Society For Clinical Vascular Surgery

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Secondary Iliocolonic Fistula After Endovascular Treatment of Iliac Occlusive Disease
Kenneth A. Softness, MD, Nadia A. Awad, MD, Evan R. Deutsch, MD, Rashad G. Choudry, MD.
Albert Einstein Medical Center, Philadelphia, PA, USA.

Objective:
Though historically associated with open surgical vascular repair, infectious and mechanical complications leading to secondary arterial-enteric fistulas are well-documented following endovascular interventions. Diagnosis can be difficult, and a high index of suspicion is typically needed.
Methods:
We discuss a case of iliocolonic fistula after endovascular intervention
Results:
An 84-year old man with history of severe, lifestyle-disabling claudication presented after failure of maximal medical management and exercise program. Because the patient had significant comorbidities, was vehemently opposed to open intervention, and had disease anatomically suitable for endovascular intervention, right and left common iliac artery kissing stents were placed.
The patient returned one month later with urosepsis. A large retroperitoneal hematoma was discovered on CT scan, which was drained percutaneously and grew multiple gram-negative species. Appropriate antibiotic coverage was initiated, and he was discharged home on antibiotics.
The patient returned again with persistent anemia and was found to have a large pseudoaneurysm of the right common iliac artery. Again, given the patient’s comorbidities, his desire to avoid open intervention, and the anatomical suitability of the defect, a percutaneous approach was taken, and a covered stent was used to exclude the defect.
Two months later the patient returned with bright red blood per rectum. An arterial blush originating from the right common iliac artery into the right colon was seen on CT angiography. He was urgently taken to the operating room in critical condition. Exploration confirmed a retroperitoneal abscess with an arterial fistula to the colon. A right hemicolectomy, right common iliac artery ligation and stent removal, and a left-to-right femoral to femoral bypass were performed. Seven days post-operatively the patient aspirated, attempts at resuscitation were unsuccessful, and the patient died.
Conclusions:
Our case illustrates the possibility of bowel complications after endovascular intervention, the application of endovascular exclusion of arterial-enteric fistula with subsequent failure due to lack of control of the infectious source, and ultimately, definitive extra-anatomic arterial reconstruction with resection and diversion of the involved bowel and omental coverage. Earlier recognition of the fistula and discussion with the patient regarding open repair in a non-emergent setting may have resulted in a better patient outcome.


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