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Introduction: Aortoduodenal fistula is a well known complication of abdominal aortic aneurysm repair and has been described after endovascular repair. This report describes a unique complication of aortoduodenal fistula secondary to duodenal perforation by previously placed embolic material.
Case: A 70 year old male underwent endograft repair of an approximately 7 cm infrarenal aneurysm with a Medtronic endograft in April 2007 at another institution. A right common iliac aneurysm was also present. Coil embolization of the internal iliac artery was unsuccessful. Two Amplatzer® (AGA Medical, Plymouth, MN ) vascular plugs and two J-tipped guidewires, therefore, were coiled in the right common iliac aneurysm to promote thrombosis of the sac (Figure 1). The common iliac aneurysm was then excluded by extension of the stent graft to the external iliac artery. Surveillance CT scans demonstrated no evidence of endoleak until 3 years later when the patient developed distal migration of the endograft resulting in a type IA endoleak and contained rupture. This endoleak was successfully treated with a Cook Renu proximal aortic cuff with suprarenal fixation.
Surveillance CT scan 4 years after the initial repair revealed air in the aneurysm sac. The retained guidewire appeared to have perforated the duodenum (Figure 2), although this could not be confirmed by pre-operative endoscopy. A staged axillo-bifemoral graft was placed, followed by removal of the infected endograft with closure of the duodenum the following day. The patient had an uneventful recovery and remained asymptomatic six months later.
Discussion: This is the first report of a retained guidewire causing an aortoduodenal fistula. Intentional off-label use of material to promote aneurysm sac thrombosis should be avoided.