The treatment for ADF consists of closure of the duodenal fistula, removal of the infected graft and vascular reconstruction using in situ repair or extra-anatomical bypass grafting (Batt et al. 2011; Bergqvist and Björck 2009; Burks et al. 2001). The mortality rates are high; 47–48% for in-situ repair and 33–51% for extra-anatomical repair (Deijen et al. 2016). Part of this mortality is caused by aortic stump ruptures or re-bleeding. The exact incidence of aortic stump ruptures is unknown.
Reviewing literature, O’Hara et al. analyzed the outcome of 84 infected abdominal aortic grafts of which 33 patients presented with an aortic enteric fistula (AEF). At a mean interval of 94 days following graft removal, aortic stump ruptures were the cause of death in 8 / 33 patients (24%) (O’Hara et al. 1986).
Kakkos et al. reviewed 823 patients with an AEF of which 62% were ADF. Open surgery was performed in 88% of the patients, extra-anatomical bypass grafting was done in 31% of the patients. In-hospital mortality was reported in 253 cases (31%). Postoperatively, a total of 23 patients died due to an aortic stump rupture; 12 within 30 days, and 11 after 30 days (Kakkos et al. 2016). Due to a limited follow-up and inhomogeneous group of patients, the exact incidence of stump ruptures in ADF could not be retrieved.
Classical treatment of an aortic stump rupture includes immediate re-laparotomy, removal of infected tissue, aortic stump over sewing and reinforcement with soft tissue flaps. However, re-laparotomy is almost never the most suitable solution since a more rapid response is often necessary. Also, within our case our patient nearly died due to a severe hemorrhagic shock. He entered the angiosuite with a systolic pressure of 40 mmHg. An endovascular treatment was the only solution to save the patient’s life.
Literature search revealed three cases in which endovascular treatment of aortic stump blow-out has been described (Marone et al. 2012; Wang et al. 2018; Terasaki et al. 1990).
Marone et al. reported a case of an aortic stump rupture nine years after treatment of an ADF. The stump rupture was treated endovascularly by brachial access using a 9F sheath and a 18-mm Amplatzer® plug (Abbott Vascular, Santa Clara, California). The plug successfully stopped the bleeding within 10 min. Five days after this procedure additional treatment was performed with removal of the plug, over sewing the aortic stump and performing duodenal repair. During laparotomy the distal end of the plug was found to be partially protruded through the aortic wall. The authors conclude that definitive surgical treatment, if possible, must be performed (Marone et al. 2012).
Wang et al. treated a persistent aortic stump bleeding trans-lumbarly using a 22-mm Amplatzer® plug (Abbott Vascular, Santa Clara, California). They placed additional coils during the procedure to obtain hemostasis. After the procedure the patient had several re-bleeds which were treated with additional coil placement. Despite this treatment, the patient expired 5 months postoperatively due to a re-bleed (Wang et al. 2018).
Finally, Terasaki et al. successfully performed transcatheter embolization of an aortic stump with 8-mm Gianturco® coils (Cook Medical, Bloomington, Indiana). In order to obtain hemostasis, additional gelatin-sponge pledgets were inserted within the aortic stump. The patient was still alive after a follow-up of 150 days postoperatively (Terasaki et al. 1990).
The choice of embolization device merits consideration. In the present case, but also in the cases described by others (Marone et al. 2012; Wang et al. 2018), an Amplatzer plug was used. This plug needs a larger access (8/9F), but has the advantage of a more rapid procedure with faster cessation of bleeding and less risk of migration. Finally, the plug has a longer delivery wire (135 cm), making it suitable to be delivered from a brachial or an axillary access point. The use of coils has the advantage of a smaller access, but has the disadvantage of a longer procedure with multiple steps. Furthermore, additional coil placement or gelatin-sponge pledgets are frequently necessary to create hemostasis. Finally, there is a risk of migration of the coils towards the fistula or renal and mesenteric artery through reflux. For both the coils and the Amplatzer® plug it is important to realize that the devices work through clot formation and therefore do not immediately stop the bleeding. A proper coagulation is therefore of great importance. Within our case the AVP was deliberately released within the aortic stump and not inside the fistula. We think that placement of the plug within the chronic infected aortic wall has a risk of further protrusion throughout the aortic wall with additional risk of re-bleed. Finally, the long-term implications of this endovascular approach remains to be elucidated. Marone et al. used this treatment as a bridge to surgery while we chose to treat our patient conservatively. ADF and especially aortic stump rupture treatment is a rare entity and therefore limited evidence is available. The decision to use this endovascular treatment as a bridge to surgery or as a definitive treatment should be based on the patient’s anatomy and clinical condition.
