Secondary Aortoenteric Fistula Research Articles

Secondary Aortoenteric Fistula Presenting as Recurrent Bacteremia

Secondary Aortoenteric Fistula Presenting as Recurrent Bacteremia

Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak

An 84-year-old female was lost to follow-up after endovascular aneurysm repair at another hospital with known type II endoleak. She later presented with presyncope and hematemesis. A referral center esophagogastroduodenoscopy showed possible duodenal diverticulum. She had recurrent symptoms and repeat computed tomography scan showed air within the aortic sac. At our center, she underwent stent graft explantation and axillofemoral reconstruction for a primary aortoenteric fistula. She was discharged and is doing well 5 months postoperatively. A high degree of suspicion for aortoenteric fistula is imperative in any patient with upper gastrointestinal hemorrhage after open or endovascular abdominal aortic aneurysm repair.

Late outcome following open surgical management of secondary aortoenteric fistula

We reviewed the perioperative and long-term outcomes after the surgical management of secondary aortoenteric fistulas. Over a 20-year period (1989-2009), 48 patients (33 men and 15 women; mean age, 64years) were treated for secondary aortoenteric fistulas (SAEF). Most of the patients presented with symptoms of gastrointestinal bleeding (42 cases), or of serious septicaemia and general septic conditions (19 cases). Twenty-eight patients (58.3%) required an emergency procedure and were admitted with an unstable hemodynamic status. Repairs were accomplished by graft removal and an axillobifemoral bypass (n = 11), in situ reconstruction with a silver-impregnated prosthetic replacement (n = 21), a Dacron graft replacement (n = 7), a cryopreserved homograft replacement (n = 8) or an in situ deep vein replacement (n = 2). Early perioperative (<30day) mortality was 45.8%. There was a significant difference in the mortality rates between patients who had an emergency procedure (59.2%) and patients who underwent urgent (38.0%) operations (p < 0.04). The average follow-up period was 48.6 ± 16months. There were eight late deaths; three of which were related to the SAEF treatment. The cumulative mortality rate was 34% at 3years. The in situ silver graft replacement group cumulative survival rate was 72% at 3years. No significant difference was observed in mortality on the complete or partial graft removal. Six late graft failures occurred; four of them resulted in amputation and three of them were associated with a recurrent infection. Freedom from amputation was 76.5% at both 3 and 5years. Late infections occurred in six patients. Freedom from recurrent infection was 80.8% and 81.4% at 3years in the whole study group and in the in situ silver graft group, respectively. The infect free rate at 3years was the same compared the complete or partial graft removal The long-term outcomes associated with aortoenteric fistula repair might be favourable when silver-impregnated grafts were used as an in situ strategy. The eradication of infection is possible in mid-term follow-up with partial graft replacement, which associated with a lesser operative load.

Successful treatment of secondary aortoenteric fistula with a Valdoni-Strong’s procedure

Secondary aortoenteric fistula is one of the important causes of gastrointestinal bleeding following synthetic graft repair of the abdominal aorta. Secondary aortoenteric fistula is frequently observed after an aneurysm repair (from 0.3 up to 2% in the first 5 years), and associated with high rates of mortality and morbidity. The diagnosis of secondary aortoenteric fistula can be difficult. In this article, we present a case of gastrointestinal bleeding due to secondary aortoenteric fistula, successfully treated with Valdoni-Strong's procedure.

Secondary aorto-enteric fistula - still a devastating complication of major vascular surgery

Despite advances in vascular surgery and intensive care, secondary aorto-enteric fistulas (AEF) remain a serious threat of major vascular interventions. This report summarizes our experience in the treatment of this condition. Nineteen patients with secondary AEF admitted between Jan 2004 and Dec 2008 were prospectively enrolled into this cohort observational study. Nine of them presented with massive gastrointestinal bleeding and hemorrhagic shock. None of the patients died preoperatively. Graft in situ replacement was performed in eight patients (42 %), extraanatomic repair in five (26 %), proximal anastomotic reconstruction in five (26 %) and aortic stump closure in one (5 %). One patient died during the operation. Twelve other patients died during hospitalization (days 1 - 100 postop). Complications occurred in 83 % of patients surviving the operation. During follow-up two further patients died suddenly, both probably due to recurrence of fistula. Overall mortality was 79 %. Four remaining patients are alive and without signs of graft infection at a mean follow-up of 45 months (34 - 57). AEF treatment still carries a significant mortality and morbidity. It seems that extraanatomic reconstruction is the best possible therapeutic modality provided the patient's condition allows for a prolonged operation. We advise cautious use of the silver-coated polyester prostheses for "in situ" reconstructions in cases with AEF.

Open or Endovascular Repair of Secondary Aortoenteric Fistulae?

Secondary aortoenteric fistula (AEF) complicate 0.3e2.5% of all open aortic surgical procedures, with the incidence being lower following endovascular aortic aneurysm repair. It is, however, one of the most dangerous complications for a patient to encounter, with the highest mortality rates being observed in patients presenting with massive haemorrhage. In the past, patients with secondary AEF have usually been treated with total graft excision and either oversewing of the aortic stump and extra anatomic revascularisation or in-situ replacement with a rifampicin bonded prosthesis or (less commonly) deep venous conduits. Because of the considerable morbidity and mortality associated with these difficult and prolonged redo open procedures; the emergence of an endovascular solution has been actively welcomed. There are considerable theoretical attractions associated with the endovascular treatment of secondary AEF, most notably; reduced physiological stresses to the patient, shorter operating times, less trauma and reduced transfusion requirements, all of which translate into lower mortality and morbidity. However, following the publication of several small case series from around the world, there are now concerns that while the endovascular treatment of AEF may confer better short term outcomes, this may come with a heavy price in the long term. In effect; the endovascular treatment of secondary AEF may

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.

Challenging Treatment of Two Secondary Aortoenteric Fistulas in the Same Patient

Challenging Treatment of Two Secondary Aortoenteric Fistulas in the Same Patient

Secondary Aortoenteric Fistula Presenting with Recurrent Episodes of Sepsis

Secondary Aortoenteric Fistula Presenting with Recurrent Episodes of Sepsis

Gastrointestinal: Aortoenteric fistula

A 65 year old man with diabetes mellitus and hypertension, presented with recurrent hematemesis and melena of 20 days’ duration requiring multiple blood transfusions. Physical examination was unremarkable except for pallor. An upper gastrointestinal endoscopy up to the duodenojejunal flexure and a colonoscopy were performed and found to be normal. He underwent a contrast enhanced computed tomogram (CECT) of the abdomen. The CECT of the abdomen revealed an atherosclerotic aortic aneurysm adherent to the third part of duodenum and adjacent inferior vena cava suggesting an aortoenteric fistula missed on endoscopy (Figure 1A and 1B). He was considered a high risk candidate for surgery and therefore was subjected to endovascular stent graft placement (Advanta V12 covered stent 16 mm × 61 mm, Atrium; Figure 2A and 2B). He did not develop any further bleeding following discharge from hospital. Contrast enhanced computed tomogram (axial image) showing A) an atherosclerotic aortic aneurysm adherent to the inferior vena cava (arrow) and B) The aneurysm is seen adherent to the 3rd part of duodenum (arrow). Digital subtraction angiogram of the abdominal aorta showing A) the aneurysm (arrow) prior to stenting and B) the aneurysm being excluded after stenting. Aortoenteric fistulas are a rare cause of acute gastrointestinal (GI) hemorrhage, but they are associated with high mortality if undiagnosed or untreated. The third portion of the duodenum is the most common site for aortoenteric fistulas. Most patients present with an initial ‘herald’ hemorrhage that is manifested by hematemesis, melena or hematochezia. This may be followed by massive bleeding and exsanguination. The classic presentation is that of an elderly patient with massive upper GI hemorrhage, a pulsatile abdominal mass and abdominal (or back) pain. However, this triad is present in only 11% of patients. Our case was unusual with respect to the intermittent character of the hemorrhage lasting for almost a month. Intermittent bleeding is possible when a blood clot temporarily seals the fistula. A negative upper GI endoscopy can be explained by thrombus formation, presence of a tiny fistula or hypotension. The most common cause of primary aortoenteric fistulas is an atherosclerotic aortic aneurysm (as was seen in our case); other causes include infectious aortitis due to syphilis or tuberculosis. Secondary aortoenteric fistulas are caused by a prosthetic abdominal aortic vascular graft eroding into the duodenum, penetrating duodenal ulcer, tumour invasion, trauma, radiation therapy, and foreign body perforation. CECT of the abdomen is helpful with a detection rate of 30–61%. Surgery is generally the preferred mode of treatment. Age and major coexisting illnesses increase the morbidity and mortality associated with surgery. The advent of interventional radiology and endovascular stent graft placement has resulted in a quicker, safer and more successful management of this life threatening entity. Contributed by

Secondary aortoenteric fistula treated by right subclavian-bifemoral bypass

Secondary aortoenteric fistula treated by right subclavian-bifemoral bypass

Secondary Aortocolic Fistula: Case Report and Review of the Literature

A secondary aortoenteric fistula (SAEF) is relatively rare after abdominal aortoiliac reconstructive surgery. Most SAEFs are associated with a graft prosthesis, and rectum involvement is rarely reported. We report a rectal SAEF after aortoiliac aneurysmorrhaphy, i.e., oversewing the artery without a graft. A 62-year-old man had an appendicitis-related infected right common iliac artery aneurysm and sterile left aortoiliac arterial aneurysm. Six weeks after an appendectomy with a right iliac aneurysmectomy, left aortoiliac reduction aneurysmorrhaphy, and femorofemoral bypass grafting, he developed repeated bloody stool. Abdominal computed tomography and colonoscopy findings strongly indicated communication between the native aortic or iliac arteries and the rectal lumen. Emergency surgery-left infected aortoiliac artery excision, oversewing the aortic stump, right axillofemoral bypass, and sigmoid protectomy with an end-colostomy-was performed. Unfortunately, the aortic stump developed a pseudoaneurysm 6 weeks after the second laparotomy. During the third emergency laparotomy, more of the stump was amputated and wrapped in the omentum. At 45-month follow-up, the patient was well and without infection recurrence or leg ischemia. This case is a reminder that even patients without a graft prosthesis are at risk for SAEF after any aortoiliac surgery. We also comprehensively reviewed the English literature from 1960 to 2008 on prosthesis-free SAEF patients.

Response to Letter to the editor re: ‘Aortic and Oesophageal Endografting for Secondary Aorto-enteric Fistula’

Response to Letter to the editor re: ‘Aortic and Oesophageal Endografting for Secondary Aorto-enteric Fistula’

Endovascular treatment of a bleeding secondary aortoenteric fistula in a high-risk patient

We report a patient with life-threatening gastrointestinal bleeding caused by a secondary aortoenteric fistula (AEF). Because the patient had severe medical comorbidities, an endovascular approach was chosen for hemorrhage control. Endovascular treatment of aortoenteric fistula provides another treatment option that may be particularly valuable in patients whose comorbidities would preclude open repair.

Secondary Aortoenteric Fistulas Versus Paraprosthetic Erosions: Is Bleeding Associated with a Worse Outcome?

Direct communication between an aortic prosthesis and the gastrointestinal (GI) tract may present with GI bleeding (aortoenteric fistulas [AEF]) or be incidental to a graft infection (paraprosthetic erosions [PPE]). The purposes of this study were to compare the outcomes of AEF versus PPE and to determine predictors of mortality associated with these lesions. Since 1992, 38 patients (23 men, 15 women; mean age 67 years) presented with AEF (n=16) or PPE (n=22). After complete graft excision, 26 patients (8 AEF, 18 PPE) underwent in situ revascularization using femoral vein (n=24) or rifampin-soaked prosthetic graft (n=2); 12 (8 AEF, 4 PPE) underwent extraanatomic bypass. There was no significant difference in mortality for AEF versus PPE (38% versus 36%). Postoperative complications developed in 25 (66%) patients, including 10 (26%) with GI complications requiring reintervention (5 colon necrosis, 5 duodenal bleed or leak). There were no differences between AEF and PPE in operative transfusions, operative times, GI complications, ICU stay, hospital stay, or final discharge status. Multivariate stepwise logistic regression analysis revealed that GI complications (odds ratio [OR], 52.5; 95% CI, 3.5 to 781; p=0.004) and age (OR, 1.2; 95% CI, 1.02 to 1.3; p=0.026) were the only independent predictors of in-hospital mortality. Surgical management of AEF and PPE should be tailored to patient illness and the extent of graft infection. Mortality from both lesions is dependent on patient and technical factors, not on the mode of presentation.

Secondary Aortoenteric Fistula in a Patient with Behçet Disease: Successful Surgical Treatment by Direct Suture and Use of Omental Flap

The aim of this report is to present a patient with Behçet disease who developed massive lower gastrointestinal tract bleeding owing to aortoenteric fistula after abdominal aorta graft reconstruction. A 34-year-old male with a history of Behçet disease for 8 months underwent surgery owing to massive hematochezia and hemodynamic instability. A fistula was observed between the proximal small intestinal segment and the aortic graft (proximal anastomosis) at the infrarenal level. The prosthesis was not removed but was wrapped with the vascularized pedicle of the omentum that passed through the mesentery of the transverse colon. The patient was discharged on the fifty-ninth day. At the 15-month follow-up appointment, the patient was in excellent condition. Although our surgical choice was not a standard approach for this type of aortoenteric fistula, it was a lifesaving procedure in our patient.

Aortofemoral graft limb–to–colon paraprosthetic fistula

A 58-year-old man presented with fever. During several hospitalizations in the preceding 3 months, bacteremia had been documented on seven occasions. Escherichia coli, Clostridium, and Candida spp were repeatedly recovered in blood cultures. The patient’s history was pertinent for tobacco abuse and severe claudication, which was initially treated with femorofemoral bypass graft. This failed, however, which prompted conversion to an aortobifemoral bypass (performed elsewhere), with resultant complete relief of claudication. The patient denied abdominal pain and had no evidence of overt or occult gastrointestinal (GI) bleeding. Fever and malaise persisted for 3 months. Abdominal computed tomography (CT) scans were performed on two occasions, and the results interpreted as negative. The Vascular Surgery Service was ultimately consulted and determined the patient’s clinical history and CT were highly suggestive of a secondary aortoenteric fistula (SAEF) involving the left aortobifemoral graft limb and the colon (A, arrow). The graft body, right limb, and both femoral regions appeared to be free of infection. An indium-111 white blood cell scan suggested isolated left midprosthetic limb involvement (B, arrow), and colonoscopy unequivocally established the diagnosis (Cover). Single-stage redo femorofemoral bypass and left aortofemoral graft limb excision was performed. At laparotomy, the left graft limb was densely incorporated to adjacent tissues, without gross contamination. The limb was transected and oversewn proximally. When followed distally, it was noted to traverse the sigmoid colon (C). Partial sigmoid resection with primary anastomosis was performed. The patient has since done well, without evidence of recurrent infection and with patent vascular reconstructions. SAEF is a direct communication between a vascular prosthesis and the GI tract. Most aortoenteric fistulas involve the graft-aortic suture line, with fistulization into the bowel lumen and resultant GI hemorrhage. A less common type of fistula, termed a paraprosthetic fistula, is defined as a communication between the surface of the graft body and the bowel lumen without suture line involvement or actual fistulization into the vascular lumen. The duodenum is the most frequently involved bowel segment for both types of SAEFs. Graft-colonic fistulae are much less common, comprising only 4.8% to 6.6% of cases in reported SAEF series. Because they do not involve the anastomosis, paraprosthetic fistulas do not result in GI hemorrhage, but rather sepsis, malaise, and other less specific symptoms. In patients who do not require emergency intervention, CT is the recommended initial diagnostic study of choice whenever SAEF is considered. A positive indium-111 white blood cell scan supports the diagnosis of SAEF. Endoscopy can be a definitive diagnostic tool, but may also serve to exclude other pathology in patients with GI bleeding. Traditional therapy for SAEF, especially for aortoduodenal fistula, is GI tract restoration, complete prosthetic graft excision, aortic stump closure, and extra-anatomic bypass. More conservative approaches such as partial graft preservation, excision of the involved limb, and extra-anatomic bypass, as used in this patient, are simpler, effective, and have potentially less morbidity in carefully selected, high-risk patients.

Endovascular Management of Acute Bleeding Arterioenteric Fistulas

The objective of this study was to review the outcome of endovascular transcatheter repair of emergent arterioenteric fistulas. Cases of abdominal arterioenteric fistulas (defined as a fistula between a major artery and the small intestine or colon, thus not the esophagus or stomach), diagnosed over the 3-year period between December 2002 and December 2005 at our institution, were retrospectively reviewed. Five patients with severe enteric bleeding underwent angiography and endovascular repair. Four presented primary arterioenteric fistulas, and one presented a secondary aortoenteric fistula. All had massive persistent bleeding with hypotension despite volume substitution and transfusion by the time of endovascular management. Outcome after treatment of these patients was investigated for major procedure-related complications, recurrence, reintervention, morbidity, and mortality. Mean follow-up time was 3 months (range, 1-6 months). All massive bleeding was controlled by occlusive balloon catheters. Four fistulas were successfully sealed with stent-grafts, resulting in a technical success rate of 80%. One patient was circulatory stabilized by endovascular management but needed immediate further open surgery. There were no procedure-related major complications. Mean hospital stay after the initial endovascular intervention was 19 days. Rebleeding occurred in four patients (80%) after a free interval of 2 weeks or longer. During the follow-up period three patients needed reintervention. The in-hospital mortality was 20% and the 30-day mortality was 40%. The midterm outcome was poor, due to comorbidities or rebleeding, with a mortality of 80% within 6 months. In conclusion, endovascular repair is an efficient and safe method to stabilize patients with life-threatening bleeding arterioenteric fistulas in the emergent episode. However, in this group of patients with severe comorbidities, the risk of rebleeding is high and further intervention must be considered. Patients with cancer may only need treatment for the acute bleeding episode, and an endovascular approach has the advantage of low morbidity.

Late Gastrointestinal Bleeding After Infrarenal Aortic Grafting: A 16-Year Experience

To review the manifestation and management of gastrointestinal (GI) bleeding caused by secondary aortoenteric fistula (AEF) after infrarenal aortic grafting. Between 1991 and 2006, nine patients underwent emergency treatment for secondary AEF localized in the duodenum (78%), ileum (11%), or sigmoid colon (11%). Three (33%) patients suffered hypovolemic shock. There were two (22%) real fistulas and seven (78%) paraprosthetic fistulas. Graft infection was confirmed in four (45%) patients and four (45%) had proximal sterile pseudoaneurysms. Surgical management consisted of graft removal with (n = 5) or without simultaneous extra-anatomic bypass (n = 1), in situ Dacron graft interposition (n = 3), ileo-duodenorrhaphy (n = 8), sigmoidectomy with colostomy (n = 1), and segmentary ileectomy (n = 1). Endografting was used only as a temporary measure to control bleeding in two patients. The mortality rate was 55% (n = 5). There were no intraoperative deaths, but 75% of the septic patients, 66% of those with preoperative hemodynamic instability, 50% of those with pseudoaneurysms, and 100% of those who required bowel resection died during the early postoperative period. Moreover, all of the surviving patients suffered early postoperative morbidity, resulting in prolonged intensive care unit stay and hospitalization. Secondary AEF is life-threatening, difficult to treat, and associated with high morbidity and mortality, especially in patients with sepsis or hemodynamic instability and those requiring bowel resection.

Complications of open abdominal aortic surgery: the endovascular solution

Aorto-enteric fistulas (AEFs) and para-anastomotic aneurysms (PAAs) are uncommon complications of open aortic surgery (0.5-2.5%) and (0.2-15%), respectively. AEF if untreated is often fatal and surgical management is associated with mortality up to 90%. The risk of PAA rupture carries a mortality of 58%. We present our experience in ten patients with the endovascular treatment of these complications to define the role of endovascular repair in this high-risk group. This is a retrospective review of patients presenting acutely with complications of open aortic surgery. From January 2003 to March 2006, ten patients, all males with a mean age of 73 years presented through the Accident and Emergency department and were assessed with contrast enhanced CT. Five patients presented with secondary AEFs. Three patients with PAAs. Another patient presented with a secondary mycotic aneurysm of the thoracic aorta following open repair of abdominal aortic aneurysm and finally a patient with a femoral pseudoaneurysm. The mean time from the original procedure to presentation was 50 months. All patients were offered endovascular management after stabilisation as they were deemed as high-risk surgical patients. No intra-procedural complications were recorded. The in-hospital 30-day mortality was 1 (10%) patient due to multiple organ failure. One patient died six months later due to an unrelated event. The average in-hospital stay was 5.4 days; median follow-up period was 28 months. All patients were repeatedly admitted after discharge due to septic episodes for which they received IV antibiotics. Repeated cultures for all patients were only positive on four occasions. Endovascular stent-graft repair of AEF and PAAs is a viable alternative to open surgery. It is likely to be associated with less mortality and morbidity and in-hospital stay. It should be considered as an alternative in high-risk patients. Persistence of the infection remains a problem, however, in our experience; it can be well controlled through long-term antibiotics.