Sealing the tract, a novel approach using cardiac septal occluder and anterocutaneous fistula closure. Anterocutaneous fistula occurs when an abnormal tract or connection forms between the small intestine and the skin. Several factors contribute to the development of anterocutaneous fistulas including malignancy, inflammatory bowel diseases, or post-surgical complications. Management of anterocutaneous fistula is often surgical, although there was a recent paradigm shift for endoscopic closures. Endoscopic approaches can be done in certain cases and includes endoscopic suturing, endoscopic vacuum therapy, over-the-scope clips, and novel off-label use of various devices. We present a 61-year-old woman with a history of metastatic colon cancer, status post-sigmoid resection with loop ileostomy, and palliative chemotherapy. Her course was complicated by a symptomatic anterocutaneous fistula. She was deemed a poor surgical candidate and glue injections attempted multiple times but failed, therefore referred to our institution for possible endoscopic closure. Ileoscopy with possible endoscopic closure was attempted but failed as fistula was unable to be reached despite advancing a guide wire via the cutaneous opening into the bowel under fluoroscopy. Further discussions with surgery and patient were held, and decision was to reattempt endoscopic closure, for which plans were made for a single-balloon enteroscopy with possible closure versus septal occluder placement. Small bowel enteroscopy was normal to midge genome. To attempt closure, a guide wire was placed from the skin through the enterocutaneous fistula and coiled in the small bowel under fluoroscopic guidance, and despite further advancement with enteroscopy, we were unable to reach the guide wire or the fistula location. As anti-grade small bowel enteroscopy and ileoscopy failed to reach the fistula, the decision was made to deploy the septal occluder device. The septal occluder device is a self-expandable double-disc device with a connecting waist. Made from a 19-ohm wire mesh that is coated with prothrombotic and pro-endothelialization dacrine patches, the two discs are linked together with a short connecting waist. To set up the device, a delivery cable is threaded into a TOHI-borst adapter which is attached to the loader. Then, the septal occluder is screwed into the delivery cable. The septal occluder is loosely threaded into the delivery cable and withdrawn into the loader while using water as a lubricant. Separately, the dilator is passed into the lumen of the delivery sheath. At the time of deployment, the dilator is placed within the loader to deploy the device. Over the guide wire, an 8-fringe catheter was placed. Contrast-injected and confirmed catheter was in the small intestine. Keeping the catheter in place and removing the guide wire, a muscular septal occluder was successfully deployed. Contrast was injected against the cutaneous side of the occluder with no extravasation into the bowel, confirming successful closure. To activate the inner portion of the occluder, blood was injected. Patient did well post-procedurally and she was discharged home. Follow-up after 2 days, 1 month and 3 months confirmed there was no leakage and resolution of symptoms. This case report is unique in highlighting a purely fluoroscopic closure of anterior cutaneous fistula despite failure to reach the fistula with an endoscopic approach. While further studies and long-term follow-up are needed to establish the safety and efficacy of this approach, it underscores the importance of a multidisciplinary approach and the exploration of innovative solutions in challenging clinical scenarios.

anterocutaneous fistula

cardiac septal occluder

colon cancer

endoscopic closure

fluoroscopic approach