title: Secondary aortoduodenal fistula following endovascular repair of inflammatory abdominal aortic aneurysm due to Streptococcus anginosus infection: A case report and literature review.
abstract: BACKGROUND
  Aortoenteric fistula is a rare but very serious complication of both surgical and endovascular abdominal aortic reconstruction. Since the advent of endovascular abdominal aortic aneurysm repair (EVAR), 20 cases of aortoduodenal fistula associated with aortic stent grafts have been reported.(1) However, only a handful has been reported following inflammatory abdominal aortic aneurysm repair. It most commonly presents with bleeding, usually from the upper gastro-intestinal tract. With recent advances in the screening, diagnosis and management of abdominal aortic aneurysms either surgically or through an endovascular approach, the diagnosis of an aortoduodenal fistula in patients with gastro-intestinal bleeding must be suspected and excluded.
  
  
  METHODS
  We describe a case of secondary aortoduodenal fistula that occurred two and a half years following endovascular stent graft repair of an inflammatory abdominal aortic aneurysm. We also outline the emergency correction plan and the attempts at repair.
  
  
  CONCLUSIONS
  This case defies the general concept that patients with inflammatory abdominal aortic aneurysms are relatively immune to rupture. Although the presence of a peri-aneurysm thick inflammatory membrane decreases the possibility of rupture, these patients are more susceptible to other related complications such as aorto-enteric and aorto-caval fistulas.(2) This case also demonstrates the peculiar presence of Streptococcus anginosus as the pathological organism leading to graft infection and subsequent fistula, as opposed to enterococci which are often found in endograft infection.
  
  
  CONCLUSIONS
  Aorto-enteric fistulas are associated with a grave prognosis. Early diagnosis is crucial and extra vigilance should be taken in cases of inflammatory AAA.
authors.affiliation: Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University College Hospital, Galway (UCHG), Newcastle Road, Galway, Ireland; Department of Vascular Surgery (Unit 7), El-Demerdash Hospital, Faculty of Medicine, Ain-Shams University, Cairo, Egypt. Electronic address: mmmzaki@hotmail.com.
authors.forename: M
authors.initials: M
authors.lastname: Zaki
authors.affiliation: Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University College Hospital, Galway (UCHG), Newcastle Road, Galway, Ireland. Electronic address: wael.tawfick@hse.ie.
authors.forename: W
authors.initials: W
authors.lastname: Tawfick
authors.affiliation: Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University College Hospital, Galway (UCHG), Newcastle Road, Galway, Ireland; Department of Vascular Surgery (Unit 7), El-Demerdash Hospital, Faculty of Medicine, Ain-Shams University, Cairo, Egypt. Electronic address: drmahmoud81@msn.com.
authors.forename: M
authors.initials: M
authors.lastname: Alawy
authors.affiliation: Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University College Hospital, Galway (UCHG), Newcastle Road, Galway, Ireland. Electronic address: dr-m7md@hotmail.com.
authors.forename: M
authors.initials: M
authors.lastname: ElKassaby
authors.affiliation: Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University College Hospital, Galway (UCHG), Newcastle Road, Galway, Ireland; Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland. Electronic address: niamh.hynes@hse.ie.
authors.forename: N
authors.initials: N
authors.lastname: Hynes
authors.affiliation: Western Vascular Institute (WVI), Department of Vascular and Endovascular Surgery, University College Hospital, Galway (UCHG), Newcastle Road, Galway, Ireland; Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland. Electronic address: sherif.sultan@hse.ie.
authors.forename: S
authors.initials: S
authors.lastname: Sultan