Treatment Of Aortoenteric Fistula Research Articles

1664 A Herald Bleed: A Case Report of an Aortoenteric Fistula Causing an Acute Lower Gastrointestinal Bleed

INTRODUCTION: Aortoenteric fistula (AEF) is a rare, life-threatening condition with an incidence of 0.007/million. Primary AEF arises de novo, secondary AEF (SAEF) occurs following abdominal aortic aneurysm (AAA) repair. Majority of AEF’s involve the duodenum, due to proximity to the aorta. It may present as an exsanguinating herald GI bleed, associated with high mortality rates. SAEF has a 45.8% mortality rate in the first month. CASE DESCRIPTION/METHODS: A 66-year-old female presented with sudden onset of large volume bright red blood per rectum (BRBPR). She denied any prior episodes of GI bleed, alcohol or NSAID use and had never had prior endoscopy. She mentioned cholecystectomy and hysterectomy as her only surgical interventions. On examination she was hemodynamically unstable, lethargic and had a midline abdominal scar. Digital rectal exam showed BRBPR. Her lab workup showed: Hgb 9.5, Hct 29%, platelets 147000, INR 1. An emergent EGD was negative. Colonoscopy showed a 5 cm, pulsatile submucosal mass with an actively bleeding ulcerated area. Epinephrine was injected for temporary hemostasis. A hemoclip was placed to mark the site for potential embolization, as the lesion was not amenable for definitive endoscopic intervention. A stat CT angiogram of the abdomen and pelvis revealed a large left external iliac artery (LEIA) pseudoaneurysm in the region of the clip placed during colonoscopy. Vascular surgery emergently placed a LEIA stent. It appeared the patient had an open aorto-bi-iliac bypass 15 years ago for a AAA which resulted in the development of SAEF. She did well post operatively. DISCUSSION: AEF is important to consider in older patients who present with large volume hematochezia. The presence of prior signs of abdominal surgery should raise suspicion for SAEF as it is difficult to diagnose because of its rarity. The commonest symptom of SAEF is gastrointestinal bleeding. Other symptoms are fever, sepsis, pulsating abdominal or groin mass, abdominal or back pain. CT and GI endoscopy are frequently used for diagnosis. Without treatment AEF often proves to be fatal. Treatment of AEF includes volume resuscitation, antibiotics, and aortic repair. Given our patient's bleed with tenuous clinical status, large body habitus, medical comorbidities, poor functional status as well as previous aorto-bi-iliac bypass, decision was made to approach the pseudoaneurysm endovascularly, despite possible presence of vessel-enteric fistula, as she was deemed unstable for an open approach.

Deep Femoral Vein Reconstruction of the Abdominal Aorta and Adaptation of the Neo-Aortoiliac System Bypass Technique in an Endovascular Era.

Primary infection of the abdominal aorta is a rare pathology that may threaten the integrity of the aortic wall, while secondary aortic prosthesis infection represents a devastating complication to open surgical and endovascular aortic surgery. Curative treatment is achievable by removal of all infected prosthetic material followed by a vascular reconstruction. Twelve consecutive patients treated with the neo-aortoiliac system bypass (NAIS) procedure were reviewed. Nine were treated for a secondary aortic prosthesis infection (tube graft n = 3, bifurcated graft n = 4, endovascular aortic repair (EVAR) stent graft n = 1, and fenestrated EVAR [FEVAR] stent graft n = 1), while 3 patients underwent NAIS repair due to an emergent primary mycotic aortoiliac aneurysm. Ten of 12 patients survived 30 days. Three patients were operated on acutely, and 9 patients had elective or subacute NAIS surgery. Two of 3 patients operated acutely died within 30 days, whereas no 30-day or 1-year mortality was observed in patients undergoing elective or subacute surgery. The median time from primary reconstruction to the NAIS procedure was 11 months (range: 0-201 months). Stent grafts (n = 5 of 12) were in 4 cases explanted using endovascular balloon clamping. Of the explanted endografts, 2 patients presented with a secondary graft infection after EVAR/FEVAR, while 3 patients had been emergently treated with endovascular cuffs as a "bridge-to-surgery" procedure due to aortoenteric fistula (AEF). Patients who received a "bridge-to-surgery" regimen were treated with the NAIS procedure within 8 weeks (median 27 days, range: 27-60) after receiving emergency stent grafting. Aortic balloon-clamping during explantation of infected aortic prosthetic endografts is feasible and facilitates complete endograft removal. Endovascular bridging procedures could be beneficiary in the treatment of AEF or anastomotic dehiscence due to graft infection, offering a possibility to convert the acute setting to an elective definitive reconstructive procedure with a higher overall success rate.

Current status of endovascular treatment of aortoenteric fistula

Aortoenteric fistula (AEF) is one of the most challenging diagnostic and therapeutic entities in vascular surgery. AEF can occur either primarily involving the aorta and the gastrointestinal tract or, more commonly, secondary to previous aortic reconstructive surgery. Traditionally, the treatment of AEF includes graft excision and extra-anatomic bypass surgery or in situ graft replacement. However, recently endovascular repair has emerged as an alternative therapeutic option. In this article, we present published and current evidence for endovascular repair of primary and secondary AEF. When endovascular treatment is applied where appropriate, early outcomes seem to be superior compared to open surgery. This benefit may be lost during long-term follow-up, implying that a staged approach with early conversion to in situ grafting may realize the best patient survival and morbidity. Lifelong administration of antibiotics is associated with a reduction in re-infection. An endovascular approach used as a bridging procedure in unstable patients is recommended, followed by definitive open therapy, if feasible, in patients with good life expectancy.

Superficial Femoral Vein is Superior to Cryopreserved Allografts for in situ Aortic Reconstruction

This is an important manuscript reporting the results of native aortic and aortic graft infections managed with cryopreserved aortic allografts in a large series of patients. The main finding is the relatively high graft-related complication rates of nearly 20% at a median follow-up of just over 1 year. Ten patients developed early graft complications, the most concerning being the four cases of allograft body disruption and two anastomotic disruptions, which brings into question the ability of the aortic graft to withstand the cryopreservation process while maintaining its inherent integrity to pulsatile aortic pressures. The four cases of midallograft rupture occurred in patients with more virulent Gram-negative infection or after the treatment of aortoenteric fistula, potentially higher risk groups. Notwithstanding this however, as the authors recognise in their discussion the high early graft-related complications as the main impediment to the use of cryopreserved allografts. They also recognise the concerns of late degenerative changes in both fresh and cryopreserved allografts. This series highlights the difficulties of obtaining robust long-term follow-up data in this patient cohort. These cases are rare and therefore the literature is littered with case reports and small series. This unit has a large aortic practice; their own prosthetic aortic graft infection rate was 1.4%, with over 40% of the cases described above having undergone their primary aortic procedures at other units. These patients have both high shortand medium-term mortality rates, the authors reporting 39% mortality at a median of just 12 months’ follow-up. A recent study of 25 patients, also from France, using cryopreserved allografts reported an in-hospital mortality rate of 48%. Longer-term mortality rates of 54% at 2.5 years in the USA have been reported in a contemporary series, which also highlighted the high in-hospital mortality rates associated with aorto-enteric fistulae. Both French series identified age and chronic renal impairment as poor prognostic factors, in keeping with many other vascular conditions. The usefulness of these poor prognostic indicators is debatable when the outcomes of conservative management of aortic graft infection are extremely poor. The authors have only included data on patients who underwent aortic reconstruction with allografts, and have not reported outcomes for patients who

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

Evolving strategies for the treatment of aortoenteric fistulas

Aortoenteric fistulas (AEFs) are a rare but often fatal cause of gastrointestinal bleeding. Operative repair of AEF has been historically associated with extremely high morbidity and mortality. We reviewed our experience of open surgical and endovascular treatment of AEF to compare outcomes over a contemporaneous time period. Over a 9-year period between January 1997 and January 2006, 16 patients (11 men and 5 women) were diagnosed with and treated for AEFs. Seven patients underwent open surgical repair, and nine, with anatomically suitable lesions, underwent endovascular repair. The outcome after treatment of these patients was investigated for survival, perioperative complications, length of hospital stay, and long-term disposition. Three primary and 13 secondary AEFs were treated. The mean time from the initial aortic operation until AEF diagnosis was 5.9 years (range, 0.7-12.2 years) for patients with secondary AEFs. The overall 30-day mortality rate was 18.8%. One intraoperative death and one in-hospital death secondary to multisystem organ failure occurred in patients undergoing open repair. One in-hospital death related to persistent sepsis occurred in the endovascular group. The overall perioperative complication rate was 50.0%. Complications in the open group included sepsis, renal failure, bowel obstruction, and pancreatitis. Complications in the endovascular group were related to persistent sepsis. The mean in-hospital length of stay was significantly longer for patients undergoing open repair compared with endovascular repair (44.0 vs 19.4 days; P = .04). Four (80%) of five patients who were discharged from the hospital in the open group were placed in skilled nursing facilities, and seven (87.5%) of eight patients discharged in the endovascular group returned home. The median overall survival after hospital discharge was 23.1 months. There were no late aneurysm-related deaths or late deaths related to septic complications. Patients with AEFs have limited overall survival. Endovascular therapy offers an alternative to open surgical repair, seems to be associated with decreased perioperative morbidity and mortality and a shorter in-hospital stay, and allows for acceptable survival given the presence of coexisting medical comorbidities. Furthermore, endovascular repair provides a therapeutic option to control bleeding and allow for continued intervention in a stabilized setting.

Successful Endovascular Treatment of Bleeding Aortoenteric Fistula: A Case Report

Aortoenteric fistula (AEF) is an infrequent but disastrous complication of open abdominal aortic repair. Left untreated, it has a 100% fatality rate. The traditional approaches to the repair of secondary AEF (SAEF) are associated with average mortality rates of 21-59% and numerous major complications. Here, we report a case of acute gastrointestinal bleeding due to SAEF, successfully treated with endovascular stent graft repair. At 1-year follow-up, the patient was doing well without any signs of recurrent fistula. Endovascular treatment of AEF provides another treatment option that may be particularly valuable in patients whose comorbidities would preclude open repair.