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Wang et al. Vessel Plus 2018;2:3. I http://dx.doi.org/10.20517/2574-1209.2017.38 Page 3 of 5

Figure 2. After placement of a metallic clip in the duodenum at the visualized lesion, a computed tomography angiogram demonstrated a
diverticulum of the aortic stump (black arrow) near the duodenal clip (white arrow) concerning for another aorto-enteric fistula

A B

Figure 3. Digital subtraction angiography (A) and fluoroscopy (B) demonstrated placement of the Amplatzer II Vascular Plug so that 2/3
of the plug remained intraluminally (black arrow) in the aortic stump while 1/3 remained in the periaortic space (white arrow). Microcoils
were deployed distal to the intraluminal plug to further assist in stump thrombosis (black arrowhead). The close association between the
aortic stump and the duodenum is demonstrated by the endoclip placed at the time of double-balloon endoscopy (white arrowhead)

Approximately 14 weeks after our procedure, the patient presented with recurrent GI bleeding. The AEF
was again identified by endoclip on upper GI endoscopy. The patient underwent further coil placement
within the aortic stump via the radial artery. Following this reintervention, he was discharged home
without repeat bleeding. Unfortunately, he proceeded to present in similar fashions 2 additional times; the
first was managed with endoscopic clipping. However, on his final presentation 5 months postoperatively,
the decision was made to proceed with definitive surgical ligation of the aortic stump given multiple
failed endovascular and endoscopic interventions. On the day prior to his scheduled surgery, the patient
developed acute hemorrhagic shock identified via his nasogastric tube. Unfortunately, he became
hemodynamically unstable, was emergently intubated, and initiated on a massive transfusion protocol.
After discussion with the patient’s family, code status was changed to “do not resuscitate”, comfort care
was initiated, and he ultimately expired.

DISCUSSION
AEF is a rare and highly morbid complication following aortic intervention with an incidence of
[1]
approximately 1% . In the aortic reconstruction patient, it is thought that pathogenesis is related to