Late outcome following open surgical management of secondary aortoenteric fistula

Improved perioperative mortality after secondary aorto-enteric fistula repair and lessons learned from a 20-year experience

BACKGROUND

Secondary aorto-enteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes.

METHODS

We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints.

RESULTS

A total of 57 patients (63% male; n = 36) presented with SAEF (median age, 69 years; interquartile range [IQR], 61-74 years). Median follow-up time was 10 months (interquartile range, 3-21 months. The most common presenting symptoms were gastrointestinal bleeding (60%; n = 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n = 17) underwent extra-anatomic bypass with aortic ligation, 30% (n = 17) rifampin-soaked Dacron graft, 26% (n = 15) femoral vein (eg, neoaortoiliac system), and 14% (n = 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n = 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n = 35). Thirty-day mortality was 35% (n = 20) with no significant difference between 90 days (39%; n = 22) and 180 days (42%; n = 24). Morbidity was 70% (n = 40), with gastrointestinal (30%; n = 17; leak [9%]), pulmonary (25%; n = 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n = 32). One-year and 3-year survival was 54% ± 6% and 48% ± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P = .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P = .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome.

CONCLUSIONS

In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

Emergent percutaneous chimney endovascular aortic repair of a secondary aortoenteric fistula in the setting of a solitary kidney

Secondary aortoenteric fistula is a potentially lethal complication after aortic surgery. Traditional treatment consists of open graft excision with extra-anatomic bypass or in situ reconstruction. Patients who present in extremis, however, are generally poor candidates for re-do open aortic surgery. Endovascular repair has emerged as an alternative treatment modality for patients who would otherwise be unable to tolerate an extended operation. We report here a case of urgent endovascular repair of a juxtarenal secondary aortoenteric fistula via endovascular aneurysm repair with a renal artery chimney in a patient with a solitary kidney who presented in hemorrhagic and septic shock.

Case series of aortoenteric fistulas: a rare cause of gastrointestinal bleeding

BACKGROUND

Aortoenteric fistula (AEF) is a rare cause of gastrointestinal bleeding and is often misdiagnosed in clinical practice. Herein, a case series of AEFs are presented and the clinical characteristics, diagnosis, and management strategies are summarized.

METHODS

A retrospective analysis was performed on consecutive hospitalized patients with a final diagnosis of AEF at Beijing Friendship Hospital, Capital Medical University, between January 1, 2007 and March 31, 2020. The clinical data including diagnostic and management procedures as well as outcomes were collected and summarized.

RESULTS

A total of nine patients were included in this study, five with primary AEF and four with secondary AEF. Eight of the patients were male, and the median age was 63 years. The fistulas were located in both the small intestine and the colon. All patients presented with gastrointestinal bleeding and pain, followed by weight loss, anorexia, and fever. A typical abdominal triad was found in only two cases. Seven patients experienced complications with preoperative abdominal infections and sepsis, and multiple organ failure occurred in four of these patients. All patients were assessed by computed tomography and five underwent abdominal and/or iliac aorta angiography. Two of these patients showed contrast agent leakage from the abdominal aorta into the intestine. Two cases were diagnosed with AEF by endoscopy before the operation. Eight patients received surgery and six patients survived.

CONCLUSIONS

AEF is a rare cause of gastrointestinal bleeding that is associated with high mortality. Gastrointestinal bleeding and pain are the most common presentations. Timely diagnosis and multidisciplinary management are crucial to achieve a positive outcome.

The Herald Bleed: A Case Report of an Aortoenteric Fistula causing an Acute Lower Gastrointestinal Bleed

Aortoenteric fistula (AEF) is a rare life-threatening condition. Secondary AEF (SAEF) occurs in patients with abdominal aortic aneurysm (AAA) repair and has a high mortality rate. We present a case of a 66-year-old female who presented to the emergency room with hematochezia and hemodynamic instability. Emergent esophagogastroduodenoscopy (EGD) was negative. Colonoscopy revealed a 5 cm, pulsatile, bleeding, submucosal mass. A stat computed tomography (CT) angiogram of the abdomen and pelvis revealed a large left external iliac artery (LEIA) pseudoaneurysm. Vascular surgery emergently placed a LEIA stent. It appeared the patient had an aorto-bi-iliac (ABI) common iliac artery (CIA) bypass, 15 years ago, for a large AAA that had resulted in a SAEF, with the rare finding of communication with the colon. She had a complicated course involving surgical and medical management but with successful outcomes.

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.

The Results of In Situ Prosthetic Graft Replacement for Infected Aortic Disease

BACKGROUND

Infected aortic disease is a serious clinical condition associated with significant morbidity and mortality. This study reviewed the outcomes of in situ aortic replacement with a prosthetic graft for infected aortic disease, including primary infected abdominal aortic aneurysms (PIAAA), infected aortic prosthetic grafts (IAPG), and infected aortic stent grafts (IASG).

METHODS

Twenty-eight consecutive patients who underwent in situ aortic replacement with a prosthetic graft for PIAAA, IAPG, and IASG at a single center from January 2001 to December 2015 were retrospectively analyzed. Demographics, clinical characteristics, medical management, surgical procedure, and clinical outcomes were included.

RESULTS

Nineteen patients with a PIAAA, three with an IAPG following open repair of abdominal aortic aneurysm (AAA), and six with an IASG following endovascular aortic repair underwent in situ prosthetic graft replacement with infected tissue and graft removal. In-hospital mortality was 7.1% (2/28). One died of bleeding on postoperative day 12, and the other died of hepatic failure on postoperative day 32. Of six patients with an IASG, two had major complications that were related to barb injury at the proximal aorta. The reinfection rate was 14.3% (4 of 28) during a mean follow-up of 35.7 months (1-142 months). All new grafts of three patients with IAPG were reinfected. The other patient became reinfected after surgery for PIAAA with iatrogenic small bowel perforation that was not detected during surgery.

CONCLUSIONS

In situ graft replacement of PIAAA and IASG is feasible with acceptable outcomes, but the outcome for IAPG is questionable.

A case report of successful treatment of secondary aortoenteric fistula complicated with gastrointestinal bleeding and retroperitoneal abscess in an elderly patient

RATIONALE

The treatment of secondary aortoenteric fistula (SAEF) involves maintaining hemodynamic stability, infection control, revascularization, and surgical repair. Conventional open repair is associated with high mortality, whereas endovascular stent-graft repair is associated with recurrent infection or bleeding.

PATIENT CONCERNS

We report the case of an 85-year-old man with SAEF who presented with gastrointestinal bleeding and retroperitoneal abscess.

DIAGNOSES

He was misdiagnosed for 5 months. SAEF was eventually diagnosed by CT and gastroduodenoscopy.

INTERVENTIONS

The patient underwent hybrid open surgery: extraanatomic left axillofemoral bypass graft reconstruction, exploratory laparotomy, aortic stent graft excision, infrarenal abdominal aortic suture, left common iliac artery ligation, extensive surgical debridement, and retroperitoneal abscess resolution and drainage, along with duodenal defect repair and jejunal feeding tube placement.

OUTCOMES

He survived the complicated surgery and several life-threatening complications with multidisciplinary management. He has kept well for 15 months.

LESSONS

Elderly SAEF patients can undergo open repair when circumstances permit, but multidisciplinary management is crucial.

Imaging work-up and endovascular treatment options for aorto-enteric fistula

Aorto-enteric fistula (AEF) is a rare life-threatening condition. Early recognition and diagnosis are of paramount importance to improve outcome. In this article four cases of AEF with relevant pre- and post-procedural images are presented to demonstrate the utility of cross-sectional imaging in the work-up of AEF. The literature is reviewed to describe the typical presentation of AEF, the diagnostic work-up of AEF, and the different methods used to treat AEF. Endovascular repair of AEF is gaining increasing attention due to its decreased short-term mortality compared to open surgical techniques.

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.

A Case of Primary Aortoenteric Fistula: Review of Therapeutic Challenges

BACKGROUNDS

Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity.

CASE REPORT

A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding.

CONCLUSIONS

Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction.

Critical gastrointestinal bleed due to secondary aortoenteric fistula

Secondary aortoenteric fistula (SAEF) is a rare yet lethal cause of gastrointestinal bleeding and occurs as a complication of an abdominal aortic aneurysm repair. Clinical presentation may vary from herald bleeding to overt sepsis and requires high index of suspicion and clinical judgment to establish diagnosis. Initial diagnostic tests may include computerized tomography scan and esophagogastroduodenoscopy. Each test has variable sensitivity and specificity. Maintaining the hemodynamic status, control of bleeding, removal of the infected graft, and infection control may improve clinical outcomes. This review entails the updated literature on diagnosis and management of SAEF. A literature search was conducted for articles published in English, on PubMed and Scopus using the following search terms: secondary, aortoenteric, aorto-enteric, aortoduodenal, aorto-duodenal, aortoesophageal, and aorto-esophageal. A combination of MeSH terms and Boolean operators were used to device search strategy. In addition, a bibliography of clinically relevant articles was searched to find additional articles (Appendix A). The aim of this review is to provide a comprehensive update on the diagnosis, management, and prognosis of SAEF.

The First Case of a Nellix Sac-Anchoring Endoprosthesis Removal for Aortoenteric Fistula

The Nellix device (Endologix, Irvine, CA), has been designed with a brand new concept to seal the abdominal aortic aneurysms, minimizing endoleaks and reducing reinterventions. We present the first open conversion of a Nellix endograft due to aortoduodenal fistula of a 74-year-old male patient treated for an abdominal aortic aneurysms of 62-mm diameter.

Silver acetate coating promotes early vascularization of Dacron vascular grafts without inducing host tissue inflammation

BACKGROUND

Silver acetate is frequently used as an antimicrobial coating of prosthetic vascular grafts. However, the effects of this coating on the early inflammatory and angiogenic host tissue response still remain elusive. Therefore, the aim of the present in vivo study was to analyze the biocompatibility and vascularization of silver acetate-coated and uncoated vascular grafts during the initial phase after implantation.

METHODS

Two different prosthetic vascular grafts (ie, uncoated Dacron and silver acetate-coated Dacron Silver) were implanted into the dorsal skinfold chamber of C57BL/6 mice (n = 8 per group) to study angiogenesis and leukocytic inflammation at the implantation site by means of repetitive intravital fluorescence microscopy over a 14-day period. At the end of the in vivo experiments, collagen formation, apoptosis, and cell proliferation were analyzed in the newly developed granulation tissue surrounding the implants by histology and immunohistochemistry.

RESULTS

During the initial 14 days after implantation, Dacron Silver exhibited an improved vascularization, as indicated by a significantly increased functional capillary density compared with Dacron. This was not associated with a stronger leukocytic inflammatory host tissue response to the implants. Moreover, silver acetate coating did not affect collagen formation, apoptosis, and cell proliferation at the implantation site.

CONCLUSIONS

Silver acetate coating of prosthetic vascular grafts improves their early vascularization without inducing severe inflammatory side effects. Accordingly, this material modification crucially contributes to an improved incorporation of the implants into the host tissue, which may decrease the risk of vascular graft infection.