017, the Canadian Cardiovascular Society (CCS) published guidelines endorsing postoperative cardiac troponin surveillance in higher-risk patients having non-cardiac surgery. The objective of this study was to evaluate the proportion of non-cardiac surgery patients recommended for post-operative troponin testing and use of troponin testing in accordance with this guideline. Methods: We conducted a retrospective observational study of patients aged 40-105 years having moderate to high risk non-cardiac surgery in Ontario, Canada from January 1, 2010 to December 31, 2017. Classes of surgeries included orthopedics, gynecology, general, urology, vascular, and thoracic. Recommendations for troponin testing was determined by CCS criteria. Troponin testing within 2 days of the surgery was ascertained using the Ontario Laboratory Information System. Results: There were 268,269 patients in the cohort recommended for troponin testing during the study period. Mean age was 66.7 ± 11.9 years, 58.2% were female, and 12.3% underwent urgent surgery. According to CCS guidelines, 72.4% of elective surgery patients and 81.2% of urgent surgery patients would be recommended for post-operative troponin screening. The observed testing rate was 10.5% for elective patients and 26.4% for urgent surgery patients. Observed rates of testing for CCS recommended patients varied significantly by surgery: 5.5% for hysterectomies to 64.0% for open abdominal aortic aneurism repair (see Figure). Conclusions: Based on the current CCS guidelines, the majority of patients undergoing moderate to high-risk surgery should receive troponin testing. However, testing rates in Ontario were substantially lower with significant variations based on the type of surgery. The implication for routine troponin testing recommendation is substantial given the low utilization of troponin testing.

A very rare complication of an Abdominal Aortic Aneurysm: Primary Aortoduodenal Fistula without gastrointestinal bleeding.

An abdominal aortic aneurism (AAA) is an enlargement of the lower part of the aorta that extends through the abdominal area.The diameter of the aneurismatic vessel is represented by 3 cm or more in either anterior – posterior , or transverse planes. The developpement of Abdominal aortic aneurysm (AAA) is a complex, multifactorial process involving destructive remodeling of aortic wall connective tissue. Four interrelated factors involved in this process include: (1) chronic inflammation associated with neovascularization and increased proinflammatory cytokine production, (2) increased and dysregulated production of matrix-degrading proteinases, (3) destruction of structural matrix proteins, and (4) decreased medial smooth muscle cell (SMC) presence, resulting in impaired connective tissue repair. This understanding has developed from a characterization of human AAA tissue, as well as the use of different animal models that replicate human disease. The mortality of ruptured AAA is set between 40 – 70% in patients that manage to arrive alive in the emergency room, and that of 90% in overall patients confirmed with rAAA in the autopsy results. A ruptured abdominal aortic aneurysm (rAAA) represents a disruption of a dilated aortic wall that leads to blood outside the aortic wall.

Aortoduodenal fistula after abdominal aortic aneurism resection: Two case reports

Introduction. Aortoenteric fistula (AEF) is rare and extremely difficult complication of aortic surgery. We presented two cases of secondary aortoduodenal fistula (SADF) as complication after aortic surgery. Case reports. In the first patient SADF happened 11 years after open abdominal aneurysmal resection with gastrointestinal tract (GIT) bleeding. After negative esophagogastroduodenoscopy (EGDS) we performed multislice computed tomography (MSCT) which revealed contrast leakage in duodenum from 10 cm wide visceral aortic aneurysm. The patient was treated with graft excision, aneurysmal reduction, sewing of proximal and distal aortal stumps, bowel repair followed by axillobifemoral bypass (AxFF). The patient dismissed on 30th postoperative day. The second case of ADF happened five months after endovascular reconstruction of abdominal aorta with GIT bleeding and fewer. During following 8 days, he had three negative EGDS. On MSCT we found signs of endoleak, free air in aneurysmal sac, and signs of blood in the intestine. On urgent operation we extracted stent graft, sewed proximal and distal aortal stumps, performed bowel repair and AxFF. The patient died a day after operation with signs of sepsis and multiple organ failure syndrome. Conclusion. Conventional treatment of ADF means extraanatomic AxFF with complete excision of infected graft or stent graft, with closure of aorta?s proximal and distal stumps and duodenal repair. Because of high mortality, prompt diagnostic evaluation and quick decision of an adequate operative treatment is necessary. Although European Society of Vascular Surgery recommendations, as a guide, are very helpful, there is no unique attitude about management of AEF, so each patient should be specifically treated.