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POTD: Aorticenteric Fistula (AEF)

AEF must be considered in any patient with GI bleeding and history of abdominal aortic surgery. Although AEF is not the most common cause of GI bleeding in these patients, it is life threatening.

The most common location is along the third or fourth portion of the duodenum. A large abdominal aortic aneurysm can erode primarily into the duodenum at these locations, resulting in fistula formation. Fun fact: Postoperative AEF is most often associated with a graft infection.

Aortoenteric fistula can present with a sentinel or herald bleed that is minor, or with a sudden catastrophic bleed with hematemesis, melena, or hematochezia (so don’t rely on just upper or lower GI bleed).

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 Aortoenteric Fistula-A Bomb in the Emergency Department: Suspect and do not Wait

They usually present 8–18 months after the original aortic surgery. The patient complains of abdominal or back pain, fever, nausea, vomiting, and symptoms of GIB. A delay in identification of the fistula can give rise to fatal bleeding.

Articles of Interest

Abdominal Vascular Graft Complications

This is a relatively rare complication of aortic graft placement at 0.4-1.6%, however it is arguably the deadliest with a mortality rate as high as 50% even with operative intervention.

Aorto-enteric Fistula After Endovascular Abdominal Aortic Aneurysm Repair: Case Report and Review

An aortojejunal fistula is a possible long-term complication of endovascular treatment of abdominal aortic aneurysm. An explantation of the infected graft and aortic replacement by a cryopreserved allograft is a valuable surgical treatment.

Aortoenteric Fistula after Endovascular Aneurysm Repair

Aortoenteric fistula is a rare complication following endovascular abdominal aortic aneurysm repair. However, there is a significant morbidity and mortality associated with this complication. Patients can present with gastrointestinal hemorrhage, fever, or nonspecific features of chronic infection. Extra anatomic bypass with complete graft explanation is the standard management.

Aortoenteric Fistula: A Differential Diagnosis of Anemia

Aortoenteric fistulas (AEFs) are a rare and deadly cause of gastrointestinal bleeding that can be easily overlooked, leading to massive bleeding. Secondary AEFs are more common than primary AEFs. An example of a secondary cause of anemia is postoperative hemorrhage due to a surgically placed aortic graft or after endovascular aneurysm repair.

Aortoenteric Fistulas: CT Features and Potential Mimics

Prompt diagnosis of aortoenteric fistulas is imperative for patient survival. The clinical signs of aortoenteric fistula include hematemesis, melena, sepsis, and abdominal pain, but the condition also may be clinically occult.

Emergency CTA Diagnosis and Successful Endovascular Management of Aorto-duodenal Fistula

The AEF is a life-threatening condition, with the mortality rate reaching almost 100% in the case of no prompt surgical or endovascular treatment. Secondary forms of AEF are more frequent than primary forms and may occur in patients with previous aortic interventions, and more frequently in the case of open aortic reconstruction.

The emergency medicine approach to abdominal vascular graft complications

Aortoenteric fistula is arguably the deadliest complication with a mortality rate as high as 50%, even with operative intervention. Although much more common after open AAA repair (0.4%-1.6%), aortoenteric fistula may occur after EVAR. Fistulas are more common after open repair because of the difficulty of obtaining complete tissue coverage of the graft. These fistulas may occur anywhere along the GI tract (esophagus, duodenum, small bowel).

Under the Radar: A Case Report of a Missed Aortoenteric Fistula

Gastrointestinal bleeding is the most common initial presentation, occurring in 90% of patients. Abdominal pain is only present in 28%, and fever is present in up to 25%. The classically taught triad of GI bleeding, abdominal pain, and a palpable mass, however, is seen in only 6–12% of patients.