Abnormal Contrast in the Duodenum: Axial contrast-enhanced (IV only) CT image at the level of the kidneys showing the abnormal presence of contrast in the 3rd part of the duodenum (arrows). | Ho, S., Liu, B., Loya, R., & Koury, I. (2016). Primary Aortoenteric Fistula: A Rare Case of a Massive Gastrointestinal Bleed. Cureus, 8(9), e766–e766. https://doi.org/10.7759/cureus.766
PAEF From Another View: Sagittal reformatted contrast-enhanced (IV only) CT image showing the presence of an AAA and associated fistula (arrow). | Ho, S., Liu, B., Loya, R., & Koury, I. (2016). Primary Aortoenteric Fistula: A Rare Case of a Massive Gastrointestinal Bleed. Cureus, 8(9), e766–e766. https://doi.org/10.7759/cureus.766
Primary Aortoenteric Fistula (PAEF): Axial contrast-enhanced (IV only) CT image, obtained a few slices inferior to Figure Figure1,1, shows an abdominal aortic aneurysm (AAA) measuring up to 11 cm and presence of a fistula leading into the duodenum (arrow). | Ho, S., Liu, B., Loya, R., & Koury, I. (2016). Primary Aortoenteric Fistula: A Rare Case of a Massive Gastrointestinal Bleed. Cureus, 8(9), e766–e766. https://doi.org/10.7759/cureus.766
3D Reconstruction of PAEF: Left lateral 3D reconstructed contrast-enhanced (IV only) CT image showing the presence of an AAA, fistula (arrowhead), and layering contrast within the 3rd part of the duodenum (arrows). | Ho, S., Liu, B., Loya, R., & Koury, I. (2016). Primary Aortoenteric Fistula: A Rare Case of a Massive Gastrointestinal Bleed. Cureus, 8(9), e766–e766. https://doi.org/10.7759/cureus.766
CT-angiogram:
(A) Axial image from CT angiogram revealing focal aortic disruption (black arrow), duodenum draping over the aorta (white arrowhead), and focus of gas within the aortic aneurysm sac (white arrow). (B) Coronal reconstructed image demonstrating disruption of aortic wall (black arrow) with adjacent focus of gas within the aneurysm sac (white arrow). (C) Aortogram before endovascular repair highlighting site of aortic disruption (black arrow). (D) Aortogram after endovascular aortic repair (before balloon molding) confirming contrast within the bowel (black arrowheads). (E) Digital subtraction angiogram image from completion aortography showing resolution of aortoenteric fistula with widely patent endograft. CT, computed tomography. | Chick, J. F. B., Castle, J. C., Cooper, K. J., Srinivasa, R. N., Eliason, J. L., Osborne, N. H., … Khaja, M. S. (2017). Aortoenteric fistulae temporization and treatment: lessons learned from a multidisciplinary approach to 3 patients. Radiology Case Reports, 12(2), 331–334. https://doi.org/10.1016/j.radcr.2017.03.008
(A) Axial image from CT angiogram showing relationship of esophageal stent (black arrowhead) and aortic injury (white arrowhead). (B) Sagittal reconstructed image demonstrating esophageal stent (black arrowhead) and aortic disruption with contrast material within the esophageal stent (white arrow). (C) Digital subtraction angiography image from lateral aortography confirming irregularity along the anterior aorta (white arrow) near the rostral aspect of the esophageal stent (black arrowhead). (D) Digital subtraction angiography image from completion aortogram with a widely patent aortic endograft and resolution of anterior aortic irregularity. No endoleak was seen. CT, computed tomography. | Chick, J. F. B., Castle, J. C., Cooper, K. J., Srinivasa, R. N., Eliason, J. L., Osborne, N. H., … Khaja, M. S. (2017). Aortoenteric fistulae temporization and treatment: lessons learned from a multidisciplinary approach to 3 patients. Radiology Case Reports, 12(2), 331–334. https://doi.org/10.1016/j.radcr.2017.03.008
(A) Axial image from CT angiogram showing relationship of aorta with anterior disruption (black arrow), inflammatory aneurysm sac (white arrow) and anteriorly located small bowel (white arrowhead). (B) Sagittal reconstructed image showing the irregular aortic contour (white arrow) and anteriorly located small bowel (white arrowhead). (C) Digital subtraction angiography image from oblique aortography confirming aortoenteric fistula with contrast noted in the bowel (black arrowheads). Also noted is the native left iliac artery (black arrow) as the aortobifemoral bypass graft was created with an end-to-side proximal anastomosis. (D) Fluoroscopic image demonstrating position of inflated Coda balloon (black arrow) occluding the infrarenal aorta. (E) Fluoroscopic image illustrating coverage of main body with extension endoprotheses (between white arrowheads) and iliac artery Viabahn stent grafts (white arrows). Also noted is contrast within the small bowel (black arrowhead). (F) Digital subtraction angiography image from completion aortography showing resolution of aortoenteric fistula with widely patent endograft. Again noted is the native left iliac artery (black arrow). CT, computed tomography. | Chick, J. F. B., Castle, J. C., Cooper, K. J., Srinivasa, R. N., Eliason, J. L., Osborne, N. H., … Khaja, M. S. (2017). Aortoenteric fistulae temporization and treatment: lessons learned from a multidisciplinary approach to 3 patients. Radiology Case Reports, 12(2), 331–334. https://doi.org/10.1016/j.radcr.2017.03.008
Management
Endovascular treatments:
Retrograde balloon occlusion of the aorta
Stent-graft deployment
Coil, fibrin, and glue embolization of the fistulous tract
Surgical management:
En-bloc resection of the aortic segment and small bowel. | Rhéaume, P., Labbé, R., Thibault, E., & Gagné, J.-P. (2008). A rational, structured approach to primary aortoenteric fistula. Canadian Journal of Surgery. Journal Canadien de Chirurgie, 51(6), E125–E126. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19057723
Patients likely require lifelong antibiotics and remain at risk for secondary infection and refistulation.
