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A unique staged treatment approach for iliac-enteric fistula
Chad E. Jacobs, MD, Aksim Rivera, MD, Sherry Cavanagh, MD, Peter Hunt, MD, Robert March, MD, Walter J. McCarthy, MD.
Rush University Medical Center, Chicago, IL, USA.
Objectives:
This report describes the use of covered stents in two acutely bleeding patients with iliac-enteric fistula and discusses the results with this approach.
Methods:
Case review and discussion of complex treatment strategy.
Results :
Case 1: A 65 year old female with chronic iliopsoas abscess developed GI bleeding from a pseudoaneurysm of the external iliac artery. She was treated with coil embolization, covered stent placement and transverse colostomy. Although initially successful in controlling the bleeding, she returned with GI bleeding. Sigmoidoscopy at that time revealed the coils had eroded into the colonic lumen. Two-staged repair was performed: cross femoral bypass with iliac plug placement, followed by resection of the colon, external iliac artery, and covered stent.
Case 2: A 62 year old male with history of kidney/pancreas transplant complicated by graft pancreatectomy for recurrent pancreatitis presented with GI bleeding from an iliac artery to small bowel fistula. This was treated with covered stent placement that subsequently thrombosed, requiring cross femoral bypass. He later presented with sepsis, and on workup the only identifiable source was the covered stent. He underwent bowel resection and ligation of the right common, internal and external iliac arteries with removal of the stent. He later returned to the hospital with a massive GI bleed, was found to have ruptured the stump of the right common iliac artery, and subsequently expired.
Primary aortoenteric fistula has been described in less than 300 cases. This report describes two unique cases of iliac-enteric fistula that were initially treated with an endovascular approach. Both patients subsequently required extra-anatomic bypass and removal of the infected endograft.
The standard treatment for arterial-enteric fistula is vessel ligation, extra-anatomic bypass, and debridement of devitalized and infected tissue. However, in a septic or unstable patient, endovascular options can temporize the bleeding until the patient can tolerate conventional open surgery.
Conclusions:
Primary iliac-enteric fistula is a very rare condition; definitive treatment typically involves open surgery with resection of the infected structures. These cases highlight a temporizing and minimally invasive approach to treat patients with arterial-enteric fistula. However, the likelihood of the endoprosthesis becoming infected is high. It is therefore recommended that once these patients recover they be formally repaired with extra-anatomic bypass.
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