Recurrent Aortoenteric Fistula Research Articles

Long-term outcomes of stapled closure of the aortic stump with axillo-bifemoral bypass grafting for abdominal aortic infection

ObjectivesThe stapled suture is used to close the aortic stump during surgery for abdominal aortic infection. The current study aimed to investigate the short- and long-term outcomes of stapled closure of the aortic stump with axillo-bifemoral (AxBF) bypass grafting. MethodsThe short- and long-term outcomes of 11 patients who underwent surgery for abdominal aortic infection were retrospectively analyzed. ResultsOf 11 patients, 7 underwent stapled closure of the aortic stump with AxBF bypass grafting, and four underwent other reconstructive procedures with no aortic stump. Four patients (three who underwent stapled closure of the aortic stump and one who underwent other reconstructive procedures without the aortic stump) had operative death. However, none of the patients had aortic stump blow-out during the same hospitalization for surgery. The 1- and 5-year survival rates of the patients who underwent stapled closure of the aortic stump with AxBF bypass grafting were 57% and 29%, respectively. One patient developed aorto-duodenal fistula at 32 months after surgery. The patient survived for 12 months until bleeding in the recurrent aorto-enteric fistula occurred. ConclusionStapled closure of the aortic stump is durable. The use of a linear stapler is a useful technique for reinforcing the aortic stump in patients who underwent excision of an infected abdominal aortic aneurysm or an infected abdominal graft.

Hybrid Treatment: Expanding the Armamentarium for Infected Infrarenal Abdominal Aortic and Iliac Aneurysms

PurposeTo investigate safety and efficacy of hybrid treatment for infected aortic and iliac aneurysms. Materials and MethodsBetween July 2007 and May 2011, hybrid treatment was performed in 6 male patients (mean age, 67.7 y; range, 57–76 y). Hybrid treatment consisted of extraanatomic bypass (EAB) and isolation of infected aneurysm with vascular plugs. Aneurysms were divided into primary and secondary infected aneurysms. Primary infected aneurysm refers to an aneurysm arising from bacterial infection of the native arterial wall; secondary infected aneurysm refers to infection involving an aneurysm that was previously treated with graft placement. ResultsThe infected aneurysm involved the infrarenal abdominal aorta in 4 patients and common iliac artery in 2 patients. Hybrid treatment was successful in all 6 patients. The 3 patients with primary infected aneurysms required only hybrid treatment, whereas infected graft excision and new graft interposition was performed in 2 of the 3 patients with secondary infected aneurysms. No 30-day mortality or complications were reported. During mean follow-up of 58.6 months (range, 32.6–75.8 months), 1 patient (17%) with a secondary infected aneurysm who did not undergo additional surgery died 32.6 months after hybrid treatment from hypovolemic shock secondary to recurrent aortoenteric fistula. Cumulative survival was 100%, 100%, 83%, and 83% at 3 months, 1 year, 3 years, and 5 years. ConclusionsHybrid treatment appears to be a stand-alone, curative treatment for primary infected aneurysms and serves as bridge therapy to subsequent surgery for secondary infected aneurysms.

Infective Etiology Affects Outcomes of Late Open Conversion After Failed Endovascular Aneurysm Repair

Purpose: To retrospectively review all patients undergoing late open conversion (LOC) after endovascular aneurysm repair (EVAR) in order to identify any clinical or technical predictors of poor outcome. Methods: Twenty-six consecutive patients (24 men; mean age 74.7±8.3 years) underwent LOC between June 2006 and April 2013 at our institution. The mean interval from index EVAR to LOC was 40.4±29.2 months (range 5–93 months). The indication for LOC was endoleak in 14 (54%) patients and infection in 12 (46%): 2 (8%) patients with endoleak had a ruptured aneurysm and 6 (23%) patients with infection had a recurrent secondary aortoesophageal fistula (sAEF). Results: In all 12 cases of infection and in 12 of 14 endoleaks, the entire endograft was explanted. A rifampin-soaked Dacron silver graft was implanted in all patients with infection. Patients with any infection and with recurrent AEF required more blood units than patients with endoleak (6.40 vs. 1.86, p=0.045; 6.76 vs. 1.86, p=0.0036, respectively). Compared with endoleak, the duration of conversions in the setting of infection (274 vs. 316 minutes, p=0.42) and recurrent sAEF (274 vs. 396 minutes, p=0.021) was longer. All patients with recurrent sAEF died at a mean 3.0±2.5 days after LOC from proximal anastomosis disruption and hemorrhagic shock (n=2), myocardial infarction (n=2), acute stroke (n=1), or persistent sepsis (n=1). Perioperative mortality was significantly higher in patients with endograft infection (6/12, p=0.002) and in cases of supraceliac cross-clamping (4/6, p=0.003). The association of infection with supraceliac cross-clamping was a strong predictor for perioperative mortality (p<0.001). Conclusion: In our experience, endograft infection led to greater perioperative mortality after LOC. Recurrent aortoenteric fistula in association with supraceliac cross-clamping is a strong predictor of poor outcome. Patients surviving the perioperative period may have good chances of long-term survival.

Surgery for secondary aorto-enteric fistula or erosion (SAEFE) complicating aortic graft replacement: a retrospective analysis of 32 patients with particular focus on digestive management.

Optimal management of patients with abdominal secondary aorto-enteric fistula or erosion (SAEFE) complicating aortic graft replacement is controversial. The aim of the present study was to report on the postoperative and long-term outcomes of patients operated on for SAEFE. From 2002 to 2012, consecutive patients operated on for SAEFE were identified. All were managed with in situ revascularization by cryopreserved allograft associated with the treatment of the digestive tract involved. Postoperative and long-term outcomes were collected prospectively and analysed retrospectively. A total of 32 patients (median age 65 years) underwent an aortic replacement for SAEFE after a median of 5 years after the initial aortic surgery. Fistula location was duodenal (n = 20), small bowel (n = 6), colonic (n = 5), or gastric (n = 1). Digestive treatment included suture (n = 16), resection with anastomosis (n = 13), and Hartmann's procedure (n = 3). An omentoplasty was performed in 18 patients (56 %), and 17 patients (53 %) had a feeding jejunostomy. Postoperative mortality was 25 %. Among perioperative risk factors, preoperative shock was associated with postoperative mortality (p = 0.009). Among the 24 patients who survived, 15 patients developed 27 postoperative complications (overall morbidity rate of 62.5 %), including six (25 %) patients with severe morbidity (Dindo III-IV). Reoperation was required in five (21 %) patients. During follow-up (median 31 months), no patient developed a recurrent aorto-enteric fistula. Surgery for SAEFE is a major undertaking, with high mortality and morbidity. Excision of the prosthetic graft with cryopreserved allograft replacement and management in a tertiary referral centre with expertise in both vascular and digestive surgery allows good long-term results.

Fistules aorto-intestinales après remplacement prothétique de l’aorte abdominale : résultats chirurgicaux et suivi à long terme chez 32 patients

Management of patients with abdominal secondary aorto-entericfistulae (SAEF) complicating aortic graft replacement is controversial. We retrospectively analyzed the postope- rative and long-term outcomes of all consecutive patients operated on for SAEF betwveen 2002 and2012. All were managed by in situ replacement with a cryopreserved allograft and treatment of the affected digestive tract. Thirty-two patients (median age 65 years) underwent aortic replacement for SAEFa median of 5 years after initial aortic surgery. The fistulae were located in the duodenum (n = 20), small bowel (n = 6), colon (n = 5) or stomach (n = 1). Treatment of the digestive tract included suture (n = 16), resection with anastomosis (n = 12) covered by a defunctioning stoma (n = 1), and Hartmann's procedure (n = 3). Omentoplasty was performed in 18 patients (56 %), and 17 patients (53 %) had afeedingjejunostomy. Eight patients (25 %) died post-operatively, 3 with a recurrent aorto-enteric fistula. Fifteen (62.5 %) of the remaining patients developed 27 complications, including 6 patients (19 %) with severe morbidity (Dindo III-IV). The reoperation rate was 21 %. The median hospital stay was 33 days. During follow-up (median 15 months), no further patients had a recurrent aorto-enteric fistula. We conclude that surgery for SAEF is a major procedure associated with high mortality and morbidity. Good long-term results can be obtained by excision of the prosthetic graft with cryopreserved allograft replacement, and by management in a tertialy referral center with expertise in both vascular and digestive surgery.

Emergent endovascular treatment of a bleeding recurrent aortoenteric fistula as a “bridge” to definitive surgical repair

We report the case of a 59-year-old man who developed a recurrent aortoenteric fistula (AEF) following previous aorto-bifemoral bypass grafting and subsequent AEF open repair with aorto-bifemoral graft excision and extra-anatomic reconstruction. The patient was treated emergently by means of endovascular plug deployment via a left brachial approach into the infrarenal aortic stump, obtaining recovery of hemodynamic stability. Five days later, he underwent elective relaparotomy, aortic plug removal, infrarenal aortic ligature, and duodenal repair. Endovascular strategies to rapidly stop bleeding associated with recurrent AEF may serve as a "bridge" to definitive open repair, as in the case discussed herein. Even if rare, recurrent AEF following previous prosthetic aortic graft excision and extra-anatomic revascularization represents a dreadful event. Since surgical treatment is technically demanding and time consuming in emergent settings, we present an "unconventional" endovascular option to obtain quick cessation of aortic bleeding.

Recurrent Aortoduodenal Fistula

Aortoenteric fistula is defined as a communication between the aorta and an adjacent loop of the bowel and is often the cause of devastating upper gastrointestinal tract bleeding with only few survivors. According to the etiology, the aortoenteric fistulas are classified as primary aortoenteric fistula or secondary aortoenteric fistula (SAEF) after previous aortic surgery. The recurrence of a fistula on a previous SAEF is defined as recurrent aortoenteric fistula and is reported only in a few rare cases occurring within an unpredictable period from the previous surgical treatment. We describe a unique case of recurrent aortoenteric fistula, in which the relationship with recurrence consisted of the presence of the metallic clips of a stapled suture to close the duodenal wall during the previous SAEF repair. A review of the published data on this subject was performed to analyze the clinical features, the overall results, the risk factors of recurrence, and the main technical points of surgical treatment to prevent it.

Recurrent Aortoenteric Fistula

Aortoenteric fistula is a rare but often devastating cause of GI bleeding. It is most commonly the secondary type, when a previously placed abdominal aortic graft erodes into the distal duodenum causing a life threatening GI hemorrhage. Fatality is the rule unless it is recognized early and treated promptly. A recurrent aortoenteric fistula is exceedingly rare with only a handful of cases reported in the medical literature. A 64-year-old woman presented with hematemesis and melena. Medical history was remarkable for an abdominal aortic aneurysm s/p uncomplicated elective graft repair in 1993 with subsequent development of an aortoduodenal fistula in 2000 manifested as severe GI bleeding. This was managed at our institution with emergent surgery (infected graft removal, over-sewing of the aorta, and creation of a axillary-femoral artery bypass) with full recovery. On physical exam the patient appeared comfortable. She was orthostatic and had a clean vertical abdominal scar without a pulsatile mass. Abdomen was soft and not-tender. Emergent EGD utilizing a pediatric colonoscope revealed a significant amount of non-adherent blood clots in the descending duodenum without active bleeding. No lesions or active bleeding sites were identified on the examination. A CT scan and technetium 99m pertechnetate tagged RBC scan revealed active bleeding in the distal duodenum adjacent to an aneurysmal abdominal aortic stump. Emergent laparotomy revealed a large aortic stump pseudoaneurysm with a pin size hole communicating with the distal duodenum. The pseudoaneurysm and duodenum were repaired and the fistulous communication was excised. An omentoplasty was performed in order to buffer the separation between the aortic stump and duodenum. The patient had an uneventful post-operative course and was discharged to a rehabilitation facility twelve days later. This most unusual case highlights the importance of recognizing the clinical presentation of an aortoenteric fistula and how it is an infrequent but often lethal cause of severe GI bleeding. Moreover, although such cases are quite rare, it does not preclude its recurrence. One must approach each patient with severe GI tract bleeding with a broad differential diagnosis keeping in mind both their current risk factors as well as their past history.

Endovascular Repair for Aorto-enteric Fistula: A Bridge Too Far or a Bridge to Surgery?

Purpose To review our experience of endovascular treatment of aorto-enteric fistula (AEF). Methods Between March 1999 and March 2005, 15 patients in five university and teaching hospitals in Belgium and The Netherlands were treated for AEF by endovascular repair. Twelve (80%) were male. The mean age was 67 years. Thirteen (87%) had had previous aortic or iliac surgery, 1.7–307 months before. All patients showed clinical or biochemical signs of bleeding. Eight (53%) were in shock, five (33%) had systemic signs of infection. Eight (53%) patients were treated in an emergency setting. Ten (67%) were treated with an aortouniiliac device, three (20%) with an aortobiiliac device, one with a tube graft and one with occluders only. All patients received antibiotics postoperatively for a prolonged period of time. Results All AEF were successfully sealed, the 30-days mortality was nil. Mean hospital stay was 20 (2–81) days. One patient died 2.7 months later of postoperative complications, one died of lung cancer. Until now, there are no signs of reinfection in four (27%) patients (mean follow-up 15.7 (1–44) months). However, reinfection or recurrent AEF occurred in nine (60%) patients after 9.5 (0.61–31) months. Seven patients were reoperated successfully, two patients died after reintervention. Conclusion Endovascular sealing of AEF is a promising technique, which provides time to treat shock, local and systemic infection, and co-morbidity. This creates a better situation to perform open repair in the future with possibly better outcome. Danger of reinfection remains high. Endovascular sealing of AEF should, therefore, be seen as a bridge to open surgery when possible.

Use of fascia-peritoneum patch as a pledget for an infected aortic stump

Treatment of aortic prosthetic graft infections remains a challenge. One frequently encountered technical difficulty when removing an infected prosthetic aortic graft is how to close a short, friable remnant aortic stump. We present three case reports in which we used a layer of posterior rectus fascia-peritoneum to bolster oversewing a short infected aortic stump after removal of an infected aortic graft. All three patients underwent staged extra-anatomic axillary-to-femoral artery bypass procedures, with subsequent removal of the infected aortic graft as a second operation. Two of the three procedures were semi-elective, and one was done urgently because of a recurrent aortoenteric fistula. All three patients had less than 1 cm of remaining aortic neck below the renal arteries for closure. In each instance a segment of autogenous posterior rectus fascia-peritoneum was harvested and used as a circumferential pledget to bolster the anastomosis. No patient had stump blowout, and in no case was there computed tomography evidence of aneurysmal enlargement of the stump with follow-up of 12 and 24 months in two of the three survivors. Use of autogenous fascia-peritoneum is a durable and effective method to assist stump closure and prevent stump blowout after removal of infected aortic grafts.

Aorto-Enteric Fistula is a Serious Complication to Aortic Surgery. Modern Trends in Diagnosis and Therapy

Secondary aorto-enteric fistula (AEF) is a serious, but rare, complication following surgery of the abdominal aorta. AEF occurs in 0.3–2%, but is associated with a hospital mortality between 25–90%. It is also associated with an important morbidity with a lower limb amputation rate of 9%, and a 15% risk for renewed graft infection. Nine secondary AEF were surgically treated. The hospital mortality was high, 44% (4/9). Recurrent AEF was observed in 1 patient 2 years after the first operation. During follow-up 2 patients had mild infections which were resolved by antibiotic treatment. Diagnostic modalities, and recent advancements in surgical treatment as well as preventive measures are discussed.

Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy

Secondary aorto-enteric fistula (AEF) is a serious, but rare, complication following surgery of the abdominal aorta. AEF occurs in 0.3–2%, but is associated with a hospital mortality between 25–90%. It is also associated with an important morbidity with a lower limb amputation rate of 9%, and a 15% risk for renewed graft infection. Nine secondary AEF were surgically treated. The hospital mortality was high,44% (4/9). Recurrent AEF was observed in 1 patient 2 years after the first operation. During follow-up 2 patients had mild infections which were resolved by antibiotic treatment. Diagnostic modalities, and recent advancements in surgical treatment as well as preventive measures are discussed.

Endovascular Stent Graft Repair of a Recurrent Aorto-enteric Fistula

Aorto-enteric fistulae are uncommon, usually associated with previous aortic surgery, and cause death due to exsanguination unless surgical intervention is successful. However, the mortality and morbidity of open surgical repair for this condition is high. Recurrent aorto-enteric fistulae are rare, and survival unusual. Aortic endovascular stent grafting is now technically feasible, and widely reported for elective repair of abdominal aortic aneurysms. Use of this technique in acute aortic conditions is much less common. We report successful aortic endovascular stent graft repair of a recurrent aorto-enteric fistula, and discuss the significant advantages this procedure offers, particularly in the elderly, as well as the longer term concerns.

Aortic sepsis: Is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.

Aortic sepsis: Is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.

The necessity for long-term antibiotic therapy with positive arterial wall cultures

The results of treatment after excision of infected arterial grafts were analyzed as a function of aortic/arterial wall cultures and duration of antibiotic therapy in 33 patients. Four patients died during surgery and 29 patients were observed for periods ranging from 2 weeks to 76 months. Negative arterial wall cultures (NAwC) were found in 16 patients, three of whom died of multiple-organ failure and sepsis but none of whom had aortic/arterial disruption/hemorrhage. Positive arterial wall cultures (PAwC) were found in 13 patients, seven of whom received short-term, broad-spectrum antibiotics for less than 10 days (PAwC-STA) and six of whom received long-term culture-specific antibiotic therapy (intravenous therapy for 6 weeks and oral therapy for 6 months) (PAwC-LTA). Five of seven patients in the PAwC-STA group died of aortic disruption or hemorrhage, one patient had severe hemorrhage caused by disintegration of a saphenous vein patch over the common femoral artery, and one patient had a recurrent aortoenteric fistula. There were 10 episodes of arterial disruption/hemorrhage in those seven patients. All episodes of aortic/arterial disruption/hemorrhage occurred in the PAwC-STA subgroup (seven of seven patients) and none occurred in the PAwC-LTA subgroup (none of six patients) (0.005 <p < 0.001). The incidence of aortic/arterial disruption/hemorrhage was significantly different between overall PAwC (7 of 13 patients) vs NAwC (none of 16 patients) (0.005 <p < 0.001) and NAwC-STA (none of 16 patients) vs PAwC-STA (seven of seven patients) (0.001 <p < 0.0005). Arterial and graft cultures agreed only 48% of the time (16 of 33 patients) and survival was related to arterial but not graft cultures. These data demonstrate that the risk of arterial/aortic disruption in patients with positive arterial wall cultures after excision of an infected graft is decreased by the long-term use of culture-specific antibiotics.

Secondary aortoenteric fistula: A 20 year experience

During a 20 year period at the Johns Hopkins Medical Institutions, 17 patients were operated on for secondary aortoenteric fistula. The interval from initial operation to the onset of symptoms varied greatly and averaged 2.8 years. Symptoms included not only gastrointestinal bleeding but also sepsis and abdominal or back pain. Associated advanced cardiovascular disease was common. Helpful preoperative diagnostic studies included esophagogastroduodenoscopy, aortography, barium contrast gastrointestinal series and groin sinography. However, a high index of suspicion was the most important element of diagnosis. Overall operative mortality was high (47 percent). All six patients with a graft left in the retroperitoneum had an unsatisfactory result (four instances of recurrent aortoenteric fistula). Successful repair was accomplished only in those patients undergoing graft excision and axillofemoral bypass.