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

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report

A double secondary aortoenteric fistula (AEF) occurs in a patient who has had significant aortic surgery and is characterized by a direct connection between the gastrointestinal (GI) tract and the aorta at two separate sites.

IMPORTANCE

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula.

CASE PRESENTATION

The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged.

CLINICAL DISCUSSION

Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel.

CONCLUSIONS

An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Secondary aortoenteric fistula possibly associated with continuous physical stimulation: a case report and review of the literature

BACKGROUND

Secondary aortoenteric fistula is a rare but fatal complication after reconstructive surgery for an aortic aneurysm characterized by abdominal pain, fever, hematochezia, and hematemesis, and the mortality rate is high. It has been suggested that it arises due to either continuous physical stimulation or prosthesis infection during primary surgery. We describe an aortoenteric fistula following reconstructive surgery for an abdominal aortic aneurysm together with postmortem pathological findings.

CASE PRESENTATION

A 59-year-old Japanese man who had undergone reconstructive surgery for an abdominal aortic aneurysm 20 months earlier presented with the chief complaint of hematochezia and malaise. Esophagogastroduodenoscopy and total colonoscopy revealed only colon diverticula with no bleeding. Contrast-enhanced computed tomography revealed gas within the aneurysm sac and adhesion between the replaced aortic graft and intestinal tract, suggesting a graft infection. After 18 days of antibiotic treatment, he suddenly went into a state of shock, with massive fresh bloody stool and hematemesis, followed by cardiac arrest. An autopsy revealed communication between the artery and the ileum through an ulcerative fistula at the suture line between the left aortic graft branch and the left common iliac artery. Pathological analysis revealed tight adherence between the arterial and intestinal walls, but no marked sign of infection around the fistula, suggesting that the fistula had arisen due to physical stimuli.

CONCLUSIONS

Pathological analysis suggested that the present secondary aortoenteric fistula arose due to physical stimuli. This reaffirms the importance of keeping reconstructed aortas isolated from the intestine after abdominal aortic aneurysm surgery.

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

OBJECTIVES

To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs).

METHODS

This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type.

RESULTS

Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups).

CONCLUSIONS

Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.

Aorto-enteric fistulas: a physiopathological approach and computed tomography diagnosis

Infection of an abdominal aortic prosthesis with an enteroprosthetic fistula is a very serious, life-threatening complication, leading sometimes to severe functional consequences, the most serious being amputation. Since the symptoms, if there are any, are often rather non-specific, diagnosis is frequently difficult and has always to be based on a whole series of justifications. Early diagnosis is essential and this fistula should be the first possibility considered in a patient with an abdominal aortic prosthesis who is presenting rectorrhagia or melaena (even if only to a slight degree), sepsis and/or abdominal pain. Although rare, the clinical existence of hypertrophic osteoarthropathy may assist diagnosis. A CT scan is the examination of choice, the criteria providing evidence of a fistula being the presence of gaseous images in a periprosthetic fluid collection, thickening and/or retraction of the intestinal walls in contact, the existence of a false aneurysm, and finally, very rarely, extravasation of contrast agent into the intestinal lumen. The differential diagnoses that may mimic a fistula need to be well known, and can include retroperitoneal fibrosis, an infectious aneurysm, inflammatory or infectious aortitis, and above all, a 'simple' prosthesis infection without fistulisation.

Relato de caso de tratamento endovascular de fístula aorto-entérica secundária

O tratamento tradicional da fístula aorto-entérica secundária baseia-se na retirada cirúrgica da prótese, desbridamento aórtico, enxerto extra-anatômico, ou in situ, nos casos em que o campo cirúrgico apresenta-se sem sinais de infecção. Recentemente, alguns autores vêm preconizando o tratamento endovascular em pacientes instáveis e com alto risco cirúrgico. Apresentamos um relato de caso de paciente portador de fístula aorto-entérica secundária tratado inicialmente por via endovascular.

Endovascular management of arterioenteric fistulas: a systemic review and meta-analysis of the literature

PURPOSE

To present a systemic review and meta-analysis investigating the outcomes of endovascular management of arterioenteric fistula (AEF).

METHODS

Literature review on AEF management with endovascular surgery using MEDLINE search, including two cases managed by the authors.

RESULTS

Fifty-nine patients (50 men; mean age 68 years, range 23-90) were identified. AEF was successfully managed in 55 (93%) patients and 30-day mortality was 8.5% (5/59). During follow-up, 10 (19%) patients developed recurrent bleeding, which occurred more often in AEFs due to cancer. The freedom from recurrence rate at 12 and 24 months was 71.5%. Seventeen (32%) patients developed sepsis, which was managed conservatively in 8 (7 successful). Freedom from sepsis at 12 and 24 months was 64%, while the freedom from combined recurrence and sepsis at 12 and 24 months was 59%. Patients who did not have intestinal repair had a higher rate of combined recurrence and sepsis compared to patients who did; the freedom from combined recurrence and sepsis at 12 months was 52% for patients not having intestinal repair versus 100% in patients who did (p = 0.022). Total AEF-related mortality rates at 12 and 24 months were 15% and 19%, respectively, significantly worse when AEF recurred (p = 0.001). Overall survival rates at 12 and 24 months were 68% and 52%; prognosis was worse in patients with perioperative sepsis, large bowel fistulization, tube graft placement, no intestinal repair, and recurrent AEF.

CONCLUSION

Endovascular management of AEF can achieve satisfactory short and midterm results, better than those historically reported for open surgery, despite the high rate of recurrent bleeding and sepsis. Further investigation of the role played by intestinal repair is warranted.

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.

Development of a gastric pouch-aorto-colic fistula as a complication of a revisionary open roux-en-y gastric bypass

A 45-year-old female presented with an enterocutaneous fistula and intraabdominal abscesses weeks after undergoing an open roux-en-y gastric bypass 20 years after a previous bariatric procedure. Initial management consisted of exploration with resection of the fistula, open abscess drainage, percutaneous drains, and culture-directed intravenous antibiotics. Months later, the patient developed a gastrocolic fistula and massive upper gastrointestinal bleeding from a gastro-aortic fistula. The patient underwent resection of the gastrocolic fistula followed by a damage control operation including a left thoracotomy with aortic cross-clamping for the gastro-aortic fistula. Final reconstruction necessitated an extra-anatomic opening in the diaphragm for creation of an intrathoracic esophagojejunostomy and marsupialization of the distal esophagus and gastric pouch with concomitant mucusectomy. This rare but devastating complication requires prompt surgical management. In the appropriate setting, a high suspicion must be maintained in order to act swiftly for the patient's benefit.