Aortoenteric fistula after endovascular mycotic aortic aneurysm exclusion: lessons learned during the COVID-19 era

Abstract

We report a case of aortoenteric fistula 2 years following endovascular aortic aneurysm repair (EVAR) for mycotic aneurysm presenting as upper gastrointestinal bleeding. Initial CT angiogram did not reveal the bleeding or connection to bowel, but endoscopy was suspicious of endograft in the duodenum. Management required a multidisciplinary approach. To stabilise the patient and to control bleeding, a 'bridging' endograft extension was performed. This was followed by open surgical removal of the EVAR endograft and lower limb in situ revascularisation. During postoperative recovery, the patient developed atypical, staged multisystemic symptoms (cardiac, pulmonary and neurological). With increasing awareness of the COVID-19 pandemic, the patient was found SARS-CoV-2-positive, which explained the progression of his symptoms. This was also reflected on other case reports in literature later.

Keywords: GI bleeding; interstitial lung disease; interventional radiology; vascular surgery.

Figure 1

CT angiogram demonstrating aortic mycotic saccular aneurysm initial presentation (black arrow).

Figure 2

CT angiogram 1 year post endovascular aortic aneurysm repair.

Figure 3

Oesophago-Gastro-Duodenoscopy (OGD) with blood clot and possible exposed endograft mesh (black arrow).

Figure 4

Intraoperative endograft bile staining.

Figure 5

Bovine in situ graft revascularisation.

Figure 6

Gastrograffin swallow with no evidence of contrast extravasation. Proximal cuff on previous endograft is visible (black arrow).

Figure 7

Anteroposterior Chest Xray Day 9 postoperation with non-specific bilateral patchy increased densities suggestive of COVID-19.

Figure 8

Day 11 postoperation, bilateral non-specific lung infiltrate suggestive of COVID-19.