Endovascular Management of Acute Bleeding Arterioenteric Fistulas

  • Henrik LeonhardtEmail author
  • Stefan Mellander
  • Johan Snygg
  • Lars Lönn
Clinical Investigation


The objective of this study was to review the outcome of endovascular transcatheter repair of emergent arterioenteric fistulas. Cases of abdominal arterioenteric fistulas (defined as a fistula between a major artery and the small intestine or colon, thus not the esophagus or stomach), diagnosed over the 3-year period between December 2002 and December 2005 at our institution, were retrospectively reviewed. Five patients with severe enteric bleeding underwent angiography and endovascular repair. Four presented primary arterioenteric fistulas, and one presented a secondary aortoenteric fistula. All had massive persistent bleeding with hypotension despite volume substitution and transfusion by the time of endovascular management. Outcome after treatment of these patients was investigated for major procedure-related complications, recurrence, reintervention, morbidity, and mortality. Mean follow-up time was 3 months (range, 1–6 months). All massive bleeding was controlled by occlusive balloon catheters. Four fistulas were successfully sealed with stent-grafts, resulting in a technical success rate of 80%. One patient was circulatory stabilized by endovascular management but needed immediate further open surgery. There were no procedure-related major complications. Mean hospital stay after the initial endovascular intervention was 19 days. Rebleeding occurred in four patients (80%) after a free interval of 2 weeks or longer. During the follow-up period three patients needed reintervention. The in-hospital mortality was 20% and the 30-day mortality was 40%. The midterm outcome was poor, due to comorbidities or rebleeding, with a mortality of 80% within 6 months. In conclusion, endovascular repair is an efficient and safe method to stabilize patients with life-threatening bleeding arterioenteric fistulas in the emergent episode. However, in this group of patients with severe comorbidities, the risk of rebleeding is high and further intervention must be considered. Patients with cancer may only need treatment for the acute bleeding episode, and an endovascular approach has the advantage of low morbidity.


Arterioenteric fistula Aortoenteric fistula Gastrointestinal bleeding Endovascular repair Endoprosthesis Stent-graft 



We thank Dr. Lars Karlström (Sahlgrenska University Hospital S, Göteborg, Sweden) for performing the search of the Vascular Registry in Sweden.


  1. 1.
    Knape S, Van Nieuwenhove Y, Van Tussenbroek F et al. (2005) Endovascular techniques in the management of acute arterioenteric fistulas. J Endovasc Ther 11(1):89–93CrossRefGoogle Scholar
  2. 2.
    Finch L, Heathcock RB, Quigley T et al. (2002) Emergent treatment of a primary aortoenteric fistula with N-butyl 2-cyanoacrylate and endovascular stent. J Vasc Interv Radiol 13(8):841–883PubMedCrossRefGoogle Scholar
  3. 3.
    Kim JH, Kim WH, Choi CH et al. (2003) A case of Crohn´s disease with iliac arerio-enteric fistulae. Kor J Gastroenterol 42(1):77–80Google Scholar
  4. 4.
    Bergqvist D (1987) Arterioenteric fistula. Review of a vascular emergency. Acta Chir Scand 153(2):81–86PubMedGoogle Scholar
  5. 5.
    Burks JA, Faries FL, Gravereaux EC et al. (2001) Endovascular repair of bleeding aortoenteric fistulas: A 5-year experience. J Vasc Surg 34:1055–1059PubMedCrossRefGoogle Scholar
  6. 6.
    Makar R, Reid J, Pherwani AD et al. (2000) Aorto-enteric fistula following endovascular repair of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 20:588–590PubMedCrossRefGoogle Scholar
  7. 7.
    Gozzetti G, Poggioli G, Spolaore R et al. (1984) Aortoenteric fistulae: spontaneous and after aorto-iliac operations. J Cardiovasc Surg (Toriono) 25:420–426Google Scholar
  8. 8.
    Armstrong PA, Back MR, Wilson JS et al. (2005) Improved outcomes in the recent management of secondary aortoenteric fistula. J Vasc Surg 42:660–666PubMedCrossRefGoogle Scholar
  9. 9.
    Sierra J, Kalangos A, Faidutti B et al. (2003) Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy. Cardiovasc Surg 11(3):185–188PubMedCrossRefGoogle Scholar
  10. 10.
    Dorigo W, Pulli R, Azaz L et al. (2003) Early and long-term results of conventional surgical treatment of secondary aorto-enteric fistula. Eur J Endovasc Surg 26:512–518CrossRefGoogle Scholar
  11. 11.
    Stuart WP, Chalmers RT (2002) The management of aorto-enteric fistulas. In: Branchereau A, Jacobs M (eds) Complications in vascular and endovascular surgery. Part 2. Futura, New York, pp 103–111Google Scholar
  12. 12.
    Kuestner L, Reilly L, Jicha D (1995) Secondary aortoenteric fistula: contemporary outcome with use of extra anatomic bypass and infected graft excision. J Vasc Surg 2:184–195CrossRefGoogle Scholar
  13. 13.
    Greenhalgh RM, EVAR trial participants (2005) Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 365:2179–2186Google Scholar
  14. 14.
    Lepore V, Lönn L, Delle M et al. (2002) Endograft therapy for diseases of the descending thoracic aorta: results in 43 high-risk patients. J Endovasc Ther 9:829–837PubMedCrossRefGoogle Scholar
  15. 15.
    Baril TB, Carroccio A, Ellozy SH et al. (2006) Evolving strategies for the treatment of aortoenteric fistulas. J Vasc Surg 44:250–257PubMedCrossRefGoogle Scholar
  16. 16.
    Danneels MIL, Verhagen HJM, Teijink JAW et al. (2006) Endovascular repair for aortoenteric fistula: A bridge to far or a bridge to surgery? Eur J Vasc Endovasc Surg 32:27–33PubMedCrossRefGoogle Scholar
  17. 17.
    Leonhardt H, Liedman B, Wingren U et al. (2005) Endovascular treatment in massive uncontrolled intestinal hemorrhage. Stabilization with aortic balloon allows time for angiographic survey. Lakartidningen 102(17):1326–1330PubMedGoogle Scholar
  18. 18.
    Loftus IM, Thompson MM, Fishwick G et al. (1997) Technique for rapid control of bleeding from an aortoenteric fistula. Br J Surg 84:1114PubMedCrossRefGoogle Scholar
  19. 19.
    Hastings GS (2000) Angiographic localization and transcatheter treatment of gastrointestinal bleeding. Radiograph 20:1160–1168Google Scholar
  20. 20.
    Aina R, Olivia VL, Therasse E et al. (2001) Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 12:195–200PubMedCrossRefGoogle Scholar
  21. 21.
    Schenker MP, Duszak R, Soulen MC et al. (2001) Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol 12:1263–1271PubMedCrossRefGoogle Scholar
  22. 22.
    Funaki B (2004) Microcatheter embolization of lower gasrointestinal hemorrhage: an old idea whose time has come. CardioVasc Interv Radiol 27:591–599CrossRefGoogle Scholar
  23. 23.
    Kuo WT, Lee DE, Wael EA et al. (2003) Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Intetrv Radiol 14:1503–1509Google Scholar
  24. 24.
    Wells I (1996) Internal iliac artery embolization in management of pelvic bleeding. Clin Radiol 51(12):825–827PubMedCrossRefGoogle Scholar
  25. 25.
    Velmahos GC, Demetriades D, Chahwan S et al. (1999) Angiographic embolization for arrest of bleeding after penetrating trauma to the abdomen. Am J Surg 178:367–373PubMedCrossRefGoogle Scholar
  26. 26.
    Deux JF, Bazot M, Le Blache AF et al. (2001) Is selective embolization of uterine a safe alternative to hysterectomy in patients with postpartum hemorrhage? Am J Radiol 177:145–149Google Scholar
  27. 27.
    Suzuki S, Imoto K, Uchida K et al. (2005) Endovascular repair of a presumed aortoduodenal fistula. Ann Thorac Cardiovasc Surg 11:424–428PubMedGoogle Scholar
  28. 28.
    Tomlinson MA, Gold B, Thomas MH et al. (2002) Endovascular stent graft repair of a recurrent aorto-enteric fistula. Eur J Vasc Endovasc Surg 24:459–461PubMedCrossRefGoogle Scholar
  29. 29.
    Eskandari MK, Makaroun MS, Abu-Elmagd KM et al. (2000) Endovascular repair of an aortoduodenal fistula. J Endovasc Ther 7(4):328–332PubMedCrossRefGoogle Scholar
  30. 30.
    Grabs AJ, Irvine CD, Lusby RJ (2000) Stent-graft treatment for bleeding from a presumed aortoenteric fistula. J Endovasc Ther 7(3):236–239PubMedCrossRefGoogle Scholar
  31. 31.
    Deshpande A, Lovelock M, Mossop P et al. (1999) Endovascular repair of an aortoenteric fistula in a high-risk patient. J Endovasc Surg 6:379–384PubMedCrossRefGoogle Scholar
  32. 32.
    Chuter TA, Lukaszewicz GC, Reilly LM et al. (2000) Endovascular repair of a presumed aortoenteric fistula: late failure due to recurrent infection. J Endovasc Ther 7(3):240–244PubMedCrossRefGoogle Scholar
  33. 33.
    Schlensak C, Doenst T, Blum U et al. (2000) Palliative treatment of a secondary aortoduodenal fistula by stent-graft placement. Thorac Cardiovasc Surg 48:41–42PubMedCrossRefGoogle Scholar
  34. 34.
    Semba CP, Sakai T, Slonim SM et al. (1998) Mycotic aneurysms of the thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol 9:33–40PubMedCrossRefGoogle Scholar
  35. 35.
    Husted J, Dempsey D (1986) Angiographic management of arteriocolic fistulae. CardioVasc Interv Radiol 9(3):158–160CrossRefGoogle Scholar
  36. 36.
    Hirakata R, Hasuo K, Yasumori K et al. (1991) Arterioenteric fistula. Diagnosis and treatment by angiography. Clin Radiol 43(5):328–330PubMedCrossRefGoogle Scholar
  37. 37.
    Spinosa DJ, Angle JF, McGraw JK et al. (1998) Transcatheter treatment of life-threatening lower gastrointestinal bleeding due to advanced pelvic malignancy. CardioVasc Interv Radiol 21(6):503–505CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Henrik Leonhardt
    • 1
    Email author
  • Stefan Mellander
    • 2
  • Johan Snygg
    • 3
  • Lars Lönn
    • 1
    • 4
  1. 1.Department of RadiologySahlgrenska University Hospital SGöteborgSweden
  2. 2.Department of Vascular SurgerySahlgrenska University Hospital SGöteborgSweden
  3. 3.Department of AnesthesiologySahlgrenska University Hospital SGöteborgSweden
  4. 4.Faculty of Health Sciences, Radiology, RigshospitaletCopenhagen ØDenmark

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