Aortic endograft infection with aortoduodenal fistula associated with adjacent vertebral body mycobacterial osteomyelitis (Pott's disease)

Abstract

Aortoenteric fistulas (AEFs) are a rare complication of infrarenal abdominal aortic aneurysm repair. They occur in <1% of aortic grafting procedures, result from graft defects, foreign bodies, and trauma, and are associated with a high mortality rate. We report a complex AEF associated with vertebral body osteomyelitis, likely secondary to tuberculous infection. A 78-year-old man presented with a 2-week history of abdominal pain, fever, and anemia. Past surgical history is significant for open repair of infrarenal abdominal aortic aneurysm followed later by an endovascular repair of a proximal para-anastomotic aneurysm. Computed tomography angiography revealed air in the aneurysm sac, without evidence of endoleak. The posterior aspect of the aneurysm was noted to be in continuity with a destructive osteomyelitis of the second lumbar vertebral body and an adjacent psoas abscess. Percutaneous drainage revealed purulent fluid containing mixed enteric flora. With fluoroscopic guidance, injection of contrast in the aortic sac drainage catheter demonstrated complex fistulous communications from the aortic sac to the overlying small intestine. After a course of drainage, antibiotic therapy, and parenteral nutrition, the patient underwent a transperitoneal repair of the AEF with duodeno-duodenectomy and wide debridement of the aortic sac and Dacron graft. Pathology revealed giant cell granulomas, highly suggestive of tuberculosis.