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Arterioenteric fistulae: Diagnosis and treatment by angiography
Clinical Radiology (1991) 43, 328-330
Arterioenteric Fistulae: Diagnosis and Treatment by Angiography R. H I R A K A T A , K. HASUO, K. YASUMORI, K. Y O S H I D A and K. M A S U D A
Department of Radiology, Faculty of Medicine, Kyusyu University, Fukuoka, Japan Two cases of massive gastrointestinal haemorrhage caused by arterioenteric fistulae are presented. In both cases, bleeding was controlled by interventional angiography. In the first case, a fistula between an aberrant right subclavian artery and a reconstructed oesophagus was temporarily occluded with a balloon catheter as a pre-surgical measure. In the second case a communication between the externaliliac artery and the colon in a patient with invasive cervical cancer was treated by embolization. An arterioenteric fistula should be considered as a possible cause of acute gastrointestinal haemorrhage in post-operative or cancer patients and aortography or pelvic arteriography may be required to make the diagnosis. Hirakata, R.,
Hasuo, K., Yasumori, K., Yoshida, K. & Masuda, K. (1991). Clinical Radiology 43, 328-330. Arterioenteric Fistulae: Diagnosis and Treatment by Angiography
Fistulae between the arterial system and the gastrointestinal tract are rare but they give rise to life-threatening haemorrhage (Bergqvist, 1987). We present two cases of such fistulae in which bleeding from large non-visceral arteries was both diagnosed and controlled by interventional angiography.
CASE R E P O R T S Case 1. A 55-year-old man underwent surgery for carcinoma of the lower oesophagus after receiving 30 Gy irradiation for 4 weeks. A subtotal oesophagectomy was undertaken and reconstruction of the oesophagus was accomplished by means of a cervical anastomosis using a gastric tube through the retromediastinal route. Forty-four days after the operation, the patient suddenly developed massive haematemesis and haemorrhagic shock and an arterioenteric fistula was suspected. Thoracic aortography and selective aberrant right subclavian arteriography (Fig. la) demonstrated a fistula between the subclavian artery and the reconstructed oesophagus with massive extravasation of contrast medium. The balloon of a Swan-Ganz catheter was inflated at the mouth of the fistula (Fig. lb) and this controlled the haemorrhage immediately. The balloon was kept inflated until the subclavian artery had been ligated surgically. Biopsy of the artery revealed no evidence of tumour invasion. Case 2. A 47-year-old woman had a radical hysterectomy for stage lib squamous cell carcinoma of the cervix followed by: whole pelvic irradiation of 4140 cGy for 4 weeks. Ten months later, she developed a vesicovaginal fistula. Recurrent tumour invading the sigmoid colon was found at surgery. Thirteen months after the initial operation, the patient suddenly developed massive lower gastrointestinal bleeding and haemorrhagic shock. Inferior mesenteric, superior mesenteric, and coeliac arteriography demonstrated no active site of haemorrhage. Bilateral common iliac arteriography, however, demonstrated massive extravasation of contrast medium on the left side of the pelvis and this was thought to be in the sigmoid colon (Fig. 2a). Following occlusion of the external iliac artery with four stainless steel coils (Fig. 2b) the haemorrhage ceased and the patient recovered.
DISCUSSION
nal haemorrhage and they arise most commonly as a result of complications following vascular surgery or in association with aneurysms. Less common causes of such fistulae include inflammatory diseases~ non-vascular operations, malignant tumours, foreign bodies, pancreatitis, radiotherapy, and gastroduodenal ulcers (Bergqvist, 1987). Fistula formation between an aberrant right subclavian artery and the oesophagus is extremely rare, and only eight cases have been reported. In these cases the causes include prolonged oesophageal intubation (Merchant et al., 1977; Belkin et aI., 1984; Gossot et al., 1985), overinflation of an adjacent tracheostomy balloon (Livesay et al., 1982), and aneurysms (Edwards et al., 1984; Austin and Wolfe, 1985). The cause of the fistula in our case was not clear at surgery. A combination of surgical trauma, erosion or ulcer formation secondary to placement of a gastric tube, and radiation arteritis is suspected. The use of a balloon catheter proved to be the procedure of choice to control bleeding; a technique that has been described previously (Wholey et al., 1970). Arteriocolic fistulae are also rare, and usually occur following the insertion of a prosthetic graft for an aortoiliac aneurysm or occlusive disease. Two cases similar to ours, however, in which the fistula was caused by pelvic malignancy have been reported previously (Husted and Dempsey, 1986). Massive gastrointestinal bleeding is an indication for emergency angiography and this usually includes coeliac, superior mesenteric, and inferior mesenteric studies. In post-operative or cancer patients, however, non-visceral arteries can be a source of bleeding and aortography and, when appropriate, pelvic arteriography should be performed in such cases. Arterioenteric fistulae have a high mortality because they usually involve large arteries and diagnosis and early treatment is essential. The present report indicates how arteriography can play an important role in both the diagnosis and treatment of this condition.
Arterioenteric fistulae are a rare cause of gastrointestiCorrespondence to: Dr R. Hirakata, Department of Radiology, Faculty of Medicine, Kyusyu University, 3-1-1, Maidashi Higashi-Ku, Fukuoka 812, Japan.
Acknowledgement. We thank Dr Yuji Numaguti of Department of Diagnostic Radiology, University of Maryland Medical System for editing this manuscript.
329
ARTERIOENTERIC FISTULAE
(a)
(b) Fig. 1 - (a) Selectivearteriography of an aberrant right subclavian vessel shows contrast medium extravasating into the reconstructed oesophagus. (b) A Swan-Gantz balloon catheter has been inflated at the m o u t h of the fistula (arrow).
(a)
(b) Fig. 2 - (a) A left c o m m o n iliac arteriogram shows occlusion of the external iliac artery and extravasation of the contrast medium (arrows). (b) A radiograph after embolization shows indwelling steel coils (arrows) and residual extravasated contrast medium from previous injections.
330
CLINICAL RADIOLOGY
REFERENCES Austin, EH & Wolfe, WG (1985). Aneurysm of aberrant subclavian artery with a review of the literature. Journal of Vascular Surgery, 2, 571-577. Bergqvist, D (1987). Arterioenteric fistula. Acta Chirurgica Scandinavica, 153, 81 86. Belkin, RI, Keller, FS, Everts, EC & Rosch, J (1984). Aberrant right subclavian artery-esophageal fistula: a cause of overwhelming upper gastrointestinal hemorrhage. Cardiovascular Interventional Radio[ogy, 7, 87-89. Edwards, BS, Edwards, WD, Connolly, DC & Edwards, JE (1984). Arterial-esophageal fistulae developing in patients with anomalies of the aortic arch system. Chest, 86, 732-735. Gossot, D, Nussaume, O, Kitzis, M, Cohen, G, Chalaux, G & Andreassian, B (1985). Fatal haematemesis due to erosion ofa retro-
oesophageal right subclavian artery by a nasogastric tube. La Presse Mkdicale, 14, 1655-1656. Husted, J & Dempsey0 D (1986). Angiographic management of arteriocolic fistulae. Cardiovascular Interventional Radiology, 9, 158-160. Livesay, JJ, Michals, AA & Dainko, EC (1982). Anomalous right subclavian arterial fistula: unusual complication of tracheostomy. Texas Heart Institute Journal, 9, 105 108. Merchant, F J, Nichols, RL & Bombeck, CT (1977). Unusual complication of nasogastric esophageal intubation-erosion into an aberrant right subclavian artery. Journal of Cardiovascular Surgery, 18, 147 150. Wholey, MH, Stockdale, R & Hung, TK (1970). A percutaneous balloon catheter for the immediate control of hemorrhage. Radiology, 95, 65 71.
Arterioenteric Fistulae: Diagnosis and Treatment by Angiography R. H I R A K A T A , K. HASUO, K. YASUMORI, K. Y O S H I D A and K. M A S U D A
Department of Radiology, Faculty of Medicine, Kyusyu University, Fukuoka, Japan Two cases of massive gastrointestinal haemorrhage caused by arterioenteric fistulae are presented. In both cases, bleeding was controlled by interventional angiography. In the first case, a fistula between an aberrant right subclavian artery and a reconstructed oesophagus was temporarily occluded with a balloon catheter as a pre-surgical measure. In the second case a communication between the externaliliac artery and the colon in a patient with invasive cervical cancer was treated by embolization. An arterioenteric fistula should be considered as a possible cause of acute gastrointestinal haemorrhage in post-operative or cancer patients and aortography or pelvic arteriography may be required to make the diagnosis. Hirakata, R.,
Hasuo, K., Yasumori, K., Yoshida, K. & Masuda, K. (1991). Clinical Radiology 43, 328-330. Arterioenteric Fistulae: Diagnosis and Treatment by Angiography
Fistulae between the arterial system and the gastrointestinal tract are rare but they give rise to life-threatening haemorrhage (Bergqvist, 1987). We present two cases of such fistulae in which bleeding from large non-visceral arteries was both diagnosed and controlled by interventional angiography.
CASE R E P O R T S Case 1. A 55-year-old man underwent surgery for carcinoma of the lower oesophagus after receiving 30 Gy irradiation for 4 weeks. A subtotal oesophagectomy was undertaken and reconstruction of the oesophagus was accomplished by means of a cervical anastomosis using a gastric tube through the retromediastinal route. Forty-four days after the operation, the patient suddenly developed massive haematemesis and haemorrhagic shock and an arterioenteric fistula was suspected. Thoracic aortography and selective aberrant right subclavian arteriography (Fig. la) demonstrated a fistula between the subclavian artery and the reconstructed oesophagus with massive extravasation of contrast medium. The balloon of a Swan-Ganz catheter was inflated at the mouth of the fistula (Fig. lb) and this controlled the haemorrhage immediately. The balloon was kept inflated until the subclavian artery had been ligated surgically. Biopsy of the artery revealed no evidence of tumour invasion. Case 2. A 47-year-old woman had a radical hysterectomy for stage lib squamous cell carcinoma of the cervix followed by: whole pelvic irradiation of 4140 cGy for 4 weeks. Ten months later, she developed a vesicovaginal fistula. Recurrent tumour invading the sigmoid colon was found at surgery. Thirteen months after the initial operation, the patient suddenly developed massive lower gastrointestinal bleeding and haemorrhagic shock. Inferior mesenteric, superior mesenteric, and coeliac arteriography demonstrated no active site of haemorrhage. Bilateral common iliac arteriography, however, demonstrated massive extravasation of contrast medium on the left side of the pelvis and this was thought to be in the sigmoid colon (Fig. 2a). Following occlusion of the external iliac artery with four stainless steel coils (Fig. 2b) the haemorrhage ceased and the patient recovered.
DISCUSSION
nal haemorrhage and they arise most commonly as a result of complications following vascular surgery or in association with aneurysms. Less common causes of such fistulae include inflammatory diseases~ non-vascular operations, malignant tumours, foreign bodies, pancreatitis, radiotherapy, and gastroduodenal ulcers (Bergqvist, 1987). Fistula formation between an aberrant right subclavian artery and the oesophagus is extremely rare, and only eight cases have been reported. In these cases the causes include prolonged oesophageal intubation (Merchant et al., 1977; Belkin et aI., 1984; Gossot et al., 1985), overinflation of an adjacent tracheostomy balloon (Livesay et al., 1982), and aneurysms (Edwards et al., 1984; Austin and Wolfe, 1985). The cause of the fistula in our case was not clear at surgery. A combination of surgical trauma, erosion or ulcer formation secondary to placement of a gastric tube, and radiation arteritis is suspected. The use of a balloon catheter proved to be the procedure of choice to control bleeding; a technique that has been described previously (Wholey et al., 1970). Arteriocolic fistulae are also rare, and usually occur following the insertion of a prosthetic graft for an aortoiliac aneurysm or occlusive disease. Two cases similar to ours, however, in which the fistula was caused by pelvic malignancy have been reported previously (Husted and Dempsey, 1986). Massive gastrointestinal bleeding is an indication for emergency angiography and this usually includes coeliac, superior mesenteric, and inferior mesenteric studies. In post-operative or cancer patients, however, non-visceral arteries can be a source of bleeding and aortography and, when appropriate, pelvic arteriography should be performed in such cases. Arterioenteric fistulae have a high mortality because they usually involve large arteries and diagnosis and early treatment is essential. The present report indicates how arteriography can play an important role in both the diagnosis and treatment of this condition.
Arterioenteric fistulae are a rare cause of gastrointestiCorrespondence to: Dr R. Hirakata, Department of Radiology, Faculty of Medicine, Kyusyu University, 3-1-1, Maidashi Higashi-Ku, Fukuoka 812, Japan.
Acknowledgement. We thank Dr Yuji Numaguti of Department of Diagnostic Radiology, University of Maryland Medical System for editing this manuscript.
329
ARTERIOENTERIC FISTULAE
(a)
(b) Fig. 1 - (a) Selectivearteriography of an aberrant right subclavian vessel shows contrast medium extravasating into the reconstructed oesophagus. (b) A Swan-Gantz balloon catheter has been inflated at the m o u t h of the fistula (arrow).
(a)
(b) Fig. 2 - (a) A left c o m m o n iliac arteriogram shows occlusion of the external iliac artery and extravasation of the contrast medium (arrows). (b) A radiograph after embolization shows indwelling steel coils (arrows) and residual extravasated contrast medium from previous injections.
330
CLINICAL RADIOLOGY
REFERENCES Austin, EH & Wolfe, WG (1985). Aneurysm of aberrant subclavian artery with a review of the literature. Journal of Vascular Surgery, 2, 571-577. Bergqvist, D (1987). Arterioenteric fistula. Acta Chirurgica Scandinavica, 153, 81 86. Belkin, RI, Keller, FS, Everts, EC & Rosch, J (1984). Aberrant right subclavian artery-esophageal fistula: a cause of overwhelming upper gastrointestinal hemorrhage. Cardiovascular Interventional Radio[ogy, 7, 87-89. Edwards, BS, Edwards, WD, Connolly, DC & Edwards, JE (1984). Arterial-esophageal fistulae developing in patients with anomalies of the aortic arch system. Chest, 86, 732-735. Gossot, D, Nussaume, O, Kitzis, M, Cohen, G, Chalaux, G & Andreassian, B (1985). Fatal haematemesis due to erosion ofa retro-
oesophageal right subclavian artery by a nasogastric tube. La Presse Mkdicale, 14, 1655-1656. Husted, J & Dempsey0 D (1986). Angiographic management of arteriocolic fistulae. Cardiovascular Interventional Radiology, 9, 158-160. Livesay, JJ, Michals, AA & Dainko, EC (1982). Anomalous right subclavian arterial fistula: unusual complication of tracheostomy. Texas Heart Institute Journal, 9, 105 108. Merchant, F J, Nichols, RL & Bombeck, CT (1977). Unusual complication of nasogastric esophageal intubation-erosion into an aberrant right subclavian artery. Journal of Cardiovascular Surgery, 18, 147 150. Wholey, MH, Stockdale, R & Hung, TK (1970). A percutaneous balloon catheter for the immediate control of hemorrhage. Radiology, 95, 65 71.