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Narayanan A, Hanna J, Okamura-Kho A, Tesar J, Lim E, Peden S, Dean A, Taumoepeau L, Katib N, Lyons O, Khashram M. Management of secondary aorto-enteric fistulae: a multi-centre study. ANZ J Surg 2023; 93:2363-2369. [PMID: 37012584 DOI: 10.1111/ans.18441] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/12/2023] [Accepted: 03/19/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Secondary aorto-enteric fistulae (SAEF) are a rare, complex and life-threatening complication following aortic repair. Traditional treatment strategy has been with open aortic repair (OAR), with emergence of endovascular repair (EVAR) as a potentially viable initial treatment option. Controversy exists over optimal immediate and long-term management. METHODS This was a retrospective, observational, multi-institutional cohort study. Patients who had been treated for SAEF between 2003 and 2020 were identified using a standardized database. Baseline characteristics, presenting features, microbiological, operative, and post-operative variables were recorded. The primary outcomes were short and mid-term mortality. Descriptive statistics, binomial regression, Kaplan-Meier and Cox age-adjusted survival analyses were performed. RESULTS Across 5 tertiary centres, a total of 47 patients treated for SAEF were included, 7 were female and the median (range) age at presentation was 74 years (48-93). In this cohort, 24 (51%) patients were treated with initially with OAR, 15 (32%) with EVAR-first and 8 (17%) non-operatively. The 30-day and 1-year mortality for all cases that underwent intervention was 21% and 46% respectively. Age-adjusted survival analysis revealed no statistically significant difference in mortality in the EVAR-first group compared to the OAR-first group, HR 0.99 (95% CI 0.94-1.03, P = 0.61). CONCLUSION In this study there was no difference in all-cause mortality in patients who had OAR or EVAR as first line treatment for SAEF. In the acute setting, alongside broad-spectrum antimicrobial therapy, EVAR can be considered as an initial treatment for patients with SAEF, as a primary treatment or a bridge to definitive OAR.
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Affiliation(s)
- Anantha Narayanan
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Department of Vascular Surgery, Wellington Hospital, Wellington, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Joseph Hanna
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Amy Okamura-Kho
- Department of Vascular Surgery, Auckland Hospital, Auckland, New Zealand
| | - Joshua Tesar
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Eric Lim
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Sam Peden
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anastasia Dean
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Auckland Hospital, Auckland, New Zealand
| | - Lupe Taumoepeau
- Department of Vascular Surgery, Wellington Hospital, Wellington, New Zealand
| | - Nedal Katib
- Department of Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Oliver Lyons
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery, University of Otago, Otago, New Zealand
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Secondary Aorto-Colonic Fistula: A Case Report and Literature Review of a Rare Complication after EVAR. Case Rep Surg 2022; 2022:8412460. [DOI: 10.1155/2022/8412460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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3
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Aortoenteric fistula following endovascular abdominal aortic aneurysm repair. J Vasc Surg Cases Innov Tech 2022; 8:438-440. [PMID: 35996728 PMCID: PMC9391504 DOI: 10.1016/j.jvscit.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/10/2022] [Indexed: 11/23/2022] Open
Abstract
Aortoenteric fistula is a rare complication after endovascular stent grafting. In the present report, we have described the case of a 69-year-old man 3 years after endovascular repair of an abdominal aortic aneurysm who had presented with worsening back pain and fever. Computed tomography had demonstrated dilated bowel and a thickened aortic wall, with air foci within the native aneurysm sac. He underwent emergent right axillary–bifemoral bypass with explantation of the aortic endograft and primary repair of the duodenal fistula. Tissue cultures grew Streptococcus anginosus, Prevotella denticola, and Parvimonas micra, and he was discharged home with 6 weeks of intravenous ceftriaxone and oral metronidazole after an 18-day hospital admission.
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Georgeades C, Zarb R, Lake Z, Wood J, Lewis B. Primary Aortoduodenal Fistula: A Case Report and Current Literature Review. Ann Vasc Surg 2021; 74:518.e13-518.e23. [PMID: 33549801 DOI: 10.1016/j.avsg.2020.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/27/2020] [Accepted: 12/30/2020] [Indexed: 02/07/2023]
Abstract
Primary aortoduodenal fistula is a rare, life-threatening pathology that is difficult to diagnose and manage. We present the case of a 64-year-old male with a primary aortoduodenal fistula. Our patient initially underwent an endovascular aneurysm repair at an outside institution before being transferred to our tertiary care center, where he ultimately had definitive management with an extra-anatomic bypass, aortic ligation, duodenal resection with primary anastomosis, and gastrojejunostomy tube placement. His surgical cultures grew Candida albicans, and he was discharged with a 6-week course of intravenous antibiotics with subsequent antibiotic suppression for 1 year. He died 14 months postoperatively from tongue squamous cell carcinoma. We also review the current literature regarding epidemiology, pathology, diagnostics, management, and case reports from 2015 to present. Overall, timely diagnosis and treatment is imperative for reducing mortality from primary aortoduodenal fistula, and although formal consensus is lacking regarding most clinical aspects, an increasing number of case reports has helped describe options for management.
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Affiliation(s)
- Christina Georgeades
- Department of Vascular Surgery, Milwaukee Veterans Affairs Medical Center, Milwaukee, WI; Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
| | - Rakel Zarb
- Department of Plastic Surgery, Milwaukee Veterans Affairs Medical Center, Milwaukee, WI; Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Zoe Lake
- Department of Vascular Surgery, Milwaukee Veterans Affairs Medical Center, Milwaukee, WI; Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jacob Wood
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, NC
| | - Brian Lewis
- Department of Vascular Surgery, Milwaukee Veterans Affairs Medical Center, Milwaukee, WI; Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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5
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Moriyama H, Kimura K, Takago S, Nishida Y, Shimada M, Takemura H. Aortoduodenal Fistula After Endovascular Aortic Repair for an Inflammatory Abdominal Aortic Aneurysm: A Case Report. Vasc Endovascular Surg 2020; 55:95-99. [PMID: 32875968 DOI: 10.1177/1538574420954307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Aortoenteric fistula after endovascular aortic repair for an abdominal aortic aneurysm is a rare but severe complication. Particularly, a case of inflammatory abdominal aortic aneurysm is extremely rare and there are only 3 reported cases. A 70-year-old man underwent endovascular aortic repair for impending rupture of an inflammatory abdominal aortic aneurysm and was medicated steroids for approximately 2 years. Four years after endovascular aortic repair, he developed endograft infection with an aortoduodenal fistula and a left psoas abscess. He underwent total endograft excision, debridement, in situ reconstruction of the aorta using prosthetic grafts with omental coverage, and digestive tract reconstruction to prevent leakage. Pseudomonas aeruginosa was detected in the infected aortic sac. The patient has not experienced recurrence of infection in the 35 months since his operation.
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Affiliation(s)
- Hideki Moriyama
- Department of Thoracic, Cardiovascular and General Surgery, 12858Kanazawa University, Ishikawa, Japan
| | - Keiichi Kimura
- Department of Thoracic, Cardiovascular and General Surgery, 12858Kanazawa University, Ishikawa, Japan
| | - Shintaro Takago
- Department of Thoracic, Cardiovascular and General Surgery, 12858Kanazawa University, Ishikawa, Japan
| | - Yoji Nishida
- Department of Thoracic, Cardiovascular and General Surgery, 12858Kanazawa University, Ishikawa, Japan
| | - Mari Shimada
- Department of Thoracic, Cardiovascular and General Surgery, 12858Kanazawa University, Ishikawa, Japan
| | - Hirofumi Takemura
- Department of Thoracic, Cardiovascular and General Surgery, 12858Kanazawa University, Ishikawa, Japan
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Hosaka A, Nemoto M, Motoki M, Akai A, Kato M. Aortoduodenal Fistula After Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2020; 54:445-448. [DOI: 10.1177/1538574420918969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Aortoduodenal fistula after endovascular treatment of abdominal aortic aneurysm is a very rare but life-threatening complication. Herein, we describe 4 cases of aortoduodenal fistula diagnosed at 15 to 78 months after the index aortic intervention, all successfully treated by surgery. All patients underwent primary repair of the duodenal wall, creation of tube duodenostomy, stent graft removal, and in situ reconstruction using a rifampicin-soaked prosthesis. Patients received prolonged antibiotic treatment for at least 2 months postoperatively, and all were free of recurrent infection at follow-up. Prompt and appropriate surgical intervention is required to effectively manage this condition.
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Affiliation(s)
- Akihiro Hosaka
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Fuchu-shi, Tokyo, Japan
| | - Masaru Nemoto
- Department of Surgery, Ibaraki Prefectural Central Hospital & Cancer Center, Kasama, Ibaraki, Japan
| | - Manabu Motoki
- Department of Cardiovascular Surgery, Morinomiya Hospital, Joto-ku, Osaka, Japan
| | - Atsushi Akai
- Department of Cardiovascular Surgery, Morinomiya Hospital, Joto-ku, Osaka, Japan
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital, Joto-ku, Osaka, Japan
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7
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Nguyen CL, Lindsay A, McLachlan R, Islam S, Qasabian R, Loa J. Aortoduodenal fistula 2 years after elective endovascular repair of an abdominal aortic aneurysm. ANZ J Surg 2020; 90:2374-2376. [DOI: 10.1111/ans.15773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Chu Luan Nguyen
- Vascular Surgery Department Royal Prince Alfred Hospital Sydney New South Wales Australia
- Surgery Department The University of Sydney Sydney New South Wales Australia
| | - Andrew Lindsay
- Surgery Department The University of Sydney Sydney New South Wales Australia
| | - Rohan McLachlan
- Vascular Surgery Department Royal Prince Alfred Hospital Sydney New South Wales Australia
- Surgery Department University of New South Wales Sydney New South Wales Australia
| | - Samiul Islam
- Vascular Surgery Department Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Raffi Qasabian
- Vascular Surgery Department Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Jacky Loa
- Vascular Surgery Department Royal Prince Alfred Hospital Sydney New South Wales Australia
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8
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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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9
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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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Affiliation(s)
- Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS 390, Houston, TX 77030, USA.
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11
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Janko M, Ciocca RG, Hacker RI. Vertebral Osteophyte as Possible Etiology of Aortoenteric Fistula. Ann Vasc Surg 2018; 49:313.e5-313.e7. [DOI: 10.1016/j.avsg.2017.11.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/29/2017] [Accepted: 11/21/2017] [Indexed: 10/18/2022]
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12
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Chan Y, Cheng EJ. A Rare Cause of an Already Rare Cause of GI Hemorrhage. J Can Assoc Gastroenterol 2018; 1:4. [PMID: 31294390 PMCID: PMC6487983 DOI: 10.1093/jcag/gwx006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yin Chan
- Division of Gastroenterology and Hepatology, Teaching Research and Wellness Centre, University of Calgary, Alberta, Canada
| | - Edwin J Cheng
- Division of Gastroenterology and Hepatology, Teaching Research and Wellness Centre, University of Calgary, Alberta, Canada
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13
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Cotter TG, Buckley NS, Loftus CG. Approach to the Patient With Hematochezia. Mayo Clin Proc 2017; 92:797-804. [PMID: 28473039 DOI: 10.1016/j.mayocp.2016.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/03/2016] [Accepted: 12/09/2016] [Indexed: 02/07/2023]
Abstract
The evaluation of the patient with hematochezia can be complex because of the broad differential diagnosis and the number of management strategies available. In this article, a simplified approach to the history and physical examination is presented, with management illustrated in a case-oriented manner.
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Affiliation(s)
| | - Niamh S Buckley
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Conor G Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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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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Kadhim M, Rasmussen J, Eiberg J. Aorto-enteric Fistula 15 Years After Uncomplicated Endovascular Aortic Repair with Unforeseen Onset of Endocarditis. EJVES Short Rep 2016; 31:16-18. [PMID: 28856303 PMCID: PMC5573115 DOI: 10.1016/j.ejvssr.2016.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/14/2016] [Accepted: 03/15/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction Aorto-enteric fistula after endovascular aortic repair is an exceedingly rare but serious condition. Report A rare case of a fistula between the excluded aortic sac and the transverse colon 15 years after endovascular aortic repair is described. Onset was endocarditis without gastrointestinal haemorrhage, migration, endoleak, or aortic sac dilatation. The patient was successfully treated by fistula excision, debridement and broad spectrum antibiotic treatment without endograft explantation. Discussion Aorto-enteric fistula can emerge after endovascular repair with an unforeseen onset such as endocarditis, which in this case probably occurred as metastatic sepsis from endograft infection. Uneventful endovascular aneurysm repair can generate an aorto-enteric fistula to a successful excluded and stable aneurysm sac. This case underlines the need for awareness of unusual symptoms that could represent potential late EVAR related complications. A conservative approach without graft removal seems feasible in this case with severe comorbidity.
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Affiliation(s)
- M.M.K. Kadhim
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Corresponding author.
| | - J.B.G. Rasmussen
- Department of Interventional Radiology, Rigshospitalet, Copenhagen, Denmark
| | - J.P. Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation, Rigshospitalet, Denmark
- University of Copenhagen, Copenhagen, Denmark
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16
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Wadgaonkar AD, Black JH, Weihe EK, Zimmerman SL, Fishman EK, Johnson PT. Abdominal aortic aneurysms revisited: MDCT with multiplanar reconstructions for identifying indicators of instability in the pre- and postoperative patient. Radiographics 2015; 35:254-68. [PMID: 25590402 DOI: 10.1148/rg.351130137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Rupture of an abdominal aortic aneurysm is commonly a fatal event. Multidetector computed tomographic (CT) signs of frank aortic rupture are usually readily apparent and widely understood. However, diagnosing an impending aortic rupture on the basis of imaging findings can prove more difficult. CT is the primary modality used for serial imaging in patients with aortic aneurysm and may show findings indicative of aortic instability. Therefore, it is critical that radiologists be familiar with the CT findings of aortic instability to avert the potential complications of hemorrhage, end organ or limb ischemia, and death. Various preoperative CT indicators have been previously described in both research investigations and review articles. A large baseline aneurysm size and a rapid increase in size over time are associated with a higher risk for rupture. The importance of obtaining accurate measurements with multiplanar reconstructions and the role of new semiautomated tools for obtaining accurate, reproducible measurements are discussed. Additional CT findings that reflect aortic aneurysm instability include luminal expansion with lysis of thrombus, intramural hemorrhage (ie, the crescent sign), periaortic hemorrhage, a penetrating atherosclerotic ulcer, and contained rupture (ie, the draped aorta sign). After open or endovascular aneurysm repair, CT is routinely used to monitor for graft complications. In this setting, radiologists should understand that the presence of an endoluminal stent or surgical graft does not preclude aortic rupture. Online supplemental material is available for this article.
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Affiliation(s)
- Ajay D Wadgaonkar
- From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, 601 N Caroline Street, Room 3140D, Baltimore, MD 21287
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17
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Contemporary Management of Secondary Aortoduodenal Fistula. Ann Vasc Surg 2015; 29:1614-8. [DOI: 10.1016/j.avsg.2015.06.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 11/20/2022]
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18
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Policha A, Baldwin M, Mussa F, Rockman C. Iliac Artery-Uretero-Colonic Fistula Presenting as Severe Gastrointestinal Hemorrhage and Hematuria: A Case Report and Review of the Literature. Ann Vasc Surg 2015; 29:1656.e1-6. [DOI: 10.1016/j.avsg.2015.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 07/14/2015] [Accepted: 07/30/2015] [Indexed: 12/01/2022]
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Tagowski M, Vieweg H, Wissgott C, Andresen R. Aortoenteric fistula as a complication of open reconstruction and endovascular repair of abdominal aorta. Radiol Res Pract 2014; 2014:383159. [PMID: 25302119 PMCID: PMC4180205 DOI: 10.1155/2014/383159] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/05/2014] [Indexed: 11/17/2022] Open
Abstract
The paper intends to present a review of imaging characteristics of secondary aortoenteric fistula (AEF). Mechanical injury, infection, and adherence of a bowel segment to the aorta or aortic graft are major etiologic factors of AEF after open aortic repair. The pathogenesis of AEF formation after endovascular abdominal aortic repair is related to mechanical failure of the stent-graft, to stent graft infection, and to persistent pressurization of the aneurysmal sac. The major clinical manifestations of AEF comprise haematemesis, melaena, abdominal pain, sepsis, and fever. CT is the initial diagnostic modality of choice in a stable patient. However, the majority of reported CT appearances are not specific. In case of equivocal CT scans and clinical suspicion of AEF, scintigraphy, (67)Ga citrate scans or (18)F-FDG PET/CT is useful. Diagnostic accuracy of endoscopy in evaluation of AEF is low; nevertheless it allows to evaluate other than AEF etiologies of gastrointestinal bleeding. Without adequate therapy, AEF is lethal. Conventional surgical treatment is associated with high morbidity and mortality. The endovascular repair may be an option in hemodynamically unstable and high-risk surgical patients. We also illustrate an example of a secondary AEF with highly specific albeit rare radiologic picture from our institution.
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Affiliation(s)
- Marek Tagowski
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
| | - Hendryk Vieweg
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
| | - Christian Wissgott
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
| | - Reimer Andresen
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
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Martinez Aguilar E, Fernández Alonso S, Santamarta Fariña E, Fernández Alonso L, Atienza Pascual M, Centeno Vallespuga R. Estado actual sobre el diagnóstico y tratamiento de fístulas aortoentéricas. ANGIOLOGIA 2014. [DOI: 10.1016/j.angio.2014.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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The management of endograft infections following endovascular thoracic and abdominal aneurysm repair. J Vasc Surg 2013; 58:1179-85. [DOI: 10.1016/j.jvs.2013.04.040] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 04/02/2013] [Accepted: 04/05/2013] [Indexed: 11/20/2022]
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Sörelius K, Sundbom M, Mani K, Wanhainen A. Hybrid treatment of a post-EVAR aortoenteric fistula. Vascular 2013; 22:385-9. [DOI: 10.1177/1708538113501661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This report presents a case of secondary aortoenteric fistula after endovascular aortic repair in a fragile patient: The fistula developed due to aneurysm shrinkage and remodeling of the stent graft, resulting in a kink eroding through the aneurysm wall into the duodenum. The aortoenteric fistula was successfully treated with a hybrid procedure with endovascular aortic repair, followed by open enteroraphy and omental flap coverage of the stent graft and local antibiotic irrigation. Despite the presence of the stent graft in a previously infected field, the patient has recovered from the acute event with no septic recurrence or hemorrhage during four years of follow-up.
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Affiliation(s)
- Karl Sörelius
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Sweden
| | - Magnus Sundbom
- Section of Upper Abdominal Surgery, Uppsala University, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Sweden
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Purulent cutaneous fistula: as the first symptom of the late aortic stent-graft infection-a case report and review of the literature. Case Rep Surg 2013; 2013:421780. [PMID: 23984163 PMCID: PMC3745921 DOI: 10.1155/2013/421780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 06/30/2013] [Indexed: 11/18/2022] Open
Abstract
Purpose. Aortic stent-graft infection with fistula formation is a rare complication with high mortality rate when treated surgically by stent-graft removal. We report a case of a patient with aortic stent-graft infection, prosthetic-duodenal, and prosthetic-cutaneous fistulas operated without the removal of an infected prosthesis and ineffectively tailored antibiotic therapy. Case Report. A 66-year-old patient with high cardiovascular risk and endovascular stent-graft implantation developed a symptomatic infection of the aortic stent graft 42 months after procedure. It was manifested by iliolumbar muscle abscess and two fistulas: prosthetic cutaneous and prosthetic duodenal. The prosthetic-duodenal fistula was excised and separated from the prosthesis. The perforation within the duodenum was closed in layers. Iliolumbar abscess was removed and drainage was effected .The stent graft was left. The patient received tailored antibiotic therapy. He was readmitted to hospital after 4 weeks with symptoms of infection and leakage of pus discharge in the lumbar area. Despite the antibiotic therapy, the total parenteral nutrition of the patient's clinical status and malnutrition deteriorated and he died of cardiac arrest. Conclusion. The presented case confirms that leaving off of the infected stent graft in the patient with severe comorbidity and treated with a tailored antibiotic therapy may not be effective.
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Veger HTC, Hedeman Joosten PP, Thoma SR, Visser MJT. Infection of endovascular abdominal aortic aneurysm stent graft after urosepsis: case report and review of the literature. Vascular 2012; 21:10-3. [PMID: 22619381 DOI: 10.1258/vasc.2011.cr0294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Infection of endovascular abdominal aneurysm stent grafts is an uncommon but known complication. Inoculation with bacteria of the endovascular abdominal aneurysm stent graft during the actual implantation, in the periprocedural hospitalization or later due to an aortoenteric fistula, has been described in the literature. We report a case of endovascular abdominal aortic aneurysm stent graft infection occurring 40 months after implantation in a patient doing well up to an episode of urosepsis. In conclusion, we postulate that poor intraluminal healing of stent grafts, as observed in several explant studies, may result in a higher susceptibility to episodes of bacteremia than prosthetic vascular grafts inserted during open repair. We therefore consider the administration of prophylactic antibiotics in patients with endovascular stent grafts during periods with a likelihood of bacteremia.
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Affiliation(s)
- H T C Veger
- Department of Vascular Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden.
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Lesson learned from early and long-term results of 327 cases of coexisting surgical abdominal diseases and aortic aneurysms treated in open and endovascular surgery. Updates Surg 2012; 64:125-30. [PMID: 22407592 PMCID: PMC3360141 DOI: 10.1007/s13304-012-0137-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 02/21/2012] [Indexed: 11/01/2022]
Abstract
Patients with abdominal aortic aneurysm (AAA) frequently have other abdominal pathologies of surgical interest (other diseases, OD). Out of 1,375 elective open aortic replacements for AAA, 315 cases with OD were subdivided in Group 1 (82 patients with "clean wound" OD) and Group 2 (233 patients with "clean-contaminated wound" OD). The results of the sub-groups in which OD was treated at the same time as AAA were analysed (1a, 66 cases and 2a, 86 cases) and compared with OD not treated at the same time as AAA (1b, 16 cases and 2b, 147 cases). EVAR was done in 12 patients with a infrarenal AAA and concomitant abdominal disease. In this group post-operative complications occurred in two patients (endoleaks) and no sign of endograft infection was developed. Mean follow-up was 36 months. Mortality was 0% in Group 1a, 1b, 2b and 5.8% in Group 2a. In Group 1a there were one haemoperitoneum, one ischaemic colitis and one graft infection. In Group 1b there were 4 nefrectomies for renal carcinoma and three emergency hernia repairs within 18 months from AAA operation. In Group 2a the follow-up was uneventful. In Group 2b there was no acute complication of OD and 57.2% of patients were subsequently operated for OD. In the EVAR group the 30-day and late mortality rates were 0 and 25%, respectively and all deaths were cancer-related. Contemporary correction of OD in open surgery for AAA should be performed in clean wound cases, while clean-contaminated operations can be done only in selected cases. EVAR is a valid alternative technique to open vascular surgery for the concomitant treatment of aortic aneurysms and abdominal pathologies.
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McPhee JT, Soybel DI, Oram RK, Belkin M. Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak. J Vasc Surg 2011; 54:1164-6. [DOI: 10.1016/j.jvs.2011.04.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 04/20/2011] [Accepted: 04/21/2011] [Indexed: 11/29/2022]
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Pérez SC, Galán FC, Mallagray EP, Grau JB, Marco CF. Endovascular treatment of two aortoduodenal fistulae. Vascular 2011; 19:277-81. [DOI: 10.1258/vasc.2011.cr0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We report the endovascular treatment of two patients presenting with aortoduodenal fistulae. The first patient was a 66-year-old man admitted with hematemesis. He was on clopidogrel and had received a cryopreserved aortic graft for a mycotic abdominal aortic aneurysm five years earlier. Computed tomography (CT) showed aortic pseudoaneurysms in close contact with the duodenum. Endovascular repair was carried out. Twenty-seven months after the procedure the patient remains asymptomatic. The second patient was a 78-year-old man admitted with abdominal pain and nausea. CT revealed an abdominal aortic pseudoaneurysm and aortoduodenal fistula. He suffered from severe chronic obstructive pulmonary disease that greatly increased his surgical morbidity and mortality. An endovascular repair was performed under epidural anesthesia. The patient died of a postoperative pneumonia 38 days after surgery. These two cases illustrate the importance of endovascular aortic repair especially when an open surgical procedure is either difficult or impossible.
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Affiliation(s)
- Susana Cancer Pérez
- Department of Vascular Surgery, Hospital Universitario Fundación Alcorcón, C/ Budapest 1, Alcorcón, Madrid, Spain
| | - Fernando Criado Galán
- Department of Vascular Surgery, Hospital Universitario Fundación Alcorcón, C/ Budapest 1, Alcorcón, Madrid, Spain
| | - Enrique Puras Mallagray
- Department of Vascular Surgery, Hospital Universitario Fundación Alcorcón, C/ Budapest 1, Alcorcón, Madrid, Spain
| | - Juan B Grau
- The University of Pennsylvania School of Medicine, 51 N 39th Street, Suite 2A, Philadelphia, PA 19014, USA
| | - Carmen Fiuza Marco
- Department of General Surgery, Hospital Universitario Fundación Alcorcón, C/ Budapest 1, Alcorcón, Madrid, Spain
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Abstract
Endovascular aneurysm repair (EVAR) has become an established technique for the treatment of many infrarenal aortic aneurysms. Although EVAR is obviously less invasive than open surgical repair, it is not free of complications. These can potentially result in severe morbidity or even mortality, stressing the need for an early detection and subsequent treatment. In this review article, the pathophysiology, diagnosis, and treatment of the most common complications of EVAR, with the exception of endoleaks, are described.
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Affiliation(s)
- Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
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Kasai K, Ushio A, Tamura Y, Sawara K, Kasai Y, Oikawa K, Endo M, Takikawa Y, Suzuki K. Conservative treatment of an aortoesophagial fistula after endovascular stent grafting for a thoracic aortic aneurysm. Med Sci Monit 2011; 17:CS39-42. [PMID: 21455111 PMCID: PMC3539520 DOI: 10.12659/msm.881702] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Aortoesophageal fistula (AEF) is an uncommon condition that presents a problem in therapy because of the high rate of morbidity and mortality associated with its surgical management and the uniformly fatal outcome of medical treatment. In this article we describe a case of secondary AEF after endoluminal stent grafting of the thoracic aorta, which was observed by only conservative management and followed up for 14 months with no signs of recurrent hemorrhage or chronic mediastinitis. Case Report A 54-year old man with hepatocellular carcinoma (HCC) was admitted to our hospital because of tarry stool. He had a history of traumatic aneurysm, and undergone segmental replacement with a stent graft three years ago. After admission, Esophagogastroduodenoscopy and computed tomography identified AEF. He was treated conservatively, because his stage of HCC was advanced. Oral intake was prohibited, and the patient received proton pump inhibitors, intravenous hyperalimentation and antibiotics. Afterwards, no signs of hemorrhage were observed. Although oral intake was resumed after that, another bleeding event or development of mediastinitis was not observed. Subsequently, He was received chemotherapy for advanced HCC, and we observed downstaging of his advanced HCC. Conclusions Although we observed 14 months survival in our case under conservative management of secondary AEF, it seems that the treatment of secondary AEF should do the operative management.
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Affiliation(s)
- Kazuhiro Kasai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, Morioka, Iwate, Japan.
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Fernández-Samos Gutiérrez R, Martínez Mira C, Alonso Argüeso G, Peña Cortés R, Alonso Alvarez M, Vaquero Morillo F. Fístula aortoentérica post-EVAR. Presentación de un caso y revisión de la literatura. ANGIOLOGIA 2011. [DOI: 10.1016/j.angio.2011.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ditisheim S, Girardin M, Dumonceau JM, Hadengue A, Frossard JL. Primary aortodigestive fistula: a rare and potentially lethal cause of gastrointestinal hemorrhage. Case Rep Gastroenterol 2011; 5:428-32. [PMID: 21960944 PMCID: PMC3180658 DOI: 10.1159/000329881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Primary aortodigestive fistulas (PAFs) are a rare cause of gastrointestinal bleeding, with an incidence of 0.04-0.07% in autopsy series. The diagnosis of PAF is difficult and should be considered in patients with gastrointestinal hemorrhage of obscure origin. Because of its high mortality rate, clinical recognition of prodromal symptoms for early diagnosis is crucial for effective treatment. We report on the case of a 79-year-old patient with a PAF who was admitted for hematochezia and melena. The PAF was suspected during upper gastrointestinal endoscopy and confirmed by CT angiography.
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Affiliation(s)
- Saskia Ditisheim
- Department of Gastroenterology and Hepatology, University Hospital of Geneva, Geneva, Switzerland
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Schenker MP, Majdalany BS, Funaki BS, Yucel EK, Baum RA, Burke CT, Foley WD, Koss SA, Lorenz JM, Mansour MA, Millward SF, Nemcek AA, Ray CE. ACR Appropriateness Criteria® on Upper Gastrointestinal Bleeding. J Am Coll Radiol 2010; 7:845-53. [DOI: 10.1016/j.jacr.2010.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 05/25/2010] [Indexed: 12/14/2022]
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Walker TG, Kalva SP, Yeddula K, Wicky S, Kundu S, Drescher P, d'Othee BJ, Rose SC, Cardella JF. Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2010; 21:1632-55. [DOI: 10.1016/j.jvir.2010.07.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 05/24/2010] [Accepted: 07/11/2010] [Indexed: 12/17/2022] Open
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Huang JH, Chen JS, Chu SH, Chiu KM. Recurrent cervical carcinoma presenting as a primary aortoduodenal fistula. Ann Vasc Surg 2010; 24:1133.e5-7. [PMID: 20800434 DOI: 10.1016/j.avsg.2009.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 12/08/2009] [Indexed: 11/26/2022]
Abstract
Aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding, and carries high morbidity and mortality even in modern practice. Cervical carcinoma is a major health threat among adult women, and its recurrence is not uncommon. We herein present a case of primary aortoduodenal fistula because of recurrent cervical carcinoma. Our case demonstrated that diagnosis of primary aortoenteric fistula requires a high index of suspicion and a combination of diagnostic modalities to establish the diagnosis. Prompt diagnosis and rapid treatment are critical in reducing mortality and morbidity. Although rare, metastatic carcinoma can lead to aortoenteric fistula.
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Affiliation(s)
- Jih-Hsin Huang
- Division of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, Taipei, Taiwan
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Polymicrobial Abdominal Aortic Endograft Infection Secondary to Aorto-Enteric Para-Prosthetic Erosion. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2009. [DOI: 10.1097/ipc.0b013e3181a74cfc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lazaris AM, Tsapralis D, Patapis P, Mproutzos E, Tzathas H, Kakisis JD, Vasdekis SN. Aortoiliac endograft-enteric fistula due to an ingested toothpick. J Vasc Surg 2009; 50:640-3. [DOI: 10.1016/j.jvs.2009.03.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 03/31/2009] [Accepted: 03/31/2009] [Indexed: 10/20/2022]
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Aortoesophageal fistula after thoracic aortic stent-graft placement: a rare but catastrophic complication of a novel emerging technique. JACC Cardiovasc Interv 2009; 2:570-6. [PMID: 19539264 DOI: 10.1016/j.jcin.2009.03.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 03/03/2009] [Accepted: 03/04/2009] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Our goal was to report characteristics and outcomes of 6 patients with aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR). BACKGROUND Neurologic events are severe complications of TEVAR. With growing experience of TEVAR, other yet unexpected devastating complications have emerged. METHODS Between July 1999 and August 2008, 268 patients underwent TEVAR for various thoracic aortic diseases at our institution. RESULTS Six of 268 patients (age 49 to 77 years, 50% female patients) developed AEF (incidence 1.9%) within 1 to 16 months after the procedure. Indications for TEVAR were acute aortic dissection (n = 3), chronic aortic dissection (n = 1), and thoracic aortic aneurysm (n = 2). Four patients presented with sudden massive hematemesis whereas 2 patients were readmitted for new-onset fever and elevated markers of inflammation that preceded hematemesis. Esophago-gastro-duodenoscopy identified deep esophageal ulcerations at the level of the implanted aortic stent-graft in 4 patients, but only mild erosive lesions within the proximal esophagus without signs of active bleeding in the remaining 2 patients. Surgical repair was performed in only 1 patient and declined in the remaining because of comorbidities and multiorgan system failure. Despite this, all patients died due to fatal rebleeding (n = 4) or mediastinitis (n = 2). CONCLUSIONS AEF is a rare and unusual complication of TEVAR that occurs relatively early after the procedure and is almost invariably fatal. New-onset fever with elevated inflammatory markers or hematemesis should heighten clinical suspicion of AEF in TEVAR patients and prompt computed tomography or esophago-gastro-duodenoscopy in the hope of detecting, triaging, and treating this early to improve the otherwise dismal outcomes of these patients.
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41
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Secondary Infections of Thoracic and Abdominal Aortic Endografts. J Vasc Interv Radiol 2009; 20:173-9. [DOI: 10.1016/j.jvir.2008.10.032] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 10/23/2008] [Accepted: 10/28/2008] [Indexed: 11/20/2022] Open
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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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Valentine RJ, Timaran CH, Modrall GJ, Smith ST, Arko FR, Clagett GP. Secondary Aortoenteric Fistulas Versus Paraprosthetic Erosions: Is Bleeding Associated with a Worse Outcome? J Am Coll Surg 2008; 207:922-7. [DOI: 10.1016/j.jamcollsurg.2008.08.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 08/13/2008] [Accepted: 08/13/2008] [Indexed: 10/21/2022]
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