Secondary Aortoenteric Fistula Research Articles

Midterm Outcomes of Surgical Strategy for Secondary Aorto-enteric Fistula

Midterm Outcomes of Surgical Strategy for Secondary Aorto-enteric Fistula

Secondary aorto-enteric fistula after aortic aneurysm repair

Overview: Secondary Aorto-enteric fistula (sAEF) is a serious complication after open abdominal aortic aneurysm (AAA) repair, diagnosis and treatment are the sacraments for a vascular surgeons. Objectives: Describe the patient’s characteristics and treatment results of a series of clinical cases diagnosed with Secondary Aorto-enteric Fistula after surgery to open abdominal aortic aneurysm repair.. Methods: A clinical case series. Results: Report on 3 clinical cases of Secondary Aorto-enteric Fistula admitted to the hospital due to gastrointestinal bleeding, underwent surgery to completely remove the graft infection, restore the intestinal fistula, perform extra-anatomic bypass (axillary-bifemoral), the results showed one patient died early postoperatively due to multiple organ failure, two patients had stable postoperative progress and were discharged. Conclusions: Secondary Aorto-enteric Fistula is a rare complication, diagnosis and treatment are often very difficult, early surgery to remove the graft, performing extra-anatomic bypass is an effective method, helping to reduce the mortality rate.

Secondary aortoenteric fistula: a narrative review of the view of the surgeon

Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.

Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula

BackgroundWe report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach.Case presentationA 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications.ConclusionsA one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy

ObjectiveInformation regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition. MethodsWe performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization (ISR) and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections. ResultsBetween 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent ISR and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6–62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum second part–jejunum anastomosis was performed in 43% of patients (n = 6), and perioperatively, 19% of the patients (n = 3) died. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1- and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death. ConclusionsSurgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.

A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience.

Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details. All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality. A total of twentytwo patients (68% male, median age 70years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities. Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.

Vascular graft infection with duodenal fistulization 10 years after hybrid endovascular aortic repair with renovisceral debranching: a case report

BackgroundA secondary aortoenteric fistula after an aortic graft replacement or endovascular aortic repair is a rare but devastating complication that leads to extremely high morbidity and mortality. Because reports of vascular graft infection with enteric fistulization complicating in a hybrid aortic repair with renovisceral debranching are limited, the management method such as the extent of removal of the infected graft, reconstruction procedures, and the ideal type of graft are still debatable.Case presentationWe report a successful case of a 73-year-old man presenting a vascular graft infection with duodenal fistulization, 10 years after hybrid endovascular aortic repair with renovisceral debranching for a 60-mm diameter of supra-renal abdominal aortic aneurysm. The patient had a history of polymyalgia rheumatica on oral prednisolone, perigraft seroma, deep vein thrombosis, and an allergy to rifampicin. The patient eventually recovered after partial removal of the grafts, in situ reconstruction using Fusion Bioline vascular prosthesis, primary duodenal repair, application of omental flap, and antibiotics without any evidence of re-infection after 1.5 years.ConclusionsAlthough hybrid endovascular aortic repair is considered advantageous, especially for the elderly and high-risk patients, due to the avoidance of extracorporeal circulation and thoracotomy; once a devastating complication happens, an optimal treatment method should be considered for patients with several comorbidities. Although our procedures provided favorable results, careful monitoring to avoid re-infection is mandatory.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report.

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Pseudo-aneurysm of Distal Aortic Stump – A Manifestation of Aortoenteric Fistula

Background: Secondary aortoenteric fistula (AEF) is rare but devastating complication of abdominal aortic reconstruction surgery for aortic aneurysm. Most patients presented with acute upper gastrointestinal bleeding. CTA abdomen is usually performed to attain the diagnosis. However, AEF has invariable appearances on CT where mostly are non-specific and similar to perigraft infection (PGI). A case of secondary AEF following multiple series of aortic surgery, with CT manifestation of recurrent pseudo-aneurysm of aortic stump, is presented. Case Presentation: 65 years old man who had undergone series of aortic reconstructive surgery for infra-renal abdominal aortic aneurysm presented acutely for hematemesis and per rectal bleeding. Initial CTA abdomen revealed pseudoaneurysm of the distal aortic stump, which was successfully embolized with coils. However, the symptoms recurred and repeated CTA showed new pseudo-aneurysm but no typical findings of AEF. Emergency laparotomy confirmed AEF at duodenojejunal junction that was repaired with primary closure. Unfortunately, patient died 3 days later due to multiple post-operative complications. Conclusion: Presence of pseudo-aneurysm with background of perigraft infection should raise the suspicion of AEF, especially in patients with history of aortic intervention that presented with gastro-intestinal bleeding. CTA abdomen is invaluable in providing the diagnosis of AEF despite its variable manifestations.

A Case Series of Secondary Aortoenteric Fistula after Open Aortic Aneurysm Repair: Timing and Technique of Surgery.

Secondary aortoenteric fistula (sAEF) is a rare but serious complication after open aortic aneurysm repair (OAR). Although there is no consensus on the treatment strategy for sAEF, acute management of bleeding and infection control greatly affect the outcome. We report five cases of sAEF following OAR from 2016 to 2021. One patient died of sepsis following graft infection, whereas the others had relatively good outcomes. No recurrence of infection or fistula has been observed over an average follow-up period of 29.8 months. Timely management of bleeding and infection with surgical intervention resulted in favorable outcomes in our patients.

Aortoenteric fistulas - our experiences with surgeons' nightmare

Aortoenteric fistula (AEF) is a rare medical emergency, but one of the most difficult and threatening complications of gastrointestinal (GI) bleeding. A retrospective observational study was performed on patients hospitalised with GI bleeding and a definitive AEF diagnosis. We collected operative reports and medical records of patients operated on with an AEF diagnosis. The literature data and our data were analysed and discussed. We admitted eight patients who were definitively diagnosed with AEF after reviewing our hospital records. All patients were male except one. Their ages ranged from 28 to 82, with a mean of 64. All but two patients had secondary AEF (SAEF). Four SAEF cases had open aortic surgery and three had a history of endovascular procedure. The main complaints of the patients on admission were poor general condition, abdominal pain, and GI bleeding. Melena was found in all patients. Hematemesis and hematochezia were other significant GI bleeding findings. Infected grafts were removed in all but one patient; extra-anatomical bypass surgery and bowel repairs were performed. One patient underwent endovascular repair. In all patients, the 30-day in-hospital mortality rate was 50%. In patients presenting with GI bleeding, an aortoenteric fistula should be considered. The outcome depends on early diagnosis, the patient's medical status, the severity of infection, and the anatomic location of the affected aorta. A multidisciplinary approach, appropriate treatment planning and close follow-up after treatment lead to positive outcomes.

Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center.

Objectives: To present our experience with various therapeutic approaches for the treatment of secondary aortoenteric fistulas following open and endovascular aortic aneurysm repair. Methods and Materials: A retrospective data analysis of patients treated for secondary aortoenteric fistulas in a single vascular institution between January 2005 and December 2018 was performed. Analyzed parameters included patients’ demographics, clinical presentation, diagnostic work-up, perioperative data and repair durability during follow-up. Results: Twenty-three patients with aortoenteric fistulas were treated in the target period. The fistulous connection was located in 21 cases (91.3%) in the duodenum and in two cases (8.7%) in the small intestine. Average time between the initial procedure and detection of the aortoenteric fistula was 69.4 ± 72.5 months. The most common presenting symptom was gastrointestinal bleeding (n = 12, 52.2%), followed by symptoms suggestive of chronic infection (n = 11, 47.8%). Open surgical repair was performed in 19 patients (bridging in 3 patients), and endovascular repair was carried out in two cases and one patient underwent a hybrid operation. One patient underwent abscess drainage due to significant comorbidities. Mean follow-up was 35.1 ± 35.5 months. In-hospital mortality and overall mortality were 43.5% (10/23) and 65.2% (15/23), respectively. Patients presenting with bleeding had a significantly higher perioperative mortality rate in comparison to patients presenting with chronic infection (66.7% (8/12) and 18.2% (2/11), respectively, p = 0.019). Patients who underwent stent-graft implantation for control of acute life-threatening bleeding showed significantly better perioperative survival in comparison to patients that were acutely treated with an open procedure (66.6%, (4/6) and 0% (0/6), respectively, p = 0.014). Perioperative mortality was also higher for ASA IV patients (71.4%, 5/7), when compared to ASA III Patients (31.2%, 5/16), although this did not reach statistical significance (p = 0.074). Conclusion: Treatment of secondary aortoenteric fistulas is associated with a high perioperative mortality rate. Patients who survive the perioperative period following open surgical repair in the absence of hemorrhagic shock show acceptable midterm results during follow-up. Stent-graft implantation for bleeding control in patients presenting with life-threatening bleeding seems to be associated with lower perioperative mortality rates.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms

Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood. We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival. Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72years; range, 18-94years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P=0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P=0.034) and preoperative serum albumin level <3g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P=0.033) were preoperative parameter that predicted persistent infection. AC-reactive protein level more than 5mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P<0.001) was observed in patients with persistent infection. EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Out of sight for the endoscopist? Gastrointestinal bleeding after aortic repair

Background and study aim Secondary Aortoenteric Fistulas (sAEF) are difficult to diagnose and usually result in fatal gastrointestinal (GI) bleeding following aortic repair. Outcomes are largely dependent on a timely diagnosis, but AEFs remain challenging to identify endoscopically and are usually diagnosed on computed tomography (CT) scans. The aim of our study was optimize diagnosis of AEF by identifying patients developing GI bleeding after aortic repair, investigate their clinical course and identify factors specific to different bleeding sources. Methods A retrospective, single-center study capturing all patients developing upper or lower GI bleeding after aortic surgery between January 2009 and March 2020 was performed. Electronic health records were screened for diagnostic codes of the relevant procedures. Bleeding was classified into three groups: AEF with demonstrable fistula, ischemic – macroscopic ulceration plus histological confirmation or imaging and “other” due to other recognized conventional cause, such as peptic ulcer disease. Results 47 GI bleeding episodes in 39 patients were identified. Of these, 10 episodes (21%) were caused by AEF, 16 (34%) by ischemic ulceration and 21 (45%) due to other causes. Patients with AEF exhibited more frequent hemodynamic instability requiring vasopressors and had higher mortality, while ischemic ulcerations were associated with more recent operation or hypotensive episode. Conclusions GI bleeding complications are uncommon following aortic surgery. AEF and ischemic ulceration are however frequent bleeding causes in this cohort. In patients presenting with fulminant bleeding, primary CT-scanning should be considered.

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

Secondary aortoenteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes. We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints. A total of 57 patients (63% male; n= 36) presented with SAEF (median age, 69years; interquartile range [IQR], 61-74years). Median follow-up time was 10months (interquartile range, 3-21months. The most common presenting symptoms were gastrointestinal bleeding (60%; n= 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n= 17) underwent extra-anatomic bypass with aortic ligation, 30% (n= 17) rifampin-soaked Dacron graft, 26% (n= 15) femoral vein (eg, neoaortoiliac system), and 14% (n= 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n= 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n= 35). Thirty-day mortality was 35% (n= 20) with no significant difference between 90days (39%; n= 22) and 180days (42%; n= 24). Morbidity was 70% (n= 40), with gastrointestinal (30%; n= 17; leak [9%]), pulmonary (25%; n= 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n= 32). One-year and 3-year survival was 54%± 6% and 48%± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P= .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P= .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome. In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

S2250 Polymicrobial Bacteremia With Insidious Gastrointestinal Blood Loss: A Rare Clinical and Endoscopic Manifestation of Secondary Aortoenteric Fistula

Introduction: Secondary aortoenteric fistula (AEF) is a rare (0.3-1%) but life-threatening complication after aortic reconstructive surgery with graft. Case Description/Methods: A 68-year-old man with a significant past medical history of type 2 diabetes, COPD, coronary artery disease status post cardiac stent, and aortobifemoral bypass graft performed 10 years ago, was hospitalized with presentations of shortness of breath, chills but no fever, and progressive anemia for the past 14 months. ECG and trend of cardiac enzymes were negative. Chest CT imaging revealed no evidence of pulmonary embolism. He was hemodynamically stable. The pertinent initial labs showed a hemoglobin of 7.5 g/dl (6 months earlier 8.1 g/dl, 14 months earlier 11.9 g/dl) and elevated inflammatory markers (leukocytes 9.8/nL, CRP 85.3 mg/dL) with transient lactic acidosis. Blood cultures on admission showed positive of a variety of microorganisms (Streptococcus sanguis, Lactobacillus paracasei, Candida lusitaniae). Patient reported one episode of red blood per rectum and melena between 1 to 3 weeks before admission. An esophagogastroduodenoscopy (EGD) revealed a large excavated and diverticular-like lesion, without bleeding, in the third part of the duodenum (Figure 1). The initial blood cultures growth and the subsequent blood cultures growth of another microorganism (Enterobacter Cloacae) were considered to have a likely GI source. A PET-CT scan result showed hypermetabolism signal associated with the proximal end of the aortoiliac graft, concerning for infection of the graft itself (Figure 2). The EGD finding was consistent with a secondary aorto-enteric fistula formed by infected aortic graft eroding into duodenum and served as the source of recurrent polymicrobial bacteremia. The patient subsequently underwent explantation of the infected aortobifemoral bypass graft (old graft with fistula to the duodenum), reconstruction with cryopreserved aortoiliac allograft, and resection of small intestine with anastomosis closure of duodenotomy. The removed aortic graft cultures grew a variety of microorganism (Enterococcus faecalis, Enterobacter Cloacae, Candida lusitaniae). The patient was discharged 10 days after the operation and when examined 2 months later he was doing well. Discussion: Secondary AEF should be suspected in patients presenting with unclear source of bacteremia with or without GI bleeding and a history of aortic repair. Clinical suspicion is the most important factor contributing to the right diagnosis.Figure 1.: Esophagogastroduodenoscopy suggested the secondary aortoenteric fistula in the third part of duodenum.Figure 2.: A PET-CT scan showed increased hypermetabolism signal associated with the proximal end of the aortoiliac graft (white arrow), concerning for infection of the graft itself.

Case Report: Duodenoscopy diagnosis of a secondary aorto-duodenal fistula: A case report and review of literature.

Secondary aorto-enteric fistula (SAEF) is a rare life-threatening complication occurring in patients with previous infrarenal aortic prosthetic reconstruction. The main symptom is a gastrointestinal bleeding. Its diagnosis is challenging due to the lack of a specific clinical signs. The failure of early diagnosis and treatment of this entity can lead to fatal issue. Actually, the abdominal computed tomography angiogram represents the principal exploration to confirm the diagnosis, but it is associated with a moderate specificity and sensibility. Duodenoscopy can highlight the communication between the duodenum and the prosthetic graft, but it is often inconclusive. We report in this manuscript a case of secondary aorto-enteric fistula revealed by occult gastrointestinal bleeding in an elderly patient who is admitted for severe anemia. The SAEF diagnosis was suspected by the computed tomography scan and confirmed by the duodenoscopy showing an exceptional image of Dacron graft protruding in the third duodenum lumen. Unfortunately, the patient died from cataclysmic shock before intervention. We overview also the rare previous published case reports concerning the endoscopic images of secondary aortoenteric fistula and we contrast our findings with those reported in the literature.

Thoracic Endovascular Repair for Catastrophic Aorto-Enteric Fistula Secondary to Esophageal Stent

Secondary aorto-enteric fistula (SAEF) following esophageal stenting is a rare but recognized pathology. These are multifactorial in etiology and can lead to life-threatening catastrophic hemorrhage. With the advent of thoracic endovascular covered stent technology, a minimally invasive means of addressing is problem has emerged. We aim to discuss the pathophysiology and underlying principles in managing this difficult problem. Prompt early recognition and multidisciplinary care are critical to success.

Do Not Delay Removing the Infected Graft!

A 66 year old male presented with dyspepsia. He had been treated by aortobifemoral bypass for aorto-iliac occlusions three years previously. Several thrombectomy procedures and a femorofemoral bypass were required because of symptomatic occlusion of the prosthetic left limb. Computed tomography angiography noted inflammatory tissue with air bubbles (arrow) between the proximal jejunum and the graft (secondary aorto-enteric fistula) (A). Exploratory laparotomy showed that the infected aortic graft was surrounded by the gut wall (B). Infected abdominal vascular grafts should be removed as soon as possible if the patient’s condition permits.Image 1

Roles of endovascular aneurysm repair in management of secondary aorto-enteric fistulas.

Secondary aorto-enteric fistulas (AEFs) are an uncommon but serious complication of abdominal aortic aneurysm (AAA) repair. Case review of two cases of secondary AEF are as follows: the first case involved a 75-year- old male who presented with AEF 1 year post-emergency open AAA repair, successfully managed with endovascular aortic aneurysm repair (EVAR) without complication. The second case involved a 75-year-old male patient 14 months post open AAA repair for an inflammatory aneurysm who presented with an iliac-enteric fistula. The previous repair was relined with a bifurcated EVAR with subsequent laparotomy and resection of the affected portion of the small bowel. Both patients on lifelong antibiotics without further episodes of sepsis, recurrence of AEF or mortality at 12 months follow up. EVAR can be successful in the management of secondary AEF. Careful patient selection, accurate image interpretation, and expedient management are key factors to successful short- and long-term outcomes.