Emergent Endovascular Treatment in Primary Ilio-enteric Fistula

Abstract Aortoenteric fistula (AEF) is a rare cause of gastrointestinal (GI) bleeding. If not promptly diagnosed and treated the associated mortality is very high. The role of endovascular treatment is not yet defined. In this paper we report a clinical case of a 94-year-old male admitted in the emergency department with rectal bleeding. Due to detection of a pulsatile abdominal mass, a computed tomography angiography (CTA) scan was performed, which established the diagnosis of aorto-enteric fistula due to a left common iliac artery aneurysm (CIAA) ruptured to the sigmoid colon and also revealed an abdominal aortic aneurysm (AAA) and an internal iliac artery aneurysm (IIAA). Given the age of the patient, general condition and technical difficulty inherent to the treatment of the IIAA by conventional surgery, we chose endovascular treatment. However, we wanted to avoid contact between the endograft and the colon orifice because of the risk of infection. The patient was treated emergently with an aorto-right uniiliac graft and a femoro-femoral bypass, IIAA embolization and two left iliac excluders (at the origin of the common iliac and distally, in the external iliac artery). It was decided to treat colon lesion conservatively. In this case, the aorto-uniliac graft excluded the aortic inline flow, the distal occluder prevented retrograde flow from the external iliac, the embolization prevented retrograde flow and treated the IIAA. This way, no arterial pressure and no prosthetic material existed inside the ruptured artery, hopefully allowing the spontaneous closing of the orifice leading the sigmoid colon to heal. The postoperative period was uneventful, and the patient was discharged at the 8th postoperative day. The patient outcome is a strong argument on the merit of the treatment strategy.