Figure 1
Teaching Case
SectionCardiovascular
Case TypeClinical Cases
AuthorsJ.T. Soares; J. Ressurreição; L. Batista; T. Pereira; P. Portugal;
Connected authors
65 years, male
A 65 year old man with previous coronary bypass, hypertension and diabetes, was admitted with increasing mid chest pain radiating to the back, dysphagia and dyspnea. On clinical examination there were no relevant findings.
Normal blood pressure, heart rate and temperature. Normal ECG and MNMs.
Laboratory findings revealed type II respiratory failure.
Normal blood pressure, heart rate and temperature. Normal ECG and MNMs.
Laboratory findings revealed type II respiratory failure.
Aortoesophageal fistula
Penetrating atherosclerotic ulcer
Infectious aortiitis
Mycotic aneurysm
Perigraft infection
A chest radiography revealed a hazy opacity in the left lung base(Fig.1). Angio chest CT pointed out lower left lung bronchiectasis (Fig.2), no signs of pulmonary-thromboembolism, and a 3. 5 cm sized saccular aneurysm resulting from penetrating atherosclerotic ulcer in the mid third of the descending aorta (Fig.3, 4).
24 hours later, while treated conservatively with large spectrum antibiotics, his condition worsened with tachycardia and hypotension.
Endoscopy mentioned no significant hemorrhagic findings.
Unenhanced CT revealed a bulge in the left antero-medial aspect of the descending thoracic aorta, effacement of the periaortic fat plane along with gas bubbles surrounding the aortic wall(Fig.5). Enhanced sequences showed these abnormalities related to an enlarged (4.2 cm sized) saccular aneurysm with hazy aortic wall, intramural air (Figs.6, 7) and revealed a small amount of contrast extravasation in the gastric fundus(Fig.8).
The patient was submitted to an emergency surgical intervention with poor outcome, confirming the presence of an aortoesophageal fistula.
24 hours later, while treated conservatively with large spectrum antibiotics, his condition worsened with tachycardia and hypotension.
Endoscopy mentioned no significant hemorrhagic findings.
Unenhanced CT revealed a bulge in the left antero-medial aspect of the descending thoracic aorta, effacement of the periaortic fat plane along with gas bubbles surrounding the aortic wall(Fig.5). Enhanced sequences showed these abnormalities related to an enlarged (4.2 cm sized) saccular aneurysm with hazy aortic wall, intramural air (Figs.6, 7) and revealed a small amount of contrast extravasation in the gastric fundus(Fig.8).
The patient was submitted to an emergency surgical intervention with poor outcome, confirming the presence of an aortoesophageal fistula.
The aortoenteric fistula, a rare but potentially fatal entity, is a significant challenge to radiologists when it come to diagnosis , specially because of its subtle and nonspecific imaging findings. An early diagnosis is fundamental for patient survival.
The cardinal clinical signs include hematemesis, melena, sepsis, and abdominal pain, but the condition may also be clinically occult. [1, 2]
Considering clinical signs may not be present or may not be sufficiently specific, imaging is most often necessary to achieve an accurate diagnosis.
CT has a variable specificity (33%–100%) and sensitivity (40%–90%) for the diagnosis of aortoenteric fistulas.[3, 4] For an effective use of this modality in the initial diagnostic examination, radiologists must be familiar with the spectrum of CT appearances.
Aortoesophageal fistulas are divided into primary and secondary forms, depending on the presence or absence of prior aortic reconstructive surgery. [5]
Primary aortoenteric fistulas occur in a native aorta without a history of prior intervention and are much more rare than secondary fistula. Causes include atherosclerotic penetrating ulcer (most common) , foreign bodies, aortitis, esophageal malignancies. [6, 7]
Secondary aortoenteric fistulas occur in the setting of prior surgery or intervention, in patients with prior aortic surgery or graft placement. [8]
Primary CT findings involves ectopic gas either within or directly adjacent to the aortic lumen. [1] Rarely, gas can be traced from the esophagus to the aorta. [3]
Direct extravasation of contrast from the aorta into the esophagus and leakage of enteric contrast directly into the periaortic space are extraordinarily rare.[2, 3]
Secondary CT findings encompasses effacement of the periaortic fat plane, focal thickening and tethering of a esophageal wall immediately adjacent to the aorta, periaortic free fluid and soft tissue thickening, penetrating ulcer or intramural hematoma immediately adjacent to a tethered, abnormal appearing esophagus.[9]
Mimics of aortoenteric fistulas are severe perigraft infection, aortitis, mycotic aneurysms, perianeurysmal fibrosis and immediate post-operative aorta [2, 3, 4]
Differentiation is aided by the observation of ectopic gas, loss of the normal fat plane, extravasation of aortic contrast material into the enteric lumen, or leakage of enteric contrast material into the paraprosthetic space; these features are highly suggestive of aortoenteric fistula in a patient with bleeding in the gastrointestinal tract [1,7,10].
Classical treatment involves surgical ressection of the infected graft, esophageal ressection, creation of an extra-anatomic vascular bypass graft. Mortality rates are up to 90%. Modern treatment trend implies endovascular techniques, lower risk of perioperative complications, avoids most catastrophic complications after surgery [11].
The cardinal clinical signs include hematemesis, melena, sepsis, and abdominal pain, but the condition may also be clinically occult. [1, 2]
Considering clinical signs may not be present or may not be sufficiently specific, imaging is most often necessary to achieve an accurate diagnosis.
CT has a variable specificity (33%–100%) and sensitivity (40%–90%) for the diagnosis of aortoenteric fistulas.[3, 4] For an effective use of this modality in the initial diagnostic examination, radiologists must be familiar with the spectrum of CT appearances.
Aortoesophageal fistulas are divided into primary and secondary forms, depending on the presence or absence of prior aortic reconstructive surgery. [5]
Primary aortoenteric fistulas occur in a native aorta without a history of prior intervention and are much more rare than secondary fistula. Causes include atherosclerotic penetrating ulcer (most common) , foreign bodies, aortitis, esophageal malignancies. [6, 7]
Secondary aortoenteric fistulas occur in the setting of prior surgery or intervention, in patients with prior aortic surgery or graft placement. [8]
Primary CT findings involves ectopic gas either within or directly adjacent to the aortic lumen. [1] Rarely, gas can be traced from the esophagus to the aorta. [3]
Direct extravasation of contrast from the aorta into the esophagus and leakage of enteric contrast directly into the periaortic space are extraordinarily rare.[2, 3]
Secondary CT findings encompasses effacement of the periaortic fat plane, focal thickening and tethering of a esophageal wall immediately adjacent to the aorta, periaortic free fluid and soft tissue thickening, penetrating ulcer or intramural hematoma immediately adjacent to a tethered, abnormal appearing esophagus.[9]
Mimics of aortoenteric fistulas are severe perigraft infection, aortitis, mycotic aneurysms, perianeurysmal fibrosis and immediate post-operative aorta [2, 3, 4]
Differentiation is aided by the observation of ectopic gas, loss of the normal fat plane, extravasation of aortic contrast material into the enteric lumen, or leakage of enteric contrast material into the paraprosthetic space; these features are highly suggestive of aortoenteric fistula in a patient with bleeding in the gastrointestinal tract [1,7,10].
Classical treatment involves surgical ressection of the infected graft, esophageal ressection, creation of an extra-anatomic vascular bypass graft. Mortality rates are up to 90%. Modern treatment trend implies endovascular techniques, lower risk of perioperative complications, avoids most catastrophic complications after surgery [11].
References
[1] Vu QDM et al. (Jan) Aortoenteric Fistulas: CT Features and Potential Mimics. RadioGraphics 29:197-2009 (PMID: 19168845)
[2] Hideyuki Hayashi, MD, Yohjiro Matsuoka, MD, Ichiro Sakamoto, MD, Eijun Sueyoshi, MD, Tomoaki Okimoto, MD, Kuniaki Hayashi, MD and Naofumi Matsunaga, MD (2000) Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept. RadioGraphics 20, 995-1005 (PMID: 10903689)
[3] Raman SP, Kamaya A, Federle M, Fishman EK. (2012) Aortoenteric fistulas: spectrum of CT findings. Abdom Imaging [Epub ahead of print] (PMID: 22366854)
[4] Wood A, Bendjelid SM, Bendjelid K. Primary aortoenteric fistula: should enhanced computed tomography be considered in the diagnostic work-up? Anesth (2005) Primary aortoenteric fistula: should enhanced computed tomography be considered in the diagnostic work-up?. AnesthAnalg 101: 1157–1159. (PMID: 16192537)
[5] George A. Antoniou; Stylianos Koutsias; Stavros A. Antonioua; Andreas Georgiakakis; Miltos K. Lazarides; Athanasios D. Giannoukas (2009) Outcome after endovascular stent graft repair of aortoenteric fistula: A systematic review. Journal of Vascular Surgery Volume 49, Issue 3, Pages 782–789 (PMID: 19028054)
[6] VoorhoeveR, Moll FL, de Letter JA, Bast TJ, Wester JP, Slee PH. (1996) Primary aortoenteric fistula: report of eight new cases and review of the literature. Ann Vasc Surg 10: 40–48. (PMID: 8688296)
[7] HughesFM, Kavanagh D, Barry M, Owens A, Mac-Erlaine DP, Malone DE. (2007) Aortoenteric fistula: a diagnostic dilemma. Abdom Imaging 32: 398–402. (PMID: 16933115)
[8] PipinosII, Carr JA, Haithcock BE, Anagnostopoulos PV, Dossa CD, Reddy DJ. (2000) Secondary aortoenteric fistula. Ann Vasc Surg 14: 688–696. (PMID: 11128470)
[9] Klaus D. Hagspiel; Ulku C. Turba; Ugur Bozlar; Nancy L. Harthun; Kenneth J. Cherry; Hossam Ahmed; Steven J. Bickston; John F. Angle, MDa (2007) Diagnosis of Aortoenteric Fistulas with CT Angiography. Journal of Vascular and Interventional Radiology Volume 18, Issue 4, April , Pages 497–504 (PMID: 17446540)
[10] LowRN, Wall SD, Jeffrey RB Jr, Sollitto RA, Reilly LM, Tierney LM Jr. Aortoenteric fistula and perigraft infection: evaluation with CT. Radiology1990; 175: 157–162. (1990) Aortoenteric fistula and perigraft infection: evaluation with CT. Radiology 175: 157–162. (PMID: 2315475)
[11] LG Svensson, NT Kouchoukos, DC Miller; Joseph E. Bavaria; Joseph S. Coselli , et all. (2008) Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts. The Annals of Thoracic Surgery Volume 85, Issue 1, January , Pages S1–S41 (PMID: 18083364)
Case information
| URL: | https://www.eurorad.org/case/10280 |
| DOI: | 10.1594/EURORAD/CASE.10280 |
| ISSN: | 1563-4086 |
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Figure 1
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal
Figure 2
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal.
Figure 3
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal.
Figure 4
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal.
Figure 5
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal.
Figure 6
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal.
Figure 7
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal.
Figure 8
J.T.Soares, Department of Radiology, Centro Hospitalar de Vila Nova de Gaia, Portugal.