Secondary Aortoenteric Fistula Research Articles

Emergency Endovascular Management of a Secondary Aorto-enteric Fistula: A Case Report

An aorto-enteric fistula (AEF) is an abnormal communication between the aorta and the gastrointestinal (GI) tract. It has traditionally required open surgical repair, but here we report the successful endovascular management of this surgical emergency. A 62-year-old man presented with an episode of collapse associated with meleana. Upper GI endoscopy diagnosed a secondary AEF from a previous aorto-bi-femoral bypass procedure. This was treated successfully with the endovascular deployment of an aorto-uni-iliac stent device. Endovascular repair of AEF can provide a successful bridge to open laparotomy for definitive repair of the affected part of the gastrointestinal tract.

Unusual Delayed Presentation of Secondary Aortoenteric Fistula

Purpose: Aortoenteric fistula (AEF) is an uncommon cause of gastrointestinal bleeding (GIB). Most of the reported cases were between few months to 12 years after surgical repair of the aortic aneurysm (AAA). We report a 71-year-old male who presented with an unusual delayed presentation of AEF 20 years after AAA repair. Case report: A 71-year-old paraplegic Caucasian male with AAA repaired 20 years ago, who was admitted to an outside hospital with melena and hematochezia and was found to be anemic and required blood transfusion. He underwent esophagogastroduodenoscopy (EGD) and small bowel follow through which were unrevealing. The patient undergone capsule endoscopy as outpatient which showed small non-bleeding arteriovenous malformation (AVM), however, the exam was incomplete. He undergone hemorrhoidectomy and then was discharged. Ten days later, he was admitted to an OSH again with hematemesis, hematochezia, hypotension and required transfusion again. He was transferred to our hospital for further care. He continued to have GIB. He underwent a total of four EGDs, one push enteroscopy, colonoscopy, CT abdomen, Aortogram, White blood cell scan, Meckel's diverticulum scan, two angiograms, bleeding scan, and a capsule endoscopy. Despite the extensive work up, the bleeding source remains obscured. Due to a repeated multiple episodes of massive GIB without identifiable source, the surgery team recommended exploratory laparotomy as a final step to evaluate for AEF. During the operation, several adhesions were found between the small bowel and the aorta. While attempting to lyse the adhesions, bleeding started form multiple sites in the aorta. The surgeon failed to stop the bleeding. Unfortunately, the patient exsanguinated on the table due to the massive bleeding secondary to AEF per the operative report. Patient died subsequently. Discussion: AEF is a clinically important and rare cause of GIB. AEF bleeding reportedly occurs in the first week to 14 years post surgical repair, with a mean interval from operation to diagnosis being previously reported at 15 months. We report a case presenting with an unusual delayed presentation of AEF 20 years after AAA repair. Clinicians should always have a high index of suspicion and consider AEF as a differential diagnosis of gastrointestinal bleeding in the sitting of aortic aneurysm.

Hybrid treatment of a post-EVAR aortoenteric fistula

This report presents a case of secondary aortoenteric fistula after endovascular aortic repair in a fragile patient: The fistula developed due to aneurysm shrinkage and remodeling of the stent graft, resulting in a kink eroding through the aneurysm wall into the duodenum. The aortoenteric fistula was successfully treated with a hybrid procedure with endovascular aortic repair, followed by open enteroraphy and omental flap coverage of the stent graft and local antibiotic irrigation. Despite the presence of the stent graft in a previously infected field, the patient has recovered from the acute event with no septic recurrence or hemorrhage during four years of follow-up.

Fístulas aorto-entéricas secundárias – caso clínico

Secondary aorto-enteric fistulas are a rare but potentially fatal complication after abdominal aortic surgery and remain one of the most challenging vascular disease.The authors present a case report of a female patient with past history of aortic reconstruction surgery (aortobifemoral bypass, performed 6 years previously) for treatment of peripheral artery disease, that was admitted in our hospital with a gastrointestinal bleeding. The Dacron® graft of the previous aortic procedure was visualized inside the 3rd portion of the duodenum in an esophagogastroduodenoscopy.A successful axillobifemoral bypass, with segmental duodenectomy, duodenal-jejunal bypass and a partial removal of the aorto-bifemoral was performed.The complications included irreversible ischemia of the right limb followed by above the knee amputation and the patient was discharged after a long hospital stay.

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.

An Iatrogenic Sigmoid Perforation Caused by an Aortobifemoral Graft Mimicking an Advanced Colon Cancer

A 74-year-old man was transferred to our hospital due to melena and syncope. He had a history of an abdominal aortic aneurysm treated with aortobifemoral grafting 15 years previously. One month before admission, he reported several episodes of melena for which he underwent repeated gastrointestinal endoscopic examinations. None of these examinations revealed the site of gastrointestinal bleeding. Aortoenteric fistulae can therefore be missed if they are not considered in the differential diagnosis of gastrointestinal bleeding due to their rarity. As a result, secondary aortoenteric fistulae should therefore be considered in any patient presenting with gastrointestinal bleeding and a history of aortic surgery.

Aortoenteric Fistula Diagnosed by Double Balloon Enteroscopy: A Case Report

A secondary aortoenteric fistula (AEF) is a direct communication between the gastrointestinal tract and the aorta in a patient who has undergone major surgery on the aorta, often an aorta graft operation. We experienced a patient who had undergone graft interposition for abdominal aortic aneurysm and was admitted due to three episodes of hematemesis and following hamatochezia. Gastroscopy, colonoscopy, and radioactive iodine scan failed to identify the bleeding site in the patient. He was diagnosed with AEF by double balloon enteroscopy and recovered after surgical intervention.

Bacakta Masif Apse Formasyonu ile Bulgu Veren Geç Sekonder Aortoenterik Fistül: Olgu Sunumu

Bacakta Masif Apse Formasyonu ile Bulgu Veren Geç Sekonder Aortoenterik Fistül: Olgu Sunumu

Aortic Rupture Long After Repair of Secondary Aortoenteric Fistula due to Graft Infection

Aortic Rupture Long After Repair of Secondary Aortoenteric Fistula due to Graft Infection

Incidental Detection of Gastrointestinal Bleeding From an Aortoenteric Fistula on 99mTc Leukocyte Scintigraphy

A 50-year-old-man with abdominal pain, who had undergone aortic aneurysm reconstructive surgery (aortic graft) 3 years before, was admitted to the hospital. A CT scan showed findings suggestive of perigraft infection. Scintigraphy with 99mTc-hexamethylpropylene amine oxime (HMPAO)-labeled leukocytes confirmed the diagnosis of aortic graft infection and documented an active concurrent bleeding in the gastrointestinal tract from a secondary aortoenteric fistula. This case illustrates the diagnosis of the precise location of the source of bleeding from aortoenteric fistula by leukocyte scintigraphy. The images aided the surgical team by revealing the aortic site of bleeding and the severity of the problem.

A Case of Secondary Aortoenteric Fistula with Herald Bleed and Sepsis

A Case of Secondary Aortoenteric Fistula with Herald Bleed and Sepsis

In-Situ Revascularisation for Secondary Aorto-enteric Fistulae: The Success of Silver-coated Dacron is Closely Linked to a Suitable Bowel Repair

In-Situ Revascularisation for Secondary Aorto-enteric Fistulae: The Success of Silver-coated Dacron is Closely Linked to a Suitable Bowel Repair

In-Situ Revascularisation for Secondary Aorto-enteric Fistulae: The Success of Silver-coated Dacron is Closely Linked to a Suitable Bowel Repair

ObjectivesThe purpose of this study was to assess short- and mid-term results of in-situ revascularisation (ISR) using silver-coated Dacron prostheses and bowel repair for management of secondary aorto-enteric fistulae (SAEF). DesignSingle-centre retrospective chart review. Material and methodsThis study includes all the patients treated by ISR using silver-coated Dacron for SAEF between 2006 and 2010. Primary end points were mortality and survival rates. Secondary end points were reinfection-free survival and secondary patency rates. ResultsEighteen male patients with SAEF with a median age of 64 years were operated by ISR using silver-coated Dacron during the study period without operative death. The 30-day mortality was 22% and the in-hospital mortality rate was 39%. Indeed, during hospitalisation, a duodenal leak was observed in four patients including three who died. Four others patients died due to multi-system organ failure. Median follow-up was 16 months (range 1–66). The survival rate at 12 months was 55%. One duodenal leak was observed leading to death. The reinfection-free survival and the secondary patency rates at 12 months were 60% and 89%, respectively. ConclusionIn-situ revascularisation with silver-coated Dacron provides acceptable results in terms of mortality. This treatment may be useful for simple vascular reconstruction and allow greater attention to bowel repair that is a determinant in short- and mid-term survival.

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.

Serie de casos. Experiencia de un único centro en el tratamiento de fístulas aortoentéricas

ObjectiveTo analyse our experience and results of a rare, complex and serious disease, aortoenteric fistula (AEF). Material and methodsNine patients (seven males and two females) with secondary aortoenteric fistula treated during the period 2000-2010, were grouped according to hemodynamic stability: stable three males. Four males and two females were unstable.Previous aortic pathology and its treatment were: four Leriche syndrome, two aortic aneurysms and a ruptured aortic aneurysm treated by aortobifemoral bypass and two EVAR (endovascular aneurysms repair). Other data collected: cardiovascular risk factors, previous abdominal pathology and its surgery, the location of the secondary AEF, period of time until the appearance of AEF, evolution and recurrence. ResultsThe secondary AEF appeared after a mean time of 85.8 months (median 104, range 5-204). Four were treated with extra-anatomical bypass, and three were unstable. Three patients with in situ repair, two unstable. Two with endograft, one unstable. There was one death during surgery, unstable, and during the first 30 days, four patients died, 3 unstable, one stable. The four surviving patients had a recurrence of the AEF after a mean of three months (range, 2-5), only two were treated, one patient with endograft and one with axilobifemoral bypass. ConclusionsSecondary AEF is a serious, rare and complex complication, with high morbidity and mortality. No standard treatment exists, although the urgent treatment of bleeding is essential, including endovascular therapy, with or without a new intervention for definitive treatment.

Contemporary management of infrarenal aortic graft infection: early and late results in 82 patients

Management of aortic graft infection (AGI) remains contentious. The purpose of this study was to evaluate factors of clinical significance which influence the outcome of different treatment modalities for AGI. From 2000 to 2008, 82 consecutive patients were treated for AGI. In situ reconstruction (ISR) was performed in 63 patients with various conduits, extra-anatomic reconstruction (EAR) in 11, conservative treatment in five and resection without reconstruction in three. The perioperative mortality rate for the series (33%) was similar for EAR and ISR and was higher in patients with secondary aortoenteric fistula (P < 0.001) in those undergoing emergency aortic reconstruction (P < 0.001) and in AGI caused by virulent organisms (P < 0.05). Fifteen (27%) of the surviving patients developed a recurrence of infection (RI). EAR patients were more exposed to RI (P < 0.04). In conclusion, ISR may be more appropriate for AGI, but this study cannot draw a conclusion relating to the optimal conduit for ISR.

Aortoenteric Fistula Treated With Endovascular Aortic Stent-Graft and Bilateral Chimney Stent-Grafts to Renal Arteries

We report a patient with secondary aortoenteric fistula (AEF) presenting with a rectal bleeding. The patient had multiple comorbidities, precluding major open vascular surgery. We opted to perform a two-stage procedure, where an endovascular stent-graft was first deployed to exclude the AEF from the systemic circulation. As the AEF was at the proximal anastomosis of the previous Dacron graft and close to the renal artery ostia, chimney stent-grafts were placed in both renal arteries to maintain their patency. The second stage of the procedure involved a laparotomy to repair the defect in the duodenum to prevent further contamination from bowel contents.

Secondary Aortoenteric Fistula: A Case Report of Acute Aortic Occlusion Following Cellulitis

A secondary aortoenteric fistula is a relatively rare complication of abdominal aortic reconstruction. The clinical manifestation of aortoenteric fistula is usually upper gastrointestinal bleeding. We report a patient who developed acute aortic occlusion following chronic cellulitis, which is an uncommon finding. A 50-year-old man with a history of aortobifemoral bypass grafting was admitted for tiredness, fever and swelling of his right leg. On the 40th day of admission, he developed acute aortic occlusion. Computed tomography revealed right distal aortic graft occlusion and the presence of gas surrounding the graft. Gastroduodenoscopy showed an underlying Dacron graft consistent with an aortoenteric fistula in the third part of the duodenum. We excised the infected graft and reconstructed the abdominal aorta with a new prosthetic graft in situ, which was wrapped with the vascularized pedicle of the omentum. The duodenal defect was repaired with segmental duodenal resection and end-to-end anastomosis. The patient recovered well after surgical management and has remained in good condition for 2 years without developing any signs of recurrence of infection.

Early and Late Results of Contemporary Management of 37 Secondary Aortoenteric Fistulae

Early and Late Results of Contemporary Management of 37 Secondary Aortoenteric Fistulae

Herald Bleeding: A Diagnosis of Aorto-Duodenal Fistula Treated with Graft Within a Graft Repair

Purpose: Introduction: An aortoenteric fistula is a communication between the aorta and an adjacent loop of the bowel. Secondary aortoenteric fistula is an uncommon but very important complication of abdominal aortic reconstruction. Herald bleeding sometimes precedes a catastrophic bleed. We report a case with this rare complication with typical herald bleeding treated with endovascular graft repair. Case report: An 80-year-old Caucasian male with a history of abdominal aortic aneurysm repair 18 years ago with a tube graft, presented with back pain, and vomiting “bloody slime.” He was on aspirin, but denied taking non-steroidal anti-inflammatory drugs or blood thinners. On examination, he was afebrile, his heart rate was 108/min and blood pressure was 101/53 mm Hg. His hemoglobin was 6.4 g/dL. He received packed red cells transfusion. An endoscopy was performed which revealed a large adherent clot in the third portion of the duodenum. This was not removed as there was a concern for aorto-enteric fistula. A review of previous CT scan revealed a closely adherent tube graft to the duodenum. Patient was deemed to be a poor surgical candidate and an endovascular graft repair was performed using a stent graft with CO2 angiography. A repeat upper endoscopy after removal of the adherent clot showed the previous aortic graft eroding through the duodenal wall, but there was no active bleeding. Patient had no further episodes of bleeding and was discharged with a close follow up. Discussion: Aorto-duodenal fistulas (ADF) after endovascular abdominal aneurysm repair are rare. Secondary ADF is an uncommon (0.3-2%) and life-threatening, long-term complication of aortic reconstructive surgery. The classic presentation of an aortoduodenal fistula is that of a “herald bleed” (brief, with spontaneous resolution), followed anywhere from hours to weeks later by a massive upper gastrointestinal bleed. Untreated cases have a mortality rate of up to 100%. In our patient, intermittent hematemesis was a warning symptom. Though laparotomy with repair is the treatment of choice, our patient was treated with graft within a graft repair in view of the comorbidities. In summary we report a rare case of aorto-duodenal fistula treated with endovascular graft repair.Figure: Visible aortic graft in the duodenum.