Endovascular Repair in the Presence of Aortic Infection

Outcome after endovascular stent graft repair of aortoenteric fistula: A systematic review

BACKGROUND

Aortoenteric fistula (AEF) is a critical clinical condition, which may present with gastrointestinal hemorrhage, with or without signs of sepsis. Conventional open surgical repair is associated with high morbidity and mortality. Endovascular stent graft repair has been attempted, but recurrent infection remains of major concern. We conducted a systematic review to assess potential factors associated with poor outcome after endovascular treatment.

METHODS

The English literature was searched using the MEDLINE electronic database up to April 2008. All studies reporting on the primary management of primary or secondary AEF with endovascular stent graft repair were considered.

RESULTS

Data were extracted from 33 reports that included 41 patients and were entered in the final analysis. Persistent/recurrent/new infection or recurrent hemorrhage developed in 44% of the patients, after a mean follow-up period of 13 months (range, 0.13-36). Secondary, as compared to primary, AEF had an almost threefold increased risk of persistent/recurrent infection. Evidence of sepsis preoperatively was found to be a factor indicating unfavorable outcome (P < .05). Persistent/recurrent/new infection after treatment was associated with worse 30-day and overall survival compared with those who did not develop sepsis (P < .05).

CONCLUSION

Endovascular stent graft repair of AEF was associated with a high incidence of infection or recurrent bleeding postoperatively. Evidence of sepsis preoperatively was indicating poor outcome.

Unusual forms of ruptured abdominal aortic aneurysms

Over 95% of abdominal aortic aneurysms (AAAs) rupture into the retroperitoneal space. Rare types of AAA ruptures comprise ruptures into the inferior vena cava with aortocaval fistula formation (ACF), ruptures into the duodenum with formation of a primary aortoduodenal fistula (ADF), and chronic contained ruptures (CCRs). This article presents a study of 41 cases with unusual forms of ruptured AAA of a series of 506 patients with AAA rupture treated within a 14-year period. There were 11 cases of CCR, 5 cases with ADF, and 25 cases with ACF. The correct preoperative diagnosis was established in 6 (of 11) cases of CCR, in 2 (of 5) cases of primary ADF, and in 13 (of 25) cases of ACF. AAA replacement was performed in 8 cases using a tube graft, whereas a bifurcated graft was used in 31 patients because of the distant extent of the atherosclerotic/aneurysmatic lesions engaging iliac arteries. Two patients had an axillobifemoral bypass. The overall 30-day mortality rate was 19% (8 of 41), with subgroup mortality rates of 0 (CCR), 60% (ADF), and 20% (ACF). Diagnosis and treatment are simplest in cases of CCR and the most complicated in cases of ADF.

Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: A systematic review

BACKGROUND

Surgical treatment for mycotic aortic aneurysms is not optimal. Even with a large excision, extensive debridement, in situ or extra-anatomical reconstruction, and with or without lifelong antibiotic treatment, mycotic aneurysms still carry very high mortality and morbidity. The use of endovascular aneurysm repair (EVAR) for mycotic aortic aneurysms simplifies the procedure and provides a good alternative for this critical condition. However, the question remains: if EVAR is placed in an infected bed, what is the outcome of the infection? Does it heal, become aggravated, or even cause a disastrous aortic rupture? In this study, we tried to clarify the risk factors for such an adverse response.

METHODS

A literature review was undertaken by using MEDLINE. All relevant reports on endoluminal management of mycotic aortic aneurysms were included. Logistic regressions were applied to identify predictors of persistent infection.

RESULTS

A total of 48 cases from 22 reports were included. The life-table analysis showed that the 30-day survival rate was 89.6% +/- 4.4%, and the 2-year survival rate was 82.2% +/- 5.8%. By univariate analysis, age 65 years or older, rupture of the aneurysm (including those with aortoenteric fistula and aortobronchial fistula), and fever at the time of operation were identified as significant predictors of persistent infection, and preoperative use of antibiotics for longer than 1 week and an adjunct procedure combined with EVAR were identified as significant protective factors for persistent infection. However, by multivariate logistic regression analysis, the only significant independent predictors identified were rupture of aneurysm and fever.

CONCLUSIONS

EVAR seems a possible alternative method for treating mycotic aortic aneurysms. Identification of the risk factors for persistent infection may help to decrease surgical morbidity and mortality. EVAR could be used as a temporary measure; however, a definite surgical treatment should be considered for patients present with aneurysm rupture or fever.

Endovascular Repair of an Actively Hemorrhaging Aortoduodenal Fistula

Aortoenteric fistulae require urgent definitive intervention and traditionally carry a high mortality. We describe a patient who suffered a traumatic aortic dissection following an auto versus pedestrian collision. He underwent open fenestration of his infrarenal aorta and visceral resection, complicated by abdominal sepsis and enterocutaneous fistulae. One month later he developed massive hematemesis, and endoscopic examination revealed an aortoduodenal fistula. Due to an impassable abdominal wall, a stent-graft repair was performed. This report describes the successful use of endovascular techniques to achieve immediate hemostasis in an actively hemorrhaging aortoduodenal fistula. An endovascular approach provides a valuable option in settings where a hostile abdomen precludes the traditional open technique and may serve as a bridge to later definitive repair.

Endovascular Treatment of a Bleeding Secondary Aorto-Enteric Fistula. A Case Report with 1-Year Follow-up

We report a patient with life-threatening gastrointestinal bleeding caused by a secondary aorto-enteric fistula. Because the patient had several comorbid conditions, we succesfully stopped the bleeding by endovascular placement of a bifurcated aortic stent-graft. The patient developed periaortic infection 4 months later, but he was managed with antibiotics. The patient is well 1 year after the procedure.

Successful Treatment of an Aorto-Ileal-Conduit Fistula with an Endovascular Stent Graft: Report of a Case

A 55-year-old man presented with a massive hemorrhage from the ileal conduit of the left ureter. He had previously undergone a total pelvic exenteration with ileal conduit construction of the ureters due to rectal carcinoma. A right ureteroarterial fistula developed, and he underwent an excision of the right common iliac artery with a femorofemoral bypass and a right cutaneous ureterostomy. Seven months later, a pseudoaneurysm developed at the aortic stump, followed by an aorto-ileal-conduit fistula. The patient was treated successfully with endovascular stent grafting and has since showed a good recovery no sign of graft infection or a recurrence of hematuria at the 10-month follow-up.

Successful Endovascular Treatment of Bleeding Aortoenteric Fistula: A Case Report

Aortoenteric fistula (AEF) is an infrequent but disastrous complication of open abdominal aortic repair. Left untreated, it has a 100% fatality rate. The traditional approaches to the repair of secondary AEF (SAEF) are associated with average mortality rates of 21-59% and numerous major complications. Here, we report a case of acute gastrointestinal bleeding due to SAEF, successfully treated with endovascular stent graft repair. At 1-year follow-up, the patient was doing well without any signs of recurrent fistula. Endovascular treatment of AEF provides another treatment option that may be particularly valuable in patients whose comorbidities would preclude open repair.

Stent-Graft Repair of a Mycotic Ascending Aortic Pseudoaneurysm

A 75-year-old woman with a history of coronary artery bypass surgery complicated by mediastinitis presented with hemoptysis and fever. An enlarging pseudoaneurysm of the ascending aorta was found on computed tomography (CT) and magnetic resonance imaging. After a bypass graft procedure for cerebral and cardiac protection, two endoprosthetic cuffs, which are normally used for proximal abdominal aortic stent-graft extension, were positioned over the pseudoaneurysm neck via right carotid artery access. Blood cultures revealed methicillin-sensitive Staphylococcus aureus, and antibiotic therapy was continued for 6 weeks. Follow-up CT images demonstrated exclusion of the pseudoaneurysm with decrease in size over time. Endovascular stent-graft placement combined with antibiotic therapy may offer an alternative to surgery for the management of mycotic ascending aortic pseudoaneurysm.

Evolving strategies for the treatment of aortoenteric fistulas

BACKGROUND

Aortoenteric fistulas (AEFs) are a rare but often fatal cause of gastrointestinal bleeding. Operative repair of AEF has been historically associated with extremely high morbidity and mortality. We reviewed our experience of open surgical and endovascular treatment of AEF to compare outcomes over a contemporaneous time period.

METHODS

Over a 9-year period between January 1997 and January 2006, 16 patients (11 men and 5 women) were diagnosed with and treated for AEFs. Seven patients underwent open surgical repair, and nine, with anatomically suitable lesions, underwent endovascular repair. The outcome after treatment of these patients was investigated for survival, perioperative complications, length of hospital stay, and long-term disposition.

RESULTS

Three primary and 13 secondary AEFs were treated. The mean time from the initial aortic operation until AEF diagnosis was 5.9 years (range, 0.7-12.2 years) for patients with secondary AEFs. The overall 30-day mortality rate was 18.8%. One intraoperative death and one in-hospital death secondary to multisystem organ failure occurred in patients undergoing open repair. One in-hospital death related to persistent sepsis occurred in the endovascular group. The overall perioperative complication rate was 50.0%. Complications in the open group included sepsis, renal failure, bowel obstruction, and pancreatitis. Complications in the endovascular group were related to persistent sepsis. The mean in-hospital length of stay was significantly longer for patients undergoing open repair compared with endovascular repair (44.0 vs 19.4 days; P = .04). Four (80%) of five patients who were discharged from the hospital in the open group were placed in skilled nursing facilities, and seven (87.5%) of eight patients discharged in the endovascular group returned home. The median overall survival after hospital discharge was 23.1 months. There were no late aneurysm-related deaths or late deaths related to septic complications.

CONCLUSIONS

Patients with AEFs have limited overall survival. Endovascular therapy offers an alternative to open surgical repair, seems to be associated with decreased perioperative morbidity and mortality and a shorter in-hospital stay, and allows for acceptable survival given the presence of coexisting medical comorbidities. Furthermore, endovascular repair provides a therapeutic option to control bleeding and allow for continued intervention in a stabilized setting.

Aortoesophageal Fistula Successfully Treated by Endovascular Stent-Graft

The case of a patient with an aortoesophageal fistula is presented, which was caused by ingestion of a chicken bone and was treated by endovascular stent-graft placement and esophagectomy with early reconstruction. The diagnostic and therapeutic options and challenges encountered in treating an aortoesophageal fistula are discussed.

Stent-Graft Treatment of Infected Aortic and Arterial Aneurysms

PURPOSE

To evaluate the feasibility and effectiveness of endovascular stent-graft repair of infected aortic and arterial aneurysms.

METHODS

Eight patients (5 men; mean age 56.6 years, range 30-85) with infected saccular aneurysms in the brachiocephalic artery (n=1), proximal descending thoracic aorta (n=1), infrarenal abdominal aorta (n=3), common iliac artery (n=1), and common femoral artery (n=2) were treated with stent-graft placement and intravenous antibiotic treatment for at least 6 weeks followed by case-specific administration of oral suppressive antibiotics. All patients were considered to be in the high-surgical-risk group.

RESULTS

Exclusion of the infected aneurysm was successful in all patients. However, 2 patients died within 30 days of uncontrolled sepsis, and 1 patient died at 6 months after rupture of a persistently infected aneurysm (37% mortality rate). Over a follow-up that ranged to 8 years, the 5 survivors showed complete resolution of the infected aneurysms; no stent-graft infection was observed during follow-up.

CONCLUSION

The acceptable technical and clinical success of endovascular aneurysm repair makes this a promising treatment for infected aortic and arterial aneurysms. However, it is crucial that the infection is treated adequately prior to stent-graft placement.

Aortoenteric Fistula After Endovascular Stent Grafting for an Abdominal Aortic Aneurysm: Report of a Case

We report a case of an aortoenteric fistula (AEF) developing after endovascular stent grafting (EVSG) for an abdominal aortic aneurysm (AAA). A 69-year-old male patient with a history of panperitonitis caused by rectal perforation underwent EVSG for an AAA. A follow-up contrast-enhanced computed tomography (CT) scan, done 12 months after the EVSG, confirmed shrinkage of the AAA with no endoleak. However, 19 months postoperatively, an AEF developed between the AAA and the jejunum. Although there was no endoleak on a subsequent CT scan, we noted enlargement of the AAA and inflammatory changes in the surrounding tissue. The patient was treated surgically and discharged in good health 74 days postoperatively. Thus, one should consider the possibility of this devastating complication, even in patients without an endoleak, after EVSG for AAA.

Endovascular Repair of a Bleeding Secondary Aortoenteric Fistula with Acute Leg Ischemia: a Case Report and Review of the Literature

The endovascular approach seems very attractive for patients with bleeding secondary aortoenteric fistulas (SAEF) and limb ischemia, particularly when there is no associated sepsis. Aortic stent-grafting can rapidly seal the aortoenteric communication and ensure limb reperfusion. In the present case, a 53-year-old man with a bleeding SAEF and acute leg ischemia underwent aortic stent-grafting. Ten months later, CT and leukocyte scan (Tc-99m) showed no evidence of graft infection and the patient remains well 18 months postoperatively. In the typical patient with a bleeding SAEF, endoluminal treatment, if feasible anatomically, should be considered as first-choice treatment whether it represents a "bridging" step or a "definite" solution.

Successful management of concomitant aortoesophageal and aortotracheal fistulae secondary to a thoracic aortic aneurysm: Case report and review of literature

Thoracic aortic aneurysm with fistulization into the trachea or the esophagus is usually a lethal complication. An unusual case of combined aortotracheal and aortoesophageal fistulae is presented here. The patient had a successful outcome after resection of the aneurysm with tracheal repair and esophageal resection. A review of literature on this subject is also included in this manuscript.

Staged endovascular stent-grafting and surgical treatment of a secondary aortoduodenal fistula

Secondary aortoenteric fistula is a dramatic, rather infrequent late complication occurring mostly after abdominal aortic surgery. Currently, graft excision and in situ bypass is considered the treatment of choice, but it is associated with significant mortality and morbidity. Herein, we describe the case of a secondary aortoduodenal fistula treated by staged endovascular stent-grafting and surgical closure of the fistula. Forty days after stent-grafting, Tc-99m-HMPAO labelled leukocyte scanning failed to identify leukocyte infiltration of the graft and there were no clinical signs of infection. At 8-month follow up, the patient was asymptomatic.