An aortoduodenal fistula as a complication of immunoglobulin G4-related disease

Abstract

Most primary aortoduodenal fistulas occur in the presence of an aortic aneurysm, which can be part of immunoglobulin G4 (IgG4)-related sclerosing disease. We present a case who underwent endovascular grafting of an aortoduodenal fistula associated with a high serum IgG4 level. A 56-year-old male underwent urgent endovascular reconstruction of an aortoduodenal fistula. The patient received antibiotics and other supportive therapy, and the postoperative course was uneventful, however, elevated levels of serum IgG, IgG4 and C-reactive protein were noted, which normalized after the introduction of steroid therapy. Control computed tomography angiography showed no endoleaks. The primary aortoduodenal fistula may have been associated with IgG4-related sclerosing disease as a possible complication of IgG4-related inflammatory aortic aneurysm. Endovascular grafting of a primary aortoduodenal fistula is an effective and minimally invasive alternative to standard surgical repair.

Keywords: Abdominal aortic aneurysm; Aortoduodenal fistula; Endovascular repair; Immunoglobulin G4-related disease.

Figure 1

An infrarenal aneurysm (arrow) of the abdominal aorta with gas collection in a suspected thrombotic mass in the aneurysmatic sac, suggesting an aortoenteric fistula.

Figure 2

Intraoperative computed tomography angiography after endovascular repair of abdominal aortic aneurysm with excluder stent graft.

Figure 3

Control computed tomography angiography. A: Control computed tomography (CT) angiography shows no endoleaks and reduction of thrombotic mass volume in the aneurysmatic sac with persistence of gas collection; B: Control CT angiography after 6 mo showed no endoleaks and near total reduction of thrombotic mass in the aneurysmatic sac, without gas collection.