Endovascular Repair in the Presence of Aortic Infection

Aorto-esophageal Fistula Management

Aorto-esophageal fistula is a rare but life-threatening source of massive upper gastrointestinal bleeding. Prompt diagnosis and intervention are key for patient survival. Treatments consist of aortic resection, thoracic endovascular aortic repair, esophagectomy with diversion, and primary esophageal repair. The appropriate treatment is dependent on patient hemodynamics and fitness and familiarity with operative approaches by the treating team.

Nature always sides with the hidden flaw: importance of the 'aortic team' approach

Blunt thoracic aortic injuries (BTAI) are highly lethal, though their incidence is < 1%. The treatment options for BTAI have evolved over the years, where non-operative management is advised even in grade II injuries. In patients undergoing thoracic endovascular aortic repair, it is of vital importance that the left subclavian artery is revascularized. Many authors have opted for selective revascularization of the left subclavian artery in case of an emergency situation where the clinical condition of the patient is unstable. A joint team effort involving the diagnostic radiologist, cardiologist, interventional cardiologist/radiologist/vascular surgeon, cardiac surgeon and anaesthesiologist, referred to as the 'aortic team', is vital in complex aortic interventions.

Salvaged, Staged, and Safer Management of Aortoesophageal Fistula and Mediastinitis After Removing a Pork Bone: A Case Report

Aortoesophageal fistula (AEF) caused by esophageal foreign body (EFB) ingestion is a life-threatening condition with a very low survival rate. However, the optimal management strategy remains undetermined. Here, we describe our successful management of a patient with AEF and mediastinitis. A 36-year-old man developed persistent chest and back pain and vomited fresh blood three days after removal of a pork bone in the esophagus under endoscopy in a local hospital. Computed tomography (CT) confirmed bilateral pulmonary infections, mediastinitis, and fistula of the aortic arch. After a multidiscipline discussion, a comprehensive staged strategy was made including salvaged thoracic endovascular aortic repair (TEVAR) to control fatal bleeding, adequate mediastinal debridement, drainage with cervical incision, and video-assisted thoracoscopic surgery, as well as jejunostomy to prevent nasal or gastrostomy reflux from aggravating the mediastinal infection. Furthermore, systematic personalized nutrition support and antibiotics were provided. The patient recovered well and has survived for 50 months until now. Careful assessment should be made with CT to ascertain the risk of AEF before and after the removal of EFB. A salvaged staged strategy of TEVAR with adequate mediastinal debridement and drainage in a less invasive approach may be a safer alternative for AEF patients with infections caused by EFB.

Complex Hybrid Repair of a Secondary Aortoenteric Fistula

Background

Secondary aortoenteric fistula is a rare, highly morbid and often difficult to diagnose, cause of gastrointestinal bleeding. It is associated with prior aortic surgery or placement of a synthetic aortic graft. Our case features staged hybrid endovascular stent-grafting, graft excision, aortoplasty using a bovine pericardial patch, extra-anatomical bypass and complex bowel repair.

Case Report

An 82-year-old man presented with gastrointestinal bleeding and Streptococcus Anginosus bacteraemia, with previous aorto-bi-iliac bypass surgery for left common iliac occlusive disease 15 years ago. Computed tomography angiography (CTA), gastroscopy, colonoscopy, capsule endoscopy and enteroscopy identified no bleeding source. Repeat CTA showed gas locules and stranding around the graft and the third part of the duodenum, concerning for fistulous communication. On the next day, a Zenith TX2 thoracic 28x80mm stent-graft was deployed into the infrarenal aorta. On laparotomy, a fistula was present between the Dacron graft and fourth part of the duodenum. The Dacron graft was excised, followed by aortic patching with bovine pericardium. A right-to-left femoral-femoral crossover graft was constructed. CT at one-month post-laparotomy showed no signs of perigraft endoleak and interval resolution of gas locules. He was transferred to a rehabilitation facility on the 34th post-operative day with a multidisciplinary follow-up arranged.

Discussion

Aortoduodenal fistula is a challenging entity to diagnose and should be suspected in patients with GI bleeding and prior aortic surgery. Endovascular repair alone is a less invasive option but with higher re-infection and late failure rates. Liberal use of appropriate imaging modalities, a judicious repair strategy, long-term follow-up and multidisciplinary approach are critical for its management.

Primary aortoesophageal fistula from metallic bristle ingestion

Although many patients are treated for the removal of ingested foreign objects each year, ingestions that perforate the esophagus and lead to intra-abdominal complications are rare. Aortoesophageal fistulas and aortic pseudoaneurysms are deadly complications of esophageal foreign body impaction. However, the surgical approach to aortic repair from foreign object damage has not been standardized. We have described the diagnostic, open surgical, and therapeutic approach to treating a man who had accidentally ingested a 3-cm metallic bristle that lodged in his aortic wall. The patient recovered after excision of the aortic pseudoaneurysm with CryoGraft (CryoLife, Inc, Kennesaw, Ga) replacement, drainage of abscesses, and antibiotic treatment for multiple infections.

A Case of Successful Endovascular Aortic Repair of Primary Aortoenteric Fistula Without Aortic Explantation

PURPOSE

The objective of this study is to report a case of a primary aortoenteric fistula successfully treated with endovascular repair without aortic explant.

CASE REPORT

A 48-year-old man presented with a 24-hour history of hematemesis and malena. A computed tomography (CT) abdomen and pelvis demonstrated a 6 cm infrarenal aortic aneurysm with periaortic stranding and contrast enhancement within the lumen of the third part of the duodenum. The patient underwent emergency Endovascular Aortic Repair (EVAR). The patient was discharged on day 8 of his admission on oral antibiotics. He returned 7 weeks postindex procedure and underwent a laparotomy with omental patch repair of the aortic defect. Intraoperative cultures grew candida albicans, and the patient was discharged on lifelong oral Fluconazole and Amoxycillin-Clavulanic Acid. At 18 months postoperatively, the patient was clinically stable with improved appearances on CT aortogram.

CONCLUSION

We discuss the use of EVAR without aortic explant as a possible treatment option in the management of patient with primary aortoenteric fistulae. This may potentially avoid the significant morbidity and mortality associated with aortic explant in suitable candidates without perioperative signs of sepsis.

Mycotic/Infective Native Aortic Aneurysms: Results After Preferential Use of Open Surgery and Arterial Allografts

OBJECTIVE

Mycotic/infective native aortic aneurysms (INAA) are managed heterogeneously. In the context of disparate literature, this study aimed to assess the outcomes of INAA surgical management and provide comprehensive data in alignment with recent suggestions for reporting standards.

METHODS

A retrospective review of patients presenting with INAA from September 2002 to March 2020 at two institutions was conducted. In hospital mortality, 90 day mortality, overall mortality, and infection related complications (IRCs) were the study endpoints. Overall survival and IRC free survival were estimated, and predictors of mortality tested using uni- and multivariable analyses.

RESULTS

Seventy patients (60 men [86%], median age 68 years [range 59 - 76 years]) were included. Twenty (29%) were ruptured at presentation. INAA location was thoracic in 11 (16%) cases, thoraco-abdominal in seven (10%), and abdominal in 50 (71%). Half of the abdominal INAAs were suprarenal. Two INAAs were concomitantly abdominal and thoracic. Pathogens were identified in 83%. The bacterial spectrum was scattered, with rare Salmonella species (n = 6; 9%). Open surgical repair was performed in 66 (94%) patients, including five conversions of initially attempted endovascular grafts (EVAR), three hybrid procedures, and one palliative EVAR. Vascular substitutes were cryopreserved arterial allografts (n = 67; 96%), prosthesis (n = 2), or femoral veins (n = 1). Kaplan-Meier estimates of overall survival at 30 and 90 days were 87% (95% confidence interval [CI] 76.6 - 93.0) and 71.7% (95% CI 59.2 - 80.9), respectively. The overall in hospital mortality rate was 27.9% (95% CI 1.8 - 66.5). IRCs occurred in seven (10%) patients. The median follow up period was 26.5 months (range 13.0-66.0 months). Chronic kidney disease (CKD) was independently related to in hospital mortality (odds ratio [OR] 20.7, 95% CI 1.8 - 232.7). American Society of Anesthesiologists score of 3 (OR 6.0, 95% CI 1.1 - 33.9), 4 (OR 14.9, 95% CI 1.7 - 129.3), and CKD (OR 32.0, 95% CI 1.2 - 821.5) were related to 90 day mortality.

CONCLUSION

Surgical INAA management has significant mortality and a low re-infection rate. EVAR necessitated secondary open repair, but its limited use in this report did not allow conclusions to be drawn.

Native and prosthetic graft infections of the thoracic aorta: surgical management

 

OBJECTIVES

Infection of the native aorta or after previous open or endovascular repair of the thoracic aorta is associated with high risks for morbidity and mortality. We analysed the outcome after surgical management of a native mycotic aneurysm or of prosthetic graft infection of the descending aorta.

METHODS

From June 2000 to May 2019, a total of 39 patients underwent surgery in our centre for infection of the native descending aorta (n = 19 [49%], group A) or a prosthetic descending aorta [n = 20 (51%), group B]. In the 20 patients in group B, a total of 8 patients had prior open aortic repair with a prosthesis and 12 patients had a previous endovascular graft repair.

RESULTS

The cohort patients had a mean age of 57 ± 14; 62% were men (n = 24). The most common symptoms at the time of presentation included fever, thoracic or abdominal pain and active bleeding. Emergency surgery was performed in 11 patients (28%); 3 patients had emergency endovascular stent grafts implanted during thoracic endovascular aortic repair for aortic rupture before further open repair. The 30-day mortality was 42% in group A and 35% in group B. The 90-day mortality was 47% in group A and 45% in group B. Pathogens could be identified in approximately half of the patients (46%). The most commonly identified pathogens were Staphylococcus aureus in 6 patients (15%) and Staphylococcus epidermidis in 4 patients (10%). Survival of the entire group (including patients with both native and prosthetic graft infections) was 44 ± 8%, 39 ± 8% and 39 ± 8% at 1, 2 and 3 years after surgery. The percentage of patients who survived the initial perioperative period was 81 ± 9%, 71 ± 9% and 71 ± 10% at 1, 2 and 3 years after surgery.

CONCLUSIONS

Patients with infection of the descending aorta, either native or prosthetic, are associated with both high morbidity and mortality. However, patients who survive the initial perioperative period have an acceptable long-term prognosis. In emergency situations, thoracic endovascular aortic repair may help to stabilize patients and serve as bridge to open repair.

A two-stage reconstruction for aortoesophageal fistula after replacement of thoracic aorta for Stanford Type B dissecting aortic aneurysm: esophagectomy and a double-tract reconstruction using the pedicled jejunum: a case report and literature review

An aortoesophageal fistula (AEF) is a rare, potentially fatal condition, and esophagectomy is usually performed simultaneously with aortic surgery. However, esophageal reconstruction method has not been established. This case report describes a two-stage operation for AEF after replacement of thoracic aorta for Stanford Type B dissecting aortic aneurysm. A 61-year-old man who had underwent total arch replacement with frozen elephant trunk for Stanford Type B dissecting aortic aneurysm 3 years ago admitted to the hospital with high fever. Based on the computed tomography and endoscopic findings, he was diagnosed with having aortoesophageal fistula (AEF). After administration of antibiotics with fasting foods and drinks for a month, he underwent the second aortic replacement, thoracic esophagectomy, cervical esophagostomy, gastrostomy and omental wrapping. After 3 months, he underwent double-tract reconstruction using the pedicled jejunal transfer with supercharge and superdrainage via the subcutaneous route. After reconstruction surgery, the patient was doing well. Two-stage reconstruction was a safe procedure for AEF case who underwent aortic replacement, esophagectomy and omental wrapping. The pedicled jejunum reconstruction via subcutaneous route is an optional procedure for second reconstruction surgery.

Aortic injury caused by esophageal foreign body-case reports of 3 patients and literature review

OBJECTIVES

Ingestion of a foreign body can cause different degrees of damage to esophagus, and several complications are potentially life-threatening if not properly handled. The aortic injury caused by a perforating esophageal foreign body is rare but lethal. The optimal management still remains controversial. The purpose of this report is to describe our experience in the management of the aortic injury caused by esophageal foreign body ingestion.

METHODS

Between January 2015 and December 2015, we retrospectively enrolled cases of esophageal perforation involving the aorta by foreign body. The general parameters, esophageal foreign body, types of aortic injury, treatment, and outcome were analyzed. Additionally, we reviewed the literature of the management of esophageal perforation involving the aorta caused by foreign bodies. The study was approved by the ethics committee of the First Affiliated Hospital, College of Medicine, Zhejiang University, and the need for informed consent was waived (Quick review 2019, No. 609).

RESULTS

Three cases of esophageal perforation involving the aorta by foreign body was selected in the study. Two male and 1 female patients (range, 51-58 years old) with the aorta involvement caused by a perforating foreign body in the esophagus in 3 forms were identified, including 1 patient with mycotic aortic pseudoaneurysm, 1 patient with aortoesophageal fistula and 1 patient with the aortic intramural hematoma. One patient died of the rupture of the pseudoaneurysm during the preparation of the surgery. The other 2 patients were cured with a multidisciplinary approach, which is an urgent thoracic endovascular aortic repair followed by mediastinal debridement/drainage or endoscopic retrieval. Two of 3 patients were survived until now.

CONCLUSION

The management of the aortic injury caused by esophageal foreign body injury is challenging. Early diagnosis and multidisciplinary management is crucial.

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.

Successful Endovascular Repair of a Penetrating Aortic Ulcer in Bacterial Aortitis

Infective aortitis (IA) and penetrating aortic ulcer (PAU) impending for rupture represent 2 hostile life-threatening conditions. Simultaneous presentations of these rare entities can be considered an exception. The pleomorphic clinical presentation and the multifactorial etiology require a multidisciplinary approach to reach a correct diagnosis and an urgent treatment. We report the case of a 65-year-old patient presented with acute abdominal pain and septic shock secondary to a bacterial aortitis and penetrating ulcer of abdominal aorta. Unfit for surgery due to severe comorbidities, he was treated by means of a tubular endograft and long-term antibiotic therapy. A rapid improvement of clinical conditions was observed during the subsequent hospital stay. Complete regression of aortic involvement was demonstrated after 1 year. In conclusion, for selected patients affected by IA and PAU an endovascular approach associated to long-term antibiotic therapy may be safe and effective.

Tracheo-Bronchial Obstruction and Esophageal Perforation after TEVAR for Thoracic Aortic Rupture

A 67-year-old man was referred to our hospital for an ascending aortic aneurysm, thoracoabdominal aortic aneurysm and aortic regurgitation. Graft repair of the thoracic aortic arch and aortic valve replacement was given priority and completed, however he developed descending aortic rupture before the second scheduled surgery, and endovascular stent grafting was performed. He subsequently developed tracheobronchial obstruction and esophageal perforation. The patient underwent urgent esophagectomy and enterostomy with continuity later reestablished. However, he died of sepsis 5 months after surgery. Despite the less invasive nature of endovascular treatment, esophageal perforation can nevertheless occur and postoperative vigilance is well warranted.

Therapeutic strategy for treating aortoesophageal fistulas

PURPOSE

The development fistulas between the thoracic aorta and the esophagus are highly fatal conditions. We aimed to identify a therapeutic strategy for treating aortoesophageal fistula (AEF) in this study, by investigating all AEF cases presented in this special symposium at the 65th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery.

METHODS

Forty-seven AEF patients were included in this study. The survivors and nonsurvivors at six and 18 months after diagnosis of AEF were classified into "Group A6", "Group D6", "Group A18", and "Group D18", respectively. Comparisons between Group A6 and Group D6 and between Group A18 and Group D18 were made with regard to therapeutic strategy.

RESULTS

Twenty-two (46.8 %) and 33 (70.3 %) of the 47 patients died within 6 and 18 months, respectively. The patients treated with omentum wrapping (p = 0.0052), esophagectomy (p = 0.0269) and a graft replacement strategy for the aorta (p = 0.002) were more frequently included in Group A6. The patients with the omentum wrapping (p = 0.0174) and esophagectomy (p = 0.0203) and graft replacement were more significantly included in Group A18. The results of the multivariate analysis indicated that the mortality rate at 6 and 18 months after diagnosis was significantly correlated with graft replacement (p = 0.0188) and esophagectomy (p = 0.0257), respectively. There were significant differences in the actuarial survival curves in patients who had omentum wrapping, graft replacement, and esophagectomy compared to patients who did not have these 3 therapeutic procedures.

CONCLUSION

The use of thoracic endovascular aortic repair alone for AEF should not be considered a definitive surgery. In contrast, esophagectomy, open surgery with aortic replacement using prostheses and homografts and greater omentum wrapping significantly improve the mid-term survival of AEF.

Thoracic endovascular aortic repair in management of aortoesophageal fistulas

OBJECTIVE

To provide a systematic review of the outcomes of thoracic endovascular aortic repair (TEVAR) for aortoesophageal fistula (AEF) and to identify prognostic factors associated with poor outcomes.

METHODS

Literature searches of the Embase, Medline, and Cochrane databases identified relevant articles reporting results of TEVAR for AEF. The main outcome measure was the composite of aortic mortality, recurrence of the AEF, and stent graft explantation. The secondary outcome measure was aortic-related mortality.

RESULTS

Fifty-five articles were integrated after a literature search identified 72 patients treated by TEVAR for AEFs. The technical success rate of TEVAR was 87.3%. The overall 30-day mortality was 19.4%. Prolonged antibiotics (>4 weeks) were administered in 80% of patients. Concomitant or staged resection or repair of the esophagus was performed in 44.4% of patients. Stent graft explantation was performed within the first month after TEVAR as a planned treatment in 11.1%. After a mean follow-up of 7.4 months (range, 1-33 months), the all-cause mortality was 40.2%, and the aortic-related mortality was 33.3. Prolonged antibiotic treatment (P = .001) and repair of AEFs due to a foreign body (P = .038) were associated with a significant lower aortic mortality. On univariate analysis, TEVAR and concomitant or staged adjunctive procedures (resection, repair of the esophagus, or a planned stent graft explantation) were associated with a significantly lower incidence of aortic-related mortality (P = .0121). When entered into a binary logistic regression analysis, prolonged antibiotic treatment was the only factor associated with a significant lower incidence of the endpoint (P = .003).

CONCLUSIONS

Late infection or recurrence of the AEF and associated mortality rates are high when TEVAR is used as a sole therapeutic strategy. Prolonged antibiotic treatment has a strong negative association with mortality. A strategy of a temporizing endovascular procedure to stabilize the patient in extremis, and upon recovery, an open surgical esophageal repair with or without stent graft explantation is advocated.

Endovascular treatment of a left subclavian pseudoaneurysm induced by ingestion of a foreign body

Subclavian artery-esophageal fistula is a life-threatening entity. It usually occurs in cases of an aberrant right subclavian artery. A fistula between a non-aberrant subclavian artery and esophagus is extremely rare and difficult to diagnose. It is generally due to ingestion of a foreign body and it is often lethal. We present a case of subclavian artery-esophageal fistula complicated by mediastinitis in a 45-year-old man. The fistula, induced by ingestion of a fish bone, was successfully treated by endovascular stent grafting and left thoracotomy.

Salmonella aortitis treated with endovascular aortic repair: a case report

INTRODUCTION

Salmonella is a typical cause of aortitis, which is associated with high morbidity and mortality. In infrarenal disease, besides open surgery, endovascular aortic repair as an alternative treatment has been reported. To the best of our knowledge, we report the first successful endovascular aortic repair documented by necropsy to date.

CASE PRESENTATION

A 67-year-old Caucasian man presented with low back pain, fever and positive blood cultures for Salmonella Enteritidis. A computed tomography scan showed an enlargement and intramural hematoma of the infrarenal aortic wall; a Salmonella aortitis was suspected and antimicrobial therapy initiated. Because of substantial comorbidities, endovascular aortic repair was favored over open surgery; postoperatively the antibiotic treatment was continued for 12 months. Post-mortem there were neither macroscopic nor microscopic signs of aortitis or graft infection.

CONCLUSIONS

We could demonstrate by necropsy that endovascular aortic repair of infrarenal aortitis with prolonged pre- and postinterventional antibiotic therapy for 12 months was a minimally invasive alternative and should be considered in selected clinically stable patients with substantial co-morbidities.

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.

Aortoenteric fistulae: present-day management

An aortoenteric fistula (AEF) is a communication between the aorta and an adjacent loop of the bowel. The three most useful diagnostic modalities for detecting AEF are abdominal computed tomography scan with intravenous contrast, esophagogastroduodenoscopy, and arteriography. The treatment of AEFs has improved in recent years, but despite the multiple surgical techniques reported, many of the patients do not survive or are left debilitated after treatment. Endovascular repair is an efficient and safe method to stabilize patients with life-threatening AEFs. The aim of this study is to provide a comprehensive and synthetic review of the latest advantages on the diagnosis and management of primary and secondary AEF.

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.

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.

Is Endovascular Stent-Graft Treatment of Primary Aortoesophageal Fistula Worthwhile?

Aortoesophageal fistula (AEF) as a result of prolonged nasogastric intubation is rare and certainly fatal, without prompt surgical intervention. We report the case of a 41-year-old man with morbid obesity who was admitted after suffering 55% of total body surface area burns. After several skin graft operations over the course of 12 weeks, he was rushed into surgery because of the acute onset of severe upper gastrointestinal bleeding. Exploratory laparotomy and esophagogastroduodenoscopy (EGD) suggested an AEF, which was then quickly confirmed by a diagnostic angiogram. An endovascular aortic stent graft repair was performed that successfully stopped the bleeding. We include a review of the literature pertaining to cases of AEF treated by endovascular surgery, which appears to be a promising alternative to open surgery in the unfit patient.

Aortoesophageal fistula secondary to placement of an esophageal stent: emergent treatment with cyanoacrylate and endovascular stent graft

We report on N-butyl 2-cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of an aortoesophageal fistula secondary to placement of an esophageal stent. A 53-year-old man with lung cancer was admitted with massive hematemesis due to the formation of an aortoesophageal fistula 20 days after esophageal stent placement. Injection of N-butyl 2-cyanoacrylate into the aortoesophageal fistula was performed as emergent treatment for this hemodynamically unstable condition, and an endovascular stent graft was subsequently placed via the right femoral artery. The patient was well without hematemesis until he died of pneumonia 45 days later. Cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of massive hemorrhage caused by an aortoesophageal fistula is a prompt, effective method and can be an alternative to surgical repair.

Endovascular treatment of aortoesophageal and aortobronchial fistulae

BACKGROUND

Even when promptly recognized and treated, aortoesophageal (AEF) and aortobronchial (ABF) fistulae are highly lethal conditions. Open surgical repair also carries a high risk of mortality and morbidity. Several alternative strategies have been recently reported in the literature including thoracic endovascular aortic repair (TEVAR). However, relatively little is known about results of TEVAR for AEF and ABF due to their rarity and the lack of large surveys.

METHODS

A voluntary national survey was conducted among Italian universities and hospital centers with an endovascular program. Questionnaires were distributed by e-mail to participating centers and aimed to evaluate the results of endovascular repair of established AEF or ABF.

RESULTS

Seventeen centers agreed to participate and provided data on their patients. Between 1998 and 2008, a total of 1138 patients were treated with TEVAR. In 25 patients (2.2%), the indication to treatment was an AEF and/or an ABF. In 10 of these cases (40%), an associated open surgical procedure was also performed. Thirty-day mortality rate of AEF/ABF endovascular repair was 28% (7 cases). No cases of paraplegia or stroke were observed. Mean follow-up was 22.6 months (range, 1-62). Actuarial survival at 2 years was 55%. Among the 18 initial survivors, five patients (28%) underwent reintervention due to late TEVAR failure.

CONCLUSIONS

Stent grafting for AEF and ABF represents a viable option in emergent and urgent settings. However, further esophageal or bronchial repair is necessary in most cases. Despite less invasive attempts, mortality associated with these conditions remains very high.

Endovascular treatment of an aortobronchial fistula caused by a distal aortic arch mycotic aneurysm: report of a case

We report a case of an aortobronchial fistula causing massive hemoptysis, which was managed by emergency stent grafting. Although this procedure was successful initially, the aortobronchial fistula appeared again 7 months later. Aneurysmectomy, followed by rifampicin-soaked gelatin sealed polyester graft replacement and omentopexy, was performed under cardiopulmonary bypass. The patient, a 73-year-old woman, had an uneventful postoperative course and the infection was eradicated.

Outcomes of thoracic endovascular aortic repair for aortobronchial and aortoesophageal fistulas

PURPOSE

To identify in-hospital and follow-up outcomes of thoracic endovascular aortic repair (TEVAR) for aortobronchial fistula (ABF) and aortoesophageal fistula (AEF).

METHODS

The authors reviewed all published cases of ABF and AEF undergoing TEVAR indexed in the MEDLINE, Cochrane Library CENTRAL, and EMBASE databases. After removal of duplicates, 850 articles were scrutinized for relevance and validity. Exclusion criteria included: (1) no clear description of the organs involved with the fistula, (2) no description of outcomes after TEVAR for ABF or AEF, or (3) no original data presented in the article. In this manner, 66 relevant articles were identified that included original data on 114 patients (76 men; mean age 63+/-1.5 years) with ABF (n = 71) or AEF (n = 43). Meta-analyses were performed to investigate outcomes of TEVAR for ABF and AEF.

RESULTS

Patients with AEF presented more frequently with hypovolemic shock (33% versus 13%, p = 0.012) and systemic infection (36% versus 9%, p<0.001) compared to patients with ABF. In-hospital mortality was 3% (n = 2) after TEVAR for ABF and 19% (n = 8) after TEVAR for AEF (p = 0.004). Additional thoracic surgery in the first 30 days after TEVAR was performed in 3% (n = 2) of ABF patients and in 37% (n = 16) of AEF patients (p<0.001); 12 AEF patients who had received esophageal surgery in the first month after TEVAR showed lower fistula-related mortality during 6 months of follow-up compared to patients who did not receive additional esophageal surgery (p = 0.018).

CONCLUSION

TEVAR is associated with superior outcomes in patients with ABF. Endovascular management of AEF is associated with poor results and should not be considered definitive treatment. TEVAR could serve as a bridge to surgery for emergency cases of AEF only, with definitive open surgical correction of the fistula undertaken as soon as possible.

Acutely Bleeding Aortoduodenal Fistula: Staged Endovascular and Open Surgical Repair

Secondary aortoduodenal fistula is an uncommon but potentially fatal complication that can occur after aortic reconstruction surgery and usually presents with upper gastrointestinal hemorrhage. Taking into account the accompanying multiple comorbidities of those patients, conventional open surgical repair carries with it significant mortality and morbidity rates. The purpose of this case report is to describe the successful combined endovascular and open surgical repair of an acutely ruptured aortoduodenal fistula in a 67-year-old male patient. Four months after the procedure, the patient remains well.

Endovascular repair of mycotic aneurysms of the aorta: An alternative to conventional bypass surgery in patients with acute sepsis

Treatment of mycotic aneurysms of the aorta includes excision of infected tissue followed by anatomic or extra-anatomic bypass. However, operative mortality remains high particularly in elderly patients with comorbidities. We describe here 2 patients with mycotic aneurysms of the descending aorta in whom endovascular repair was successfully performed. In 1 of these patients, stent grafting was attained during the acute, bacteraemic phase of infection. After 12 and 20 months, respectively, of diagnosis, both patients are doing well.

Stent-graft treatment for bleeding superior mesenteric artery pseudoaneurysm after pancreaticoduodenectomy

We report two cases of intraperitoneal bleeding from superior mesenteric artery (SMA) pseudoaneurysm after pancreaticoduodenectomy for pancreatic head carcinoma. In both cases, a stent-graft was deployed on the main SMA to exclude pseudoaneurysm and to preserve blood flow to the bowel. Bleeding stopped after the procedure. One patient was able to be discharged but died from carcinoma recurrence 4 months later. The other patient died of sepsis and stent-graft infection 5 months later. These patients remained free of intraperitoneal rebleeding during the follow-up period.