Aortoduodenal fistula arising from the dilatation of a knitted Dacron graft: report of a case

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

OBJECTIVES

To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs).

METHODS

This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type.

RESULTS

Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups).

CONCLUSIONS

Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.

Clinical analysis of non-anastomotic aneurysms of implanted prosthetic grafts

PURPOSE

To investigate the features of non-anastomotic aneurysms (NAAs) of implanted prosthetic grafts through our case series and present a general review of NAAs.

METHODS

We studied retrospectively, a series of NAAs of seven grafts in six patients treated between 2001 and 2010, and reviewed the data on NAAs reported between 1962 and 2009.

RESULTS

The grafts in our series were implanted between 1986 and 2006. The primary surgical procedures were bypass between the axillary and femoral artery (n = 1), bypass between the subclavian artery and abdominal aorta (n = 1), bypass between the aorta and femoral artery (n = 1), bypass between the femoral and popliteal artery (n = 1), bypass between the femoral and femoral artery (n = 2), and bypass between the aorta and iliac artery (n = 1). The graft material was knitted Dacron in all cases and the implantation period ranged from 2.7 to 24 years (median 13.8 years). All NAAs originated from a hole in the graft. Reports of NAA have decreased dramatically, although according to the data, knitted Dacron accounted for 80 % of these implanted grafts.

CONCLUSIONS

Graft deterioration and the subsequent development of an NAA can occur even with the latest knitted Dacron grafts, even though the incidence is very low.

Secondary Aortoduodenal Fistula with a Fatal Outcome: Report of Six Cases

Secondary aortoenteric fistulas (AEFs) are a well-known but uncommon cause of gastrointestinal hemorrhage. They usually occur secondary to reconstructive surgery of an abdominal aneurysm. We report six cases of secondary aortoduodenal fistulas, involving patients who, despite presenting with classic "herald bleeding," died as a result of delayed operative intervention. We also discuss the pathogenesis, clinical presentation, and diagnosis of AEFs, emphasizing the value of clinical suspicion and negative endoscopy in establishing the diagnosis and the need for early operative intervention.