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Bhatti S, Endashaw O, Short J. The Herald Bleed: A Case Report of an Aortoenteric Fistula causing an Acute Lower Gastrointestinal Bleed. Cureus 2020; 12:e6966. [PMID: 32190513 PMCID: PMC7067570 DOI: 10.7759/cureus.6966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Aortoenteric fistula (AEF) is a rare life-threatening condition. Secondary AEF (SAEF) occurs in patients with abdominal aortic aneurysm (AAA) repair and has a high mortality rate. We present a case of a 66-year-old female who presented to the emergency room with hematochezia and hemodynamic instability. Emergent esophagogastroduodenoscopy (EGD) was negative. Colonoscopy revealed a 5 cm, pulsatile, bleeding, submucosal mass. A stat computed tomography (CT) angiogram of the abdomen and pelvis revealed a large left external iliac artery (LEIA) pseudoaneurysm. Vascular surgery emergently placed a LEIA stent. It appeared the patient had an aorto-bi-iliac (ABI) common iliac artery (CIA) bypass, 15 years ago, for a large AAA that had resulted in a SAEF, with the rare finding of communication with the colon. She had a complicated course involving surgical and medical management but with successful outcomes.
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Affiliation(s)
- Sundus Bhatti
- Internal Medicine, University of Louisville School of Medicine, Louisville, USA
| | - Omer Endashaw
- Gastroenterology, University of Louisville, Louisville, USA
| | - Jacolby Short
- Radiology, University of Louisville, Louisville, USA
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2
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Kowatari R, Sasaki H, Goto S, Imamura Y, Aoki C, Fukuda I. A case of aortocolonic fistula caused by sigmoid diverticulitis. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:78-81. [PMID: 31193449 PMCID: PMC6529693 DOI: 10.1016/j.jvscit.2018.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/22/2018] [Indexed: 11/30/2022]
Abstract
The development of a secondary aortoenteric fistula is a well-described complication after open or endovascular repair of an abdominal aortic aneurysm. However, evidence regarding aortocolonic fistulas (ACFs) and their pathogenesis is currently limited. We present a case of ACF that developed 18 years after open repair of an abdominal aortic aneurysm with atypical symptoms. The patient was successfully treated with total resection of the involved aorta, prosthetic graft, and sigmoid colon, with extra-anatomic bypass and primary anastomosis of the residual colon. Pathologic examination revealed that the pathogenesis of ACF was attributed to sigmoid diverticulitis. This case report highlights the uncommon pathogenesis of ACF and the importance of considering revascularization and intestinal reconstruction in the surgical strategy for each individual case.
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Affiliation(s)
- Ryosuke Kowatari
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hanae Sasaki
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shintaro Goto
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Imamura
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Chikashi Aoki
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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3
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Takei N, Kunieda T, Kumada Y, Murayama M. Perigraft Abscess Subsequent to Aortoesophageal Fistula. Intern Med 2018; 57:3255-3259. [PMID: 29984765 PMCID: PMC6287987 DOI: 10.2169/internalmedicine.0493-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 04/10/2018] [Indexed: 11/06/2022] Open
Abstract
A 79-year-old man with appetite loss and nausea for 1 month was admitted to our hospital. His thoracic aortic aneurysm had gradually increased in size due to perigraft endoleak after the previous aneurysm repair surgery. Although he showed no hematemesis, melena, or a fever, gastrointestinal endoscopy and contrast-enhanced computed tomography (CT) revealed an aortoesophageal fistula (AEF). He developed septic shock due to a perigraft abscess and eventually died, although aortic graft replacement and esophageal transection were performed. Clinical suspicion is the most important factor for obtaining an accurate diagnosis and improving the prognosis in cases of AEF.
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Affiliation(s)
- Norie Takei
- Department of General Internal Medicine, Matsunami General Hospital, Japan
| | - Takeshige Kunieda
- Department of General Internal Medicine, Matsunami General Hospital, Japan
| | - Yoshitaka Kumada
- Department of Cardiovascular Surgery, Matsunami General Hospital, Japan
| | - Masanori Murayama
- Department of General Internal Medicine, Matsunami General Hospital, Japan
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Theriot JM, Feldman ZM, Korayem AH, Chander RK, Finlay DJ. Minimally Invasive Aortobiilliofemoral Endarterectomy for Aortoiliac Occlusive Disease Is a Compelling Alternative to Bypass. Vasc Endovascular Surg 2018; 53:97-103. [DOI: 10.1177/1538574418807104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Aortobifemoral bypass is a time-honored, durable surgery allowing restoration of lower extremity blood. However, the potential for significant complications exists, impacting mortality, morbidity, and quality of life. Minimally invasive aortobiiliofemoral endarterectomy offers an alternative to prosthetic bypass and its associated complications. Here, we present a case series using remote endarterectomy for aortoiliac occlusive disease. Methods: Nine patients with aortoiliac occlusive disease were treated at a single institution, by a single surgeon, with direct and remote endarterectomy combination. Standard femoral access approach was used. A limited longitudinal distal aorta arteriotomy into the right common iliac artery to the hypogastric bifurcation was made. Then, an open thromboendarterectomy was performed. Circumferential common femoral endarterectomies were performed bilaterally and the plaque transected, allowing manually controlled Vollmar ring passage proximally to the iliac bifurcation on the right and the aortic bifurcation on the left. Aortoiliac arteriotomy was closed, followed by the femoral arteriotomies. Morbidity, secondary interventions, recurrent stenosis (adjacent segment velocity ratios ≥2), ankle–brachial index (ABI), and patency rates were tracked postoperatively for 6 years. Kaplan-Meier life-table analysis was used to determine patency rates per the criteria of SVS and ISCS. Results: The average age was 59.1 years (54-87 years), and 88% were male. Comorbidities included hypertension (75%), former/current smokers (100%), and prior PAD surgical intervention (38%). Revascularization of 100% was achieved, with average ABI improving from 0.42 preoperatively to 0.92 postoperatively (0.91 at 8-month follow-up). Six-year patency rate was 100% without reintervention. Incidence of myocardial infarction, stroke, death, amputation, intestinal ischemia, sexual dysfunction, and aneurysmal degeneration was zero after 6 years of follow-up. Conclusion: Minimally invasive aortobiiliofemoral endarterectomy is a viable alternative to aortobifemoral bypass for the treatment of aortoiliac occlusive disease, allowing reestablishment of normal anatomic anatomy while avoiding the use of prosthetic material. Patency rates in this series was 100% at 6 years, with minimal postoperative complications or morbidity.
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Affiliation(s)
- Jared M. Theriot
- Department of Surgery, New York Medical College at Metropolitan Hospital Center, New York, NY, USA
| | - Zach M. Feldman
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Medical Center, New York, NY, USA
| | - Adam H. Korayem
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Medical Center, New York, NY, USA
| | - Rajiv K. Chander
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Medical Center, New York, NY, USA
| | - David J. Finlay
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Medical Center, New York, NY, USA
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5
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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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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Guevara-Noriega KA, Velescu A, Zaffalon-Espinal DT, Mateos-Torres E, Roig-Santamaría L, Clará-Velasco A. [Aorto-bifermoral grafs infection due to Candida parapsilosis. An unusual pathogen]. CIR CIR 2016; 85:234-239. [PMID: 27039287 DOI: 10.1016/j.circir.2016.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 01/14/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Aorto-enteric fistula is a rare and potentially lethal entity. Its presentation may be as an enteric-paraprosthetic fistula, due to injury in the gut caused by direct contact with the vascular prosthesis. OBJECTIVE We report a case of enteric-paraprosthetic fistulae with the unusual finding of Candida parapsilosis as the only isolated pathogen. CLINICAL CASE A 65-year-old male, smoker, with aortobifemoral revascularisation with dacron due to aortoiliac occlusive disease, and re-intervention for thrombosis of left arm at 6 months. Hospitalisation at 22 months was required due to a toxic syndrome, which was diagnosed as enteric-paraprosthetic fistulae after complementary studies. The graft was removed and an extra-anatomic revascularisation was performed. Microbiology specimens taken from the duodenal segment in contact with the prosthesis showed the prosthetic segment and peri-prosthetic fluid were positive to C. parapsilosis. DISCUSSION The finding of C. parapsilosis in all cultures taken during surgery, along with negative blood cultures and no other known sources of infection, is of interest. It is an unusual pathogen with low virulence and limited as regards other Candida species. Our patient had no clinical data common to cases of infection with C. parapsilosis, and the mechanism of graft infection is unknown. CONCLUSION Graft infection by C. parapsilosis may be anecdotal. However, its consequences can also be severe. Microbiological tests can be useful to adjust antimicrobial therapy in the post-operative period, but their usefulness for determining the aetiology is doubtful, as it may be just an incidental finding.
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Affiliation(s)
| | - Alina Velescu
- Servicio de Angiología y Cirugía Vascular, Parc de Salut Mar Barcelona, Barcelona, España
| | | | - Eduardo Mateos-Torres
- Servicio de Angiología y Cirugía Vascular, Parc de Salut Mar Barcelona, Barcelona, España
| | - Luis Roig-Santamaría
- Servicio de Angiología y Cirugía Vascular, Parc de Salut Mar Barcelona, Barcelona, España
| | - Albert Clará-Velasco
- Servicio de Angiología y Cirugía Vascular, Parc de Salut Mar Barcelona, Barcelona, España
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Lahoz C, Gracia CE, García LR, Montoya SB, Hernando ÁB, Heredero ÁF, Tembra MS, Velasco MB, Guijarro C, Ruiz EB, Pintó X, de Ceniga MV, Moñux Ducajú G. [Not Available]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2016; 28 Suppl 1:1-49. [PMID: 27107212 DOI: 10.1016/s0214-9168(16)30026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Carlos III, Madrid, España.
| | - Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | | | - Sergi Bellmunt Montoya
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Ángel Brea Hernando
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | | | - Manuel Suárez Tembra
- Unidad de Lípidos y Riesgo Cardiovascular, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Marta Botas Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital de Cabueñes, Gijón, España
| | - Carlos Guijarro
- Consulta de Riesgo Vascular, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Esther Bravo Ruiz
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, España
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L' Hospitalet de Llobregat, Barcelona, España
| | - Melina Vega de Ceniga
- Servicio de Angiología y Cirugía Vascular, Hospital de Galdakao-Usansolo, Vizcaya, España
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Malik MU, Ucbilek E, Sherwal AS. Critical gastrointestinal bleed due to secondary aortoenteric fistula. J Community Hosp Intern Med Perspect 2015; 5:29677. [PMID: 26653698 PMCID: PMC4677592 DOI: 10.3402/jchimp.v5.29677] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/28/2015] [Accepted: 10/30/2015] [Indexed: 12/22/2022] Open
Abstract
Secondary aortoenteric fistula (SAEF) is a rare yet lethal cause of gastrointestinal bleeding and occurs as a complication of an abdominal aortic aneurysm repair. Clinical presentation may vary from herald bleeding to overt sepsis and requires high index of suspicion and clinical judgment to establish diagnosis. Initial diagnostic tests may include computerized tomography scan and esophagogastroduodenoscopy. Each test has variable sensitivity and specificity. Maintaining the hemodynamic status, control of bleeding, removal of the infected graft, and infection control may improve clinical outcomes. This review entails the updated literature on diagnosis and management of SAEF. A literature search was conducted for articles published in English, on PubMed and Scopus using the following search terms: secondary, aortoenteric, aorto-enteric, aortoduodenal, aorto-duodenal, aortoesophageal, and aorto-esophageal. A combination of MeSH terms and Boolean operators were used to device search strategy. In addition, a bibliography of clinically relevant articles was searched to find additional articles (Appendix A). The aim of this review is to provide a comprehensive update on the diagnosis, management, and prognosis of SAEF.
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Affiliation(s)
- Mohammad U Malik
- Department of Internal Medicine, Conemaugh Memorial Medical Center, Johnstown, PA, USA;
| | - Enver Ucbilek
- Division of Gastroenterology and Hepatology - Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amanpreet S Sherwal
- Department of General Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, USA
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Janczak D, Chabowski M. An endovascular procedure (stent graft) in the treatment of a recurrent secondary aortoduodenal fistula. Hosp Pract (1995) 2014; 42:139-142. [PMID: 24779087 DOI: 10.3810/hp.2014.04.1111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A secondary aortoenteric fistula is a complication of earlier aortic grafting due to anaortic abdominal aneurysm. A primary aortoduodenal fistula (ADF) is a rare clinical entity that usually causes gastrointestinal bleeding that can be occult, intermittent, or massive. This article presents the case of a 68-year-old man with acute onset of a massive hematemesis and hematochezia.Eight years earlier he had undergone the implantation of an aortobifemoral prosthesis to treat an aortic aneurysm. The patient's condition was unstable, and it was during emergency surgery that the diagnosis of an ADF was made. An infected graft was removed in its entirety,and a new prosthesis was implanted. An omentoplasty with a pedunculated flap was performed.After 8 months, the patient had a recurrent AD F. He underwent another operation, but hemorrhaging from the aortic anastomosis occurred, so he required emergency surgery. Eventration occurred on the 14th postoperative day. The resection of the transversal colon was performed with a cecostomy for the decompression of the end-to-end anastomosis. Three months later the patient suffered a recurrent AD F. An aortobifemoral stent graft was implanted. Periaortal flow drainage was established for the irrigation of the retroperitoneal space. A microjejunostomy tube was also inserted. The patient recovered without any complications. This case represents an example of a rare serious complication of aortic abdominal aneurysm. This case report covers pathophysiology, diagnostic evaluation, and management of an aortoenteric fistula.
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[Upper gastrointestinal bleeding due to secondary aortoenteric fistula]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:305-7. [PMID: 21377235 DOI: 10.1016/j.gastrohep.2010.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 11/02/2010] [Accepted: 11/04/2010] [Indexed: 11/23/2022]
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12
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Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, van Herwaarden JA, Holt PJE, van Keulen JW, Rantner B, Schlösser FJV, Setacci F, Ricco JB. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1-S58. [PMID: 21215940 DOI: 10.1016/j.ejvs.2010.09.011] [Citation(s) in RCA: 1008] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 09/12/2010] [Indexed: 12/11/2022]
Affiliation(s)
- F L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands.
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Luo CY, Lai CH, Wen JS, Lin BW. Secondary Aortocolic Fistula: Case Report and Review of the Literature. Ann Vasc Surg 2010; 24:256.e5-12. [PMID: 19892515 DOI: 10.1016/j.avsg.2009.07.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 03/31/2009] [Accepted: 07/27/2009] [Indexed: 11/30/2022]
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Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2-49. [PMID: 19786250 DOI: 10.1016/j.jvs.2009.07.002] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Elliot L Chaikof
- Department of Surgery, Emory University, Atlanta, Ga 30322, USA.
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Secondary Arterioenteric Fistulation – A Systematic Literature Analysis. Eur J Vasc Endovasc Surg 2009; 37:31-42. [PMID: 19004648 DOI: 10.1016/j.ejvs.2008.09.023] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 09/30/2008] [Indexed: 11/21/2022]
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