2018년 8월 6일 월요일

ortic stent-induced aorto-enteric fistula

Vascular stent가 gastrointestinal tract에 fistula를 만들면 심한 출혈을 일으킬 수 있습니다. Aortic stent-induced aorto-enteric fistula 임상 화보가 있었습니다 (Intest Res 2016).

 A 63-year-old man was admitted to our hospital because of intermittent fever and anemia for 2 months. He was diagnosed as having abdominal aortic aneurysm rupture with an initial presentation of abdominal pain 4 months previously. He underwent emergency endovascular abdominal aortic aneurysm repair (EVAR) by using an aorto-bifemoral bypass graft. After EVAR, he developed intermittent fever, despite the administration of antibiotics. Blood culture yielded multiple bacterial species. Moreover, anemia with positive occult blood in stool was also found. Esophagogastroduodenoscopy and colonoscopy failed to detect the bleeding point. Thus, mid-gastrointestinal bleeding and a focus of infection in the small intestine were highly suspected by the infectious disease specialist. Capsule endoscopy demonstrated a foreign body with several V-shaped metallic wires coated on its surface in the third portion of the duodenum (Fig. A). Moreover, oozing of blood was identified in the vicinity of the foreign body (Fig. B). Abdominal X-ray showed a retained capsule in the right upper abdomen near a tortured aortic stent (Fig. C, arrow). What is your diagnosis of this foreign body? The findings of capsule endoscopy suggested a migrated aortic stent graft in the distal duodenal lumen with complications of duodenal bleeding and perforation. Non-contrast abdominal CT scan demonstrated a retained capsule near the aortic stent (Fig. D, arrow). Moreover, contrast abdominal CT demonstrated a tortured aortic stent with partial migration into the distal duodenal lumen (Fig. E, arrow). On the basis of these findings, the patient was taken for surgery. An exploratory laparotomy revealed that the aortic stent had been displaced through the distal duodenum, leading to perforation of the wall.


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