Secondary Aortocolic Fistula: Case Report and Review of the Literature

Secondary Aorto-Colonic Fistula: A Case Report and Literature Review of a Rare Complication after EVAR

Background: Aorto-enteric fistula (AEF) is a rare but fatal condition. The incidence of the overall AEF was approximately 0.36–2%, but the incidence of the aorto-colonic fistula was scarcely reported. A history of abdominal pain, fever, or gastrointestinal bleeding (GIB) in a patient with a history of aortic intervention should be highly suspected of this condition. This report describes a patient with lower GIB after an endovascular aneurysm repair (EVAR) for a symptomatic abdominal aortic aneurysm (AAA). Case Presentation: A 65-year-old man with a history of EVAR for symptomatic AAA presented with a massive lower GIB for two weeks. He also had a history of left lower quadrant pain and low-grade fever. Diverticular disease was suspected, and medical treatment was administered. After the initial conservative treatment, a colonoscopy was performed. The findings showed a fistula that exposed an aortic stent graft at the left-sided colon. An aorto-colonic fistula was diagnosed. After administering intravenous (IV) antibiotics, a staged axillo-bifemoral bypass graft with aortic stent graft explantation was performed. The patient recovered well and was discharged home after a month of hospitalization and IV antibiotics. Conclusion: In a patient with a history of aortic intervention, any abdominal pain, unknown fever, or even GIB should be suspected of complications of aortic intervention. Highly suspicious of this rare condition is the key to an early diagnosis and prompt treatment.

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.

Asymptomatic Secondary Aortoduodenal Fistula Incidentally Diagnosed During a Health Check-up: A Case Report

Secondary aortoenteric fistulas (AEFs) are an uncommon but fatal complication of abdominal aortic reconstructive surgery. Aortoduodenal fistulas (ADFs) are the most frequent secondary AEFs (80%). The incidence of secondary AEFs is increasing because of the increasing number of individuals undergoing aortic aneurysm repairs with prosthetics. In most cases of secondary AEFs, surgical repair is performed with the patient in a poor condition, owing to late diagnosis. Thus, an early diagnosis is crucial. We report a case of an asymptomatic secondary ADF that was incidentally diagnosed using esophagogastroduodenoscopy (EGD) and computed tomography during a health check-up and was successfully repaired, with the patient in a stable condition even after the development of life-threatening symptoms. Based on our case, we suggest that noticing unexplained leukocytosis in regular hematological examination and performing surveillance EGD in an asymptomatic individual who has undergone abdominal aortic reconstructive surgery may aid in the early diagnosis of secondary AEFs before fatal complications manifest.

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.

An alternative method of transperitoneal graft introduction in aortobifemoral bypass surgery

INTRODUCTION

Intestinal injury and bleeding, which usually occurs while taking the graft through the transperitoneal tunnel, is one of the most important complications of aortobifemoral bypass surgery. In this study, case reports were examined where, for some reason, the tunneller instrument could not be used to create the transperitoneal tunnel and the tunnelling forceps was used. In some of these cases, the grafts were taken through conventionally and in others an alternative method was used.

METHODS

Between 2002 and 2013, the records of 81 patients treated surgically by aortobifemoral bypass for peripheral arterial disease, were investigated retrospectively. In the conventional method, after creating a tunnel with tunnelling forceps, the forceps was re-introduced into the tunnel and the graft was clasped and brought through the tunnel. In the alternative method, a nylon tape was left as a guide in the tunnel while creating the tunnel, and the forceps was not introduced again. The graft was taken through the tunnel with the help of the nylon tape. Patients treated with the conventional method were included in group 1 (n = 49) and patients in which the graft was guided with nylon tape were included in group 2 (n = 32). The groups were compared peri-operatively.

RESULTS

There were no significant differences between the groups in terms of co-morbidity factors. Extubation time, intensive care length of stay, revision for bleeding, other postoperative complications, and infection and late-term infection rates were similar in the two groups (p > 0.05). Hospital length of stay and blood usage were significantly higher in group 1 (p < 0.05). Drainage amounts were higher in group 1 but not statistically significant.

CONCLUSION

Using nylon tape to introduce the graft into the femoral area during aortobifemoral bypass operations was found to be more effective than using the tunnelling forceps.