PMC9046796_01
Angiography and placement of the Amplatzer  Vascular Plug in the aortic stump. Angiography demonstrating the aorta (*) the duodenum (#) and the aortoduodenal fistula ( ). The upper image (A) demonstrates contrast passage from the aorta through the aortoduodenal fistula towards the duodenum. The lower graph (B), 23 minutes later, demonstrates successful closure of the aortic stump with no more contrast leakage through the aortoduodenal fistula. The angiographic catheter is marked with  , the guide wire with   and the 16 mm Amplatzer  Vascular Plug with +-.
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The patient had undergone multiple surgical procedures before transfer (Supplementary figure 1). The patient was admitted to the intensive care unit (ICU) and was considered unsuitable for open surgery due to severe haemodynamic instability and multiple previous abdominal operations (Supplementary figure 1). This effectively stopped the bleeding (Fig. 1). Because of a good clinical recovery, combined with a hostile abdomen (Supplementary figure 1), no further surgery was performed.
PET scan demonstrating persistent infection and progressive dilatation of the aortic stump. PET-scans were performed which demonstrated persistent infection of the aortic stump, with the Amplatzer  Vascular Plug in situ. Furthermore, it showed progressive dilatation of the aortic stump without signs of acute rupture. The upper image (A) shows small amounts of fluor-18-glucose (FDG) uptake around the aortic stump (diameter 20mm) in 2015 (two years after the endovascular repair). The middle image (B) shows increased FDG uptake and signs of enlargement of the aortic stump (diameter 23mm) at the beginning of January 2019. The lower image (C) demonstrates further increase in FDG uptake around the aortic stump and progressive enlargement (diameter 36mm) by the end of January 2019.
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A PET scan and CT angiography (CTA) demonstrated persistent infection of the aortic stump with progressive dilatation of the aortic stump without signs of rupture (Figure 2, Figure 3).
CTA demonstrating progressive dilatation of the aortic stump. CTA demonstrating persistent infection of the aortic stump, with the Amplatzer  Vascular Plug in situ. Also, it shows progressive dilatation of the aortic stump without signs of acute rupture. The upper, middle and lower images (A, B and C) show the progressive enlargement of the aortic stump from day 0 (A) to day 4 (B) and day 11 (C) during admission.
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A PET scan and CT angiography (CTA) demonstrated persistent infection of the aortic stump with progressive dilatation of the aortic stump without signs of rupture (Figure 2, Figure 3).
Peri-operative images. The left panel demonstrates the new aortic stump (*), the duodenum (#), pancreas ( ) and suction instrument (~). The right panel showing the removed Amplatzer Vascular Plug (AVP) in the surgeon's hand.
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A new aortic stump was created by suturing the aorta just distally to the right renal artery with Prolene 4.0 sutures, sacrificing a left accessory renal artery (Fig. 4). A small part of the severely adherent distal duodenum including the fistula was resected as well.