Non-ischemic Gastrointestinal Complications of Aortic Aneurysms
Amrina Cheema, MD, MPH, Nadia Awad, MD, Rashad Choudry, MD, Evan Deutsch, MD.
Einstein Healthcare Network, Philadelphia, PA, USA.
Objective:
While rupture remains the impetus for repair of aortic aneurysms, other complications exist which contribute to overall morbidity and mortality. Non-ischemic gastrointestinal (GI) complications are rare, but pose significant treatment issues.
Methods:
Two cases of non-ischemic GI complications of aortic aneurysms are discussed.
Results:
Case 1:
An 86-year old man with history of thoracic aortic aneurysm (TAA) and prior open infrarenal abdominal aortic aneurysm (AAA) repair presented to the emergency department with 6-months of worsening epigastric pain, dysphagia, and shortness of breath. CT angiogram demonstrated a significantly enlarged TAA causing compression of the esophagus with severe dilation proximal to the stricture. The patient underwent emergent endovascular repair with successful exclusion of the TAA and improvement of his GI symptoms. However, on post-operative day 10, the patient had multiple episodes of lower GI bleeding and repeat CT angiogram was concerning for contained perforation of the esophagus. The patient’s family ultimately withdrew care and the post-mortem confirmed the contained esophageal perforation.
Case 2:
A 78-year old man with remote history of open AAA repair and multiple episodes of lower GI bleeding presented with a large active lower GI bleed with hypotension and anemia. CT angiography demonstrated a large distal anastomotic pseudoaneurysm with extensive inflammation and pneumatosis in multiple small bowel loops adherent in that area concerning for aortoenteric fistula. The patient was taken for emergent repair and underwent axillobifemoral
bypass followed by exploratory laparotomy with explantation of the infected aortic graft and resection of the involved bowel. The patient required several return trips to the operating room, culminating with ileocecectomy and gastrostomy tube placement. The post-operative course was complicated by renal failure, prolonged ileus, and respiratory failure. Ultimately the patient was made comfort care and supportive care was withdrawn.
Conclusions:
While TAA and AAA carry inherent risk of morbidity and mortality, other organ systems can be affected. Aortoenteric fistula is a devastating complication of aneurysm repair, and even with early aggressive intervention patient outcomes are poor. Gastrointestinal stricture and associated proximal dilation from large aneurysms is very rare, but may require additional intervention after treatment of the aneurysm itself. Though gastrointestinal complications comprise a small fraction of complications of aortic aneurysms and their repair, the sequelae may be catastrophic and pose significant treatment challenges.
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