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Surgical Management Of Hypogastric Artery-colonic Fistula After Hypogastric Coiling And Stenting
Andrew Droney, DO1, Helen Potter, MD
1, Paul Anain, MD
2, Gregory Clabeaux, MD
2.
1University at Buffalo, Buffalo, NY, USA,
2Sisters of Charity - Catholic Health, Buffalo, NY, USA.
DEMOGRAPHICS:The patient is an 86 year old African-American male with history of chronic kidney disease, endovascular abdominal aortic aneurysm repair, bilateral hypogastric artery coil embolization and stent graft coverage for hypogastric aneurysms.
HISTORY:The patient was admitted two months prior for lower gastrointestinal bleeding for a large rectal ulcer seen on lower endoscopy that was treated with epinephrine injection and over-the-scope clip placement. He was discharged home but re-presented as a transfer to the intensive care unit from an outside hospital for acute lower gastrointestinal bleed and hypotension. The patient underwent flexible sigmoidoscopy and coil material was seen in the rectal vault, compatible with hypogastric artery to rectal fistula.
PLAN:Patient was planned for right femoral cutdown with angiogram to identify vessels feeding the right hypogastric artery aneurysm, along with open fistula takedown, and creation of end colostomy. Angiogram was performed via right femoral artery cutdown, and multiple feeding branches were identified and ligated. Next, via laparotomy, the aneurysm sac was opened, and prior coils removed. Two posterior feeding vessels were ligated from within the aneurysm sac. The sac was partially resected along with the fistulized rectum, and then closed. Rectal resection and end sigmoid colostomy creation was performed by the colorectal surgery team. The patient was discharged 16 days later, and has been followed closely post-operatively, continuing to do well from the procedure 12 months later.
DISCUSSION: Incidence of hypogastric artery aneurysms is exceedingly low, affecting <1% of the population. Risk of rupture dramatically increases when >3cm or if rapidly expanding. Options repair include open repair, or endovascular repair with or without coil embolization. Few cases have been reported of this rare, potentially life threatening complication. Previous cases have detailed varied management including solely endoscopic management, endovascular stent graft coverage, or palliative colonic diversion without directly addressing the fistula. Two other cases described open fistula takedown, one without fecal diversion, and the other a staged endovascular first, then open aneurysm exploration. We describe a hybrid approach including angiogram with ligation of feeding vessels, open fistula takedown, and colostomy creation. To our knowledge, this method has not previously been described.
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