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Sieber S, Busch A, Sargut M, Knappich C, Bohmann B, Karlas A, Friess H, Eckstein HH, Novotny A. A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience. Vasc Endovascular Surg 2024; 58:185-192. [PMID: 37608725 DOI: 10.1177/15385744231198363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES 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. PATIENTS AND METHODS 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. RESULTS A total of twentytwo patients (68% male, median age 70 years) 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 63 years, 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. CONCLUSION Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.
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Affiliation(s)
- Sabine Sieber
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Albert Busch
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
- Division of Vascular and Endovascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technical University of Dresden, Dresden, Germany
| | - Mine Sargut
- Department of Surgery, Technical University of Munich Hospital Rechts der Isar Medical Clinic and Polyclinic II, Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Angelos Karlas
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Technical University of Munich Hospital Rechts der Isar Medical Clinic and Polyclinic II, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Alexander Novotny
- Department of Surgery, Technical University of Munich Hospital Rechts der Isar Medical Clinic and Polyclinic II, Munich, Germany
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Chen JF, Ochoa Chaar CI, Cardella J, Dardik A, Guzman RJ, Nassiri N. Emergent percutaneous chimney endovascular aortic repair of a secondary aortoenteric fistula in the setting of a solitary kidney. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:253-257. [PMID: 33997566 PMCID: PMC8095080 DOI: 10.1016/j.jvscit.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
Secondary aortoenteric fistula is a potentially lethal complication after aortic surgery. Traditional treatment consists of open graft excision with extra-anatomic bypass or in situ reconstruction. Patients who present in extremis, however, are generally poor candidates for re-do open aortic surgery. Endovascular repair has emerged as an alternative treatment modality for patients who would otherwise be unable to tolerate an extended operation. We report here a case of urgent endovascular repair of a juxtarenal secondary aortoenteric fistula via endovascular aneurysm repair with a renal artery chimney in a patient with a solitary kidney who presented in hemorrhagic and septic shock.
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Affiliation(s)
- Julia Fayanne Chen
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Jonathan Cardella
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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3
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Lirici MM, Tierno SM, Giudice R, Coscarella C, Graziani MG, Pogany G. Secondary aortoenteric fistula successfully treated with staged endovascular repair and duodenal resection without graft removal. MINIM INVASIV THER 2019; 29:114-119. [PMID: 30848980 DOI: 10.1080/13645706.2019.1581623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Secondary aorto-enteric fistulae (SAEF) are rare life-threatening complications that occur after abdominal aortic graft implant to treat aortic aneurysm or occlusive disease. Conventional treatments such as extra-anatomic bypass grafting with aortic ligation and subsequent graft removal with bowel repair are associated with a 25% to 90% operative mortality rate. In the emergency setting, patients unsuitable for major arterial surgery may benefit from a staged, less invasive approach. We present a case of SAEF treated with endoluminal deployment of a stent graft followed by duodenojejunal resection and anastomosis without further aortic reconstruction and graft removal.
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Affiliation(s)
- Marco Maria Lirici
- Department of General Surgery, San Giovanni Hospital Complex, Rome, Italy
| | | | - Rocco Giudice
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
| | - Carlo Coscarella
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
| | | | - Gabriele Pogany
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
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Colombi D, Bodini FC, Sverzellati N, Morelli N, Capelli P, Michieletti E. A Case of Recurrent Secondary Aortoenteric Fistula 4 Months after Surgery Treated by Endovascular Coiling of the Aortic Stump and Bilateral Chimney Stent Grafts to Renal Arteries. Ann Vasc Surg 2019; 59:310.e1-310.e5. [PMID: 30802570 DOI: 10.1016/j.avsg.2018.12.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/10/2018] [Accepted: 12/15/2018] [Indexed: 01/11/2023]
Abstract
The treatment of recurrent aortoenteric fistula (AEF) previously repaired by surgery is challenging, with a high mortality rate. Open repair is often limited by "hostile abdomen," while endovascular treatment is difficult when the distance between the aortic stump and the origin of the renal arteries is short, with high risk of their occlusion. We describe a recurrent AEF repaired by surgery 4 months earlier, treated by endovascular coiling of the aortic stump after deployment of 2 renal artery stent grafts with the chimney technique.
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Affiliation(s)
- Davide Colombi
- Department of Radiology, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy.
| | - Flavio Cesare Bodini
- Department of Radiology, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Nicola Sverzellati
- Division of Radiology, Department of Clinical Sciences, University of Parma, Parma, Italy
| | - Nicola Morelli
- Department of Radiology, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Patrizio Capelli
- Department of General, Thoracic and Breast Surgery; General, Thoracic, and Vascular Surgery Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Emanuele Michieletti
- Department of Radiology, Radiology Unit, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
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Spanos K, Kouvelos G, Karathanos C, Matsagkas M, Giannoukas AD. Current status of endovascular treatment of aortoenteric fistula. Semin Vasc Surg 2017; 30:80-84. [PMID: 29248124 DOI: 10.1053/j.semvascsurg.2017.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - Christos Karathanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece.
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6
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Kakkos SK, Bicknell CD, Tsolakis IA, Bergqvist D. Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis. Eur J Vasc Endovasc Surg 2016; 52:770-786. [PMID: 27838156 DOI: 10.1016/j.ejvs.2016.09.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 09/25/2016] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- S K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Greece; Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK.
| | - C D Bicknell
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - I A Tsolakis
- Department of Vascular Surgery, University Hospital of Patras, Greece
| | - D Bergqvist
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Quatromoni JG, Orlova K, Foley PJ. Advanced Endovascular Approaches in the Management of Challenging Proximal Aortic Neck Anatomy: Traditional Endografts and the Snorkel Technique. Semin Intervent Radiol 2015; 32:289-303. [PMID: 26327748 DOI: 10.1055/s-0035-1558825] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Advances in endovascular technology, and access to this technology, have significantly changed the field of vascular surgery. Nowhere is this more apparent than in the treatment of abdominal aortic aneurysms (AAAs), in which endovascular aneurysm repair (EVAR) has replaced the traditional open surgical approach in patients with suitable anatomy. However, approximately one-third of patients presenting with AAAs are deemed ineligible for standard EVAR because of anatomic constraints, the majority of which involve the proximal aneurysmal neck. To overcome these challenges, a bevy of endovascular approaches have been developed to either enhance stent graft fixation at the proximal neck or extend the proximal landing zone to allow adequate apposition to the aortic wall and thus aneurysm exclusion. This article is composed of two sections that together address new endovascular approaches for treating aortic aneurysms with difficult proximal neck anatomy. The first section will explore advancements in the traditional EVAR approach for hostile neck anatomy that maximize the use of the native proximal landing zone; the second section will discuss a technique that was developed to extend the native proximal landing zone and maintain perfusion to vital aortic branches using common, off-the-shelf components: the snorkel technique. While the techniques presented differ in terms of approach, the available clinical data, albeit limited, support the notion that they may both have roles in the treatment algorithm for patients with challenging proximal neck anatomy.
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Affiliation(s)
- Jon G Quatromoni
- Division of Vascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ksenia Orlova
- Division of Vascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Paul J Foley
- Division of Vascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Sahu T, Suresh KR, Vishnu M, Vivekanand, Sumanthraj. Endovascular Repair of Secondary Aorto-duodenal Fistula. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2014. [DOI: 10.4103/0972-0820.142368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Borges L, Dias E, Oliveira F, Cássio I. Fístula aorto-entérica secundária - a propósito de um caso clínico. ANGIOLOGIA E CIRURGIA VASCULAR 2013. [DOI: 10.1016/s1646-706x(13)70037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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