Endovascular treatment of a small infrarenal abdominal aortic aneurysm causing duodenal obstruction: Case report and literature review

Abstract

Duodenal obstruction caused by abdominal aortic aneurysm was first described by Osler in 1905 and is named “aortoduodenal syndrome.” This condition has always been treated by open surgical repair. We report the first case of aortoduodenal syndrome successfully treated by endovascular aneurysm repair. A 74-year-old male patient referred to our hospital complaining postprandial vomit, reporting a consistent weight loss in the latest weeks. Enhanced computed tomography scans showed a small saccular abdominal aortic aneurysm compressing duodenum and inferior vena cava without any other evident pathological finding. As the patient underwent a successful endovascular treatment of the abdominal aortic aneurysm, symptoms immediately resolved so that he started back to feed and progressively gained body weight. Despite aortoduodenal syndrome is generally caused by large abdominal aortic aneurysm, this condition has to be suspected also in case of small abdominal aortic aneurysm. Differently from what has been reported in literature, endovascular aneurysm repair could be effective in the treatment of aortoduodenal syndrome.

Keywords

Aortoduodenal syndrome endovascular aneurysm repair bilious emesis abdominal aortic aneurysm duodenal compression

Introduction

Unusual symptoms of abdominal aortic aneurysms (AAAs) can include nausea, bilious emesis, and weight loss and are related to duodenal compression.

In fact, large AAAs may produce compression of adjacent abdominal structures, as well as inflammatory AAAs may cause intense retroperitoneal fibrotic adhesions thus attracting ureters with subsequent hydronephrosis. Duodenal compression caused by AAA is a rare condition called “aortoduodenal syndrome.” Firstly described by Osler,¹ to date only 33 cases of aortoduodenal syndrome are reported in literature, mainly treated by gastric bypass surgery or AAA open surgical repair.^2–27 We report the first case of aortoduodenal syndrome treated by endovascular aneurysm repair (EVAR).

Case report

A 74-year-old man referred to our hospital complaining nausea with postprandial bilious emesis, reporting a 8-kg weight loss in the last three months. His medical history was positive for coronary artery disease and severe respiratory failure requiring home oxygen therapy with no former abdominal intervention.

At an initial physical examination, the patient was afebrile and hemodynamically stable.

He had a mildly distended and pain-free abdomen; no abdominal pulsatile mass was detected. No masses were detected at rectal examination. All peripheral pulses were intact.

Blood tests revealed a mild anemia (hemoglobin 10.9 g/dL), hypochloridemia (87 mEq/L), and hypokalemia (3.3 mEq/L). C-reactive protein and erythrocyte sedimentation rate were normal.

The patient underwent gastroscopy and colonoscopy showing no endoluminal masses, with an evident gastric dilatation.

Enhanced computed tomography (CT) scan was performed as well, showing an infrarenal saccular AAA with maximum transverse diameter of 38 mm, compressing the inferior vena cava and third duodenal portion (Figure 1); celiac trunk, superior, and inferior mesenteric arteries were normally patent.

Figure 1.

Saccular AAA on multiplanar reconstruction.

An aortoduodenal syndrome was diagnosed and then AAA repair was indicated.

Because of a favorable anatomy and comorbidities, an endovascular approach was chosen.

Intervention was performed under locoregional anesthesia, after surgical exposure of both common femoral arteries. A Gore Excluder endograft (W. L. Gore & Associates, Flagstaff, AZ) was successfully deployed.

Postoperative course was uneventful, as yet in first postoperative day patient did not complain nausea nor vomit, and then started back to feed normally. After intervention, the patient underwent duplex scans, showing no evident change in aneurysm diameter, and he was discharged home on the fourth postoperative day. One-month CT scan showed the complete exclusion of the aneurysm without any endoleak, with apparent resolution of duodenum and inferior vena cava compression (Figure 2).

Figure 2.

Changes in duodenum and inferior vena cava before (A) and after (B) EVAR.

At an 11-month follow-up, the patient presented a 6-kg body weight gain; latest duplex ultrasound showed a 3-mm sac shrinkage.

Discussion

Extrinsic compression of the duodenum by an AAA is a rare condition called aortoduodenal syndrome.

At our knowledge, few more than 30 cases are reported in literature with only five cases reported since 2000 (Table 1).

Table 1.

Cases of aortoduodenal syndrome reported since 2000.

References	AAA diameter (mm)	Inflammatory	AAA treatment	Outcome
Bhama et al.²²	60	No	Open repair	Recovered
Dharmendran and Zainal²⁴	70	No	Open repair	Recovered
Torella et al.²³	60	Yes	Open repair	Recovered
Takagi et al.²⁶	50	No	Open repair	Recovered
Cahill et al.²⁷	80	No	Open repair	Recovered
Our experience	38	No	EVAR	Recovered

EVAR: endovascular aneurysm repair; AAA: abdominal aortic aneurysm.

In most cases, aortoduodenal syndrome occurs in patients with large AAAs. Deitch et al.²⁵ reported a mean AAA diameter of 79 mm in a review of 26 cases published between 1905 and 1999. Less often, in case of inflammatory aneurysm, posterior duodenal wall can be adherent to the aneurysm with variably hampered passage of chyme.^7,16,23

In our case, the patient presented a relatively small right-sided saccular aneurysm without radiological nor laboratory signs of inflammation. These morphologic data do not match features commonly reported in other case reports, so aortoduodenal syndrome should be considered also in case of small non-inflammatory aneurysms.

The ideal treatment of aortoduodenal syndrome implies the correction of fluid and electrolytic imbalance before proceeding to surgery.

Before advent of aortic surgery, the mainstay of surgical management was gastrointestinal bypass surgery (gastroenterostomies, gastrojejunostomies, or duodenojejunostomy) in order to relieve bowel obstruction: this approach was charged by consistent mortality rates (over 50%), as reported in literature.²⁵

After the advent of aortic surgery, perioperative mortality rates for aortoduodenal syndrome strongly decreased, even remaining higher than elective AAA surgery.²⁷

EVAR has been shown to improve perioperative mortality of aortic surgery compared to AAA open repair.²⁸ Despite this, EVAR has been advocated as not effective in treatment of aortoduodenal syndrome since aneurysmal sac shrinkage is not always a constant event during follow-up, and furthermore it may take months to occur.²⁹

On the other hand, it has been demonstrated that stent graft deployment produces an immediate fall in the pressure within the aneurysmal sac: from a series of eight patients, Chuter et al.³⁰ recorded a mean intra-sac pressure 36.5/33 mmHg (respectively systolic and diastolic) after stent graft deployment in comparison of a mean radial arterial pressure of 118.5/50.5 mmHg (p < 0.05).

This finding was confirmed by other authors: Shrikhande et al.³¹ demonstrated a decrease in intra-sac pressure after EVAR, with significant differences according to different devices.

Furthermore, EVAR has been demonstrated as an effective tool in relieving abdominal compression symptoms caused by AAA: Fukui et al.³² reported a case of biliary and pancreatic ducts compression caused by AAA successfully treated by EVAR.

Also in our case, compression symptoms resolved immediately after EVAR, as postprandial vomit stopped at once and the patient went back to a normal food intake.

As no shrinkage was recorded in postoperative duplex scans, it is reasonable that EVAR was able to induce an immediate aneurysmal sac depressurization sufficient to relieve duodenum compression, thus allowing chyme transit.

Conclusions

Aortoduodenal syndrome is a rare condition that should be considered also in case of small non-inflammatory aneurysm.

In literature, endovascular treatment of aortoduodenal syndrome has been considered ineffective since aneurysm shrinkage may take months to occur, but according to our experience the sac depressurization caused by stent graft deployment may be sufficient to reduce duodenal compression and then relieve symptoms.

To the best of our knowledge, this is the first reported case of a patient safely and effectively treated for aortoduodenal syndrome with endovascular stent grafting alone without all the potential complications related to laparotomy.

Footnotes

Conflict of interest

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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