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Aortic Graft Erosion Into the Duodenum Presenting With Recurrent Bacteremia

Nassri, Ammar MD1; Habib, Joseph MD2; Skarupa, David MD3; de Souza Ribeiro, Bruno MD1

doi: 10.14309/crj.0000000000000261
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1Department of Medicine, Division of Gastroenterology, University of Florida at Jacksonville, Jacksonville, FL

2Department of Surgery, Division of Vascular Surgery, University of Florida at Jacksonville, Jacksonville, FL

3Department of Surgery, Division of Acute Care Surgery, University of Florida at Jacksonville, Jacksonville, FL

Correspondence: Bruno de Souza Ribeiro, MD, Department of Medicine, Division of Gastroenterology, University of Florida, Emerson St, Building 1, Suite 300, Jacksonville, FL 32207 (Bruno.DeSouzaRibeiro@jax.ufl.edu).

Received August 12, 2019

Accepted September 30, 2019

Online date: October 29, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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CASE REPORT

A 72-year-old woman with a medical history of a coronary artery bypass graft surgery, carotid artery stents, and bilateral aortofemoral bypass 7 years ago presented with septic shock. Over the past year, she had multiple admissions for sepsis at an outside hospital and was worked up with a transesophageal echocardiogram, radiolabeled white blood cell scan, and multiple abdominal and pelvic computed tomography (CT) scans without source identification, and was treated with multiple courses of home intravenous antibiotics. On this admission, blood cultures grew Streptococcus anginosus and abdominal and pelvic CT showed no abscess with stable nonocclusive thrombus visualized within the right iliac portion of the graft (Figure 1). A positron emission tomography scan revealed no increased metabolic activity surrounding the abdominal aortic graft. Vascular surgery suspected a graft infection and consulted the gastroenterology service. A push enteroscopy was performed, which revealed a 2-cm fistula in the third portion of the duodenum with graft tissue seen in the duodenal wall but without active bleeding (Figure 2). The patient subsequently underwent a laparotomy which revealed the third portion of the duodenum to be densely adherent to the proximal graft, with a large erosion/defect approximately 40% of the circumference of the lumen (Figure 3). The duodenal defect was surgically repaired, the graft was then removed, and an end-to-end anastomosis was performed using the proximal end of a new cadaveric graft to the infrarenal aorta (Figure 4). The patient tolerated the procedure and was ultimately discharged on intravenous antibiotics. On follow-up a month later, she was doing well with no signs or symptoms of recurrent infection.

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Figure 1

Figure 2

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Figure 3

Figure 4

Figure 4

Secondary aortoenteric fistulas occur after previous aortic surgery in 0.77% to 1.6% of cases, and most commonly involve the third and fourth part of the duodenum, as it is most vulnerable to vascular impingement because of its retroperitoneal fixation and proximity to the pulsating aorta.1 Patients most commonly present with gastrointestinal bleeding (∼70%), followed by sepsis in up to 40% of patients.2 The incidence of infected aortic endografts in the modern era is less than 1%.3 CT findings may be difficult to see without a high index of suspicion, and there are a number of disorders that may mimic a fistula such as perigraft infection, aortitis, and mycotic aneurysms.4 Owing to its rarity, it is unclear how often a CT scan is unable to reach a definitive diagnosis, but small studies have suggested the sensitivity of CT in detecting aortoenteric fistula may be as low as 50%.5 In many cases upper endoscopy may be requested for direct visualization and may be diagnostic in less than half of cases.1 Patients with aortic grafts who present with recurrent bleeding or infections and questionable imaging findings should prompt gastroenterologists to consider enteroscopy for direct visualization in the evaluation of suspected aortoenteric fistulas because they may not be apparent on imaging or routine esophagogastroduodenoscopy. A high degree of clinical suspicion is warranted, and a multidisciplinary approach is essential.

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DISCLOSURES

Author contributions: All authors contributed equally to this manuscript. BS Ribeiro is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

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REFERENCES

1. Spanos K, Konstantinos G, Karathanos C, Matsagkas M, Giannoukas AD. Current status of endovascular treatment of aortoenteric fistula. Semin Vasc Surg. 2017;30(2-3):80–4.
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3. Laser A, Baker N, Rectenwald J, Eliason JL, Criado-Pallares E, Upchurch GR Jr. Graft infection after endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2011;54(1):58–63.
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5. Hughes FM, Kavanagh D, Barry M, Owens A, MacErlaine DP, Malone DE. Aortoenteric fistula: A diagnostic dilemma. Abdom Imaging. 2007;32(3):398–402.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.