Journal of

Case Reports and Images in Surgery

 
  Table of Contents    
Case Report
 
Primary right ileocolic arterial fistula: A case report
Andrew C. Gaugler1, Martin J. Carney1, Adam R. Turnock2, Brian P. Fleischer2, Wesley B. Vanderlan2,3
1DO, Fellow, Department of Trauma and Surgical Critical Care, Miller School of Medicine, University of Miami, USA.
2MD, FACS, Tulane University School of Medicine, Department of Medical Education New Orleans, LA.
3Assistant Clinical Professor of Surgery, Department of Surgery, Louisiana State University, New Orleans, Louisiana, USA.

Article ID: 100030Z12AG2016
doi:10.5348/Z12-2016-30-CR-22

Address correspondence to:
Wesley B. Vanderlan
MD, FACS, 15770 Paul Vega MD Drive
Suite 108A, Hammond, Louisiana 70403
United States of America

Access full text article on other devices

  Access PDF of article on other devices

[HTML Abstract]   [PDF Full Text] [Print This Article]
[Similar article in Pumed] [Similar article in Google Scholar]

How to cite this article:
Gaugler AC, Carney MJ, Turnock AR, Fleischer BP, Vanderlan WB. Primary right ileocolic arterial fistula: A case report. J Case Rep Images Surg 2016;2:84–87.


Abstract
Introduction: We present the first reported case of a primary ileocolic fistula occurring in an 89- year-old male.
Case Report: The patient presented with abdominal pain and massive hematochezia. Subsequent radioimaging revealed an aneurysm of the right common iliac densely adherent to the sigmoid colon. A left to right femorofemoral bypass between the proximal right common femoral artery to the left common femoral artery was constructed using a cryopreserved human aorta. Recovery was uncomplicated and the patient was discharged to home on postoperative day #11.
Conclusion: Iliac-enteric fistula is a daunting cause of gastrointestinal bleeding that carries a high mortality. While vascular reconstruction and bowel resection has been the treatment of choice, endovascular therapy may be a viable option for future cases.

Keywords: Arterioenteric fistula, Primary arterioenteric fistula, Secondary arterioenteric fistula


Introduction

Fistulae between major arteries present a unique challenge to the vascular surgeon. They are rare, difficult to diagnose, and associated with a high mortality rate [1] [2]. Most arterio-enteric fistulae arise in the setting of previous vascular intervention and are termed secondary arterioenteric fistulae [1]. Fistulae arising from native arteries are rare but do occur and are termed primary arterioenteric fistulae. Due to the infrequency of primary arterioenteric fistulae, the ideal management is not standardized and remains unproved [1]. We present the first reported case of a primary fistula between the right common iliac and sigmoid colon.


Case Report

An 89-year-old Caucasian male with a past medical history of hypertension, cerebrovascular disease, and previous thoracic aortic dissection treated with medical management presented to the emergency department of a rural community hospital with a one-day history of lower abdominal pain and massive hematochezia. Initial onset of pain began following a single episode of hematochezia. Symptoms progressed over the course of approximately two hours to frank hematochezia and marked left lower quadrant and suprapubic pain. Urgent intravenous contrasted only computed tomography (CT) of abdomen and pelvis abdomen and pelvis revealed a 6 cm right common iliac artery aneurysm with adherent sigmoid colon and fluid within the colon consistent with blood (Figure 1). This finding was diagnosed as an iliac artery aneurysmal rupture. The patient was transfused one unit of packed red blood cells, nitroprusside and esmolol infusions were begun, and the patient was transferred to our institution.

Upon arrival to our emergency department the patient was tachycardic but normotensive. The abdomen was slightly distended and suprapubic tenderness without rebound or guarding was appreciated. Distal pulses were weakly palpable (1/2) along the dorsalis pedis artery. Hemoglobin was 7.6 mg/dl. Emergent release of blood was ordered and the patient was transferred emergently to the operating room.

Hypotension resulted with anesthetic induction. 200 µg of intravenous phenylephrine was immediately provided for blood pressure intervention followed by three units of emergently transfused packed red blood cells. Access to the iliac fossa was afforded through a generous midline laparotomy. Infrarenal aortic control was first achieved with an aortic clamp. Right common iliac control was then achieved and aortic clamp. Distal control was then gained at both common femoral arteries with vessel loops. Systemic anticoagulation was then afforded using 7500 units of bolused heparin. Cryopreserved human aorta was then used to construct a left to right femorofemoral bypass between the proximal right common femoral artery to the left common femoral artery. Anastomosis was performed in end–to–side fashion using 5–0 Prolene. The right common iliac aneurysm was then opened widely and a large fecal contaminated thrombus was evacuated. Control of back – bleeding from the internal iliac artery was obtained with suture ligation using 5–0 Prolene. Culture of the evacuated thrombus returned positive for Escheria coli and Streptococcus viridans.

Attention was then directed to the sigmoid colon densely adherent to the aneurysm sac. The mesoappendix was intimately involved necessitating attendant appendectomy. Appendectomy was performed using a gastrointestinal anastomotic (GIA) stapling device. Identification of the sigmoidal fistulous defect lead to segmental resection using a GIA stapler. Damage control laparotomy techniques were elected due to the patient's acidosis, hypothermia, coagulopathy, intraoperative hemorrhage, and transient hypotension. Temporary abdominal closure was afforded using ABThera Open Abdomen Negative Pressure Therapy (Kinetic Concepts, Inc., San Antonio, Texas) and the patient was transferred directly to the surgical intensive care unit (SICU) for resuscitation. Intravenous piperacillin/tazobactam at 3.375 g every 4 hours with vancomycin 15 mg/kg (1250 mg) every 12 hours were continued until the date of discharge. Following resuscitation, the patient returned to the operating room on postoperative day-3 where he received an end sigmoid colostomy with primary fascial closure. The surgical wound was affixed with VERSAFOAM (Kinetic Concepts, Inc., San Antonio, Texas) and continuous Wound V.A.C (Kinetic Concepts, Inc., San Antonio, Texas) therapy at 75 mmHg. Delayed primary closure (DPC) was performed prior to discharge on hospital day-11. The recovery of the patient was uneventful.


Cursor on image to zoom/Click text to open image
Figure 1: Computed tomography imaging of ilio-sigmoid colonic fistula.



Discussion

Arterioenteric fistulae are an exceedingly rare cause of gastrointestinal bleeding and are classified as either primary or secondary. Primary fistulae arise in native diseased arteries and are rarer than secondary fistulae that develop in association with pseudoaneurysms or vascular anastomoses following vascular reconstruction. Most primary and secondary fistulae occur between the aorta or an aortic graft and the duodenum [1]. Although quite rare, fistulae may also arise from the iliac artery and its branches [2]. Since 2003, only 12 cases of ilioenteric fistulae have been reported [3] [4] [5] [6] [7] [8] [9] [10]. The patient presented herein constitutes the first known reported case of right iliac artery to sigmoid colon fistula.

Iliac artery aneurysms are a well-described in the medical literature. Autopsy reports from the early 20th century estimate the prevalence at 1 in 12,000 [11]. Aneurysmal disease predominantly affects the common iliac arteries (89%), followed by the internal (10%) and the external (1%) branches. Rupture is by far the most common complication of iliac artery aneurysm [11], followed by symptomatic compression of adjacent pelvic structures [12]. Fistulae involving iliac artery aneurysms have been described but the risk of developing an ilioenteric fistula with an iliac artery aneurysm has not been described. The patient in this report appeared to have developed an iliac artery aneurysm from atherosclerosis. No evidence of diverticular disease was present either grossly or on pathologic examination of the resected specimen. There was also no history of pelvic malignancy, prior vascular anastomosis, pelvic radiation or prior colonic resection.

Of the reported cases involving primary ilioenteric fistulae since 2003 [3] [4] [5] [6] [7] [8] [9] [10], all patients presented with massive lower gastrointestinal bleeding. Paralleling the natural history of aneurysmal disease, most patients present in the 6th or 7th decade of life and the incidence of vessel involvement mirrors that of aneurysmal disease with common iliac artery most frequently involved, followed by the external and internal branches [3]. Ilioenteric fistulae preferentially involve the right iliac artery and branches more frequently than the left [6]. Enteric sites demonstrated no particular preference being evenly distributed between the rectosigmoid colon, right colon/cecum, and the ileum. Most cases are diagnosed based on CT with IV contrast or emergent angiography for attempted localization of lower gastrointestinal bleeding [7]. Our patient demonstrated the more common right iliac artery involvement but uniquely involving the sigmoid colon. Diagnosis using intravenous only contrasted CT appears sufficient in our patient as the addition of oral contrast was not considered necessary and delaying operative treatment for further imaging was judged inappropriate given the clinical suspicion of impending patient instability. We believe vascular–enteric fistulae are best recognized and treated as surgical emergencies akin to pure vascular rupture.

Common iliac-enteric fistulae are most frequently associated with aneurysmal disease, with other causes attributed to malignancy and inflammatory bowel disease [1]. Internal and external iliac fistulae appear to have a predilection for the rectum and most reported cases were associated with previous pelvic malignancy and radiation.

Of twelve reported cases, eight were treated with an endovascular stent graft, three with open repair, and one staged endovascular and open procedure [3] [4] [5] [6] [7] [8] [9] [10]. Open techniques consisted of primary arterial repair with bowel resection (Crohns, Typhilitis), staged stent graft with Hartmann's, and vascular reconstruction with graft and bowel resection. Endovascular approaches consisted of stent grafts with or without coiling of iliac branches. Overall mortality regardless of technique approaches 50% and is likely related to hemorrhagic shock, a process that is poorly tolerated in the vasculopathic patient [2].


Conclusion

Iliac-enteric fistula remains a daunting cause of gastrointestinal bleeding and carries a 50% risk of mortality. Most arise from either aneurysmal disease or pelvic malignancy with a history of radiation. Diagnosis can be aided by CT or angiography, but may not be possible in the face of exsanguinating hemorrhage. Though vascular reconstruction and bowel resection has been the treatment of choice, endovascular therapy may be a viable option for this uncommon and deadly process.


References
  1. Busuttil SJ, Goldstone J. Diagnosis and management of aortoenteric fistulas. Semin Vasc Surg 2001 Dec;14(4):302–11.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Nicolaou DD, Mysko WK. Enteric fistulization of a common iliac artery aneurysm: An unusual cause of gastrointestinal hemorrhage and shock. Am J Emerg Med 1996 May;14(3):272–5.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Choi SK, Kim YI, Park SY, et al. A case of lower gastrointestinal bleeding caused by primary iliac arterio-colic fistula. [Article in Korean]. Korean J Gastroenterol 2010 Aug;56(2):113–6.   [Pubmed]    Back to citation no. 3
  4. Knape S, Van Nieuwenhove Y, van Tussenbroek F, Van den Brande P, Delvaux G. Endovascular techniques in the management of acute arterioenteric fistulas. J Endovasc Ther 2004 Feb;11(1):89–93.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Lawlor DK, DeRose G, Harris KA, Forbes TL. Primary aorto/iliac-enteric fistula-report of 6 new cases. Vasc Endovascular Surg 2004 May-Jun;38(3):281–6.   [CrossRef]   [Pubmed]    Back to citation no. 5
  6. Leonhardt H, Mellander S, Snygg J, Lönn L. Endovascular management of acute bleeding arterioenteric fistulas. Cardiovasc Intervent Radiol 2008 May-Jun;31(3):542–9.   [CrossRef]   [Pubmed]    Back to citation no. 6
  7. Whittaker CS, Ananthakrishnan G, DeNunzio MC, Quarmby JW, Bungay PM. Endovascular repair of a primary iliac-cecal fistula presenting with gastrointestinal hemorrhage. Cardiovasc Intervent Radiol . 2008 Jul;31 Suppl 2:S120–3.   [CrossRef]   [Pubmed]    Back to citation no. 7
  8. Mansfield L, Seymore H, Kianifard B. Arterio-enteric fistula as a result of typhlitis. Colorectal Dis 2010 Dec;12(12):1270–1.   [CrossRef]   [Pubmed]    Back to citation no. 8
  9. Kim JH, Kim WH, Choi CH, et al. A case of Crohn's disease with iliac arterio-enteric fistulae. [Article in Korean]. Korean J Gastroenterol 2003 Jul;42(1):77–80.   [Pubmed]    Back to citation no. 9
  10. Franchin M, Tozzi M, Piffaretti G, Carrafiello G, Castelli P. Emergency endovascular "bridge" treatment for iliac-enteric fistula. Cardiovasc Intervent Radiol 2011 Oct;34(5):1106–8.   [CrossRef]   [Pubmed]    Back to citation no. 10
  11. Richardson JW, Greenfield LJ. Natural history and management of iliac aneurysms. J Vasc Surg 1988 Aug;8(2):165–71.   [CrossRef]   [Pubmed]    Back to citation no. 11
  12. Marino R, Mooppan UM, Zein TA, Flores L, Kim H. Urological manifestations of isolated iliac artery aneurysms. J Urol 1987 Feb;137(2):232–4.   [Pubmed]    Back to citation no. 12

[HTML Abstract]   [PDF Full Text]

Author Contributions
Andrew C. Gaugler – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Martin J. Carney – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Adam R. Turnock – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Brian P. Fleischer – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Wesley B. Vanderlan – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Andrew C. Gaugler et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



  Home line About the Journal line Aim and Scope line Open Access line Archives
Apply as Editor line Apply as Reviewer line Submit Reviews - Editors line Submit Reviews - Reviewers
Instructions for Authors line Templates to Use line Copyright Form line Author Checklist
Online Submission line Email Submission line Submit Revision line Submit All Forms line Submit Page Proofs
Terms of Service line Privacy policy line Disclaimer line FAQ line Contact: Journal line Contact: Edorium Journals line Site Map
 
  Copyright © 2017. Edorium. All rights reserved.