Emergent endovascular treatment of a bleeding recurrent aortoenteric fistula as a “bridge” to definitive surgical repair

Endovascular Management of Aortic Stump Blowout by Parallel Grafting and Coil Embolization of Visceral Aorta

Aortic graft and endograft infections remain a significant source of morbidity and mortality after abdominal aortic aneurysm repair. With graft excision and extra-anatomic bypass, an infrarenal aortic stump remains which can have suture line dehiscence and catastrophic stump blowout. Treatment of this is extremely challenging, especially for severely co-morbid patients who cannot undergo major surgery, or in patients with a hostile abdomen. We present a case study of a 74-year-old male found to have an aortoenteric fistula (AEF). This case broadens operative options for this type of patient population by demonstrating an endovascular technique for addressing aortic stump blowout by parallel grafting and coil embolization of the visceral aorta.

Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy

BACKGROUND

Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition.

METHODS

We performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections.

RESULTS

Between 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent in situ revascularization and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6-62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum's second part-jejunum anastomosis was performed in 43% of patients (n = 6), and 19% of the patients (n = 3) died perioperatively. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1-year and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death.

CONCLUSIONS

Surgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.

A Novel Endovascular Treatment for Recurrent Secondary Aorto-Enteric Fistula in a Patient With Prior Infra-Renal Aortic Ligation

This report highlights the use of novel endovascular techniques in a 68-year-old male patient with massive hematemesis from a recurrent secondary aorto-enteric fistula (SAEF). With a prior history of infrarenal aortic ligation and the location of the SAEF being at the aortic sac, we explain the considerations for the techniques used and how we were able to stop the bleeding using percutaneous transarterial embolotherapy.

Endovascular treatment of aortic stump rupture after extra-anatomical aortoduodenal fistula repair is not a definite treatment: a case report and review of literature

Introduction

Endovascular treatment of an aortic stump rupture is technically feasible. Whether this is a definitive treatment or a bridge to further surgery is unknown.

Report

Previously a Case of an aortic stump rupture following extra-anatomic repair of a recurrent aortoduodenal fistula (ADF), which was successfully treated endovascularly by placement of an Amplatzer® Vascular Plug was described. The patient survived this acute procedure, but four years later was admitted with fever and back pain. Imaging revealed progressive enlargement of the aortic stump. A re-exploration was performed with removal of the infected aortic stump including the Amplatzer plug. A new aortic stump was created together with resection of an adherent part of the duodenum. The patient was discharged after five months and was able to survive for two more years without any recurring vascular complications.

Discussion

This Case demonstrates that after four years, endovascular treatment was not a definitive treatment for aortic stump rupture. Endovascular treatment should be followed by definitive treatment when the patient is fit for surgery, especially in cases of ADF. If the patient is unfit for surgery, conservative treatment with culture based antibiotics is a reasonable alternative. Positive obstinacy lengthened the survival of this patient with eight years of reasonably good quality life.

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Aortic stump ruptures are frequently lethal and demand rapid treatment.

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Aortic stump ruptures can be treated endovascularly.

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Late aortic stump enlargement prompts for definitive surgical repair.

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In certain cases, endovascular treatment should be regarded as a bridge to further surgery.

A Technical Tip of Aortic Stump Reinforcement with Plication of the Falciform Ligament of the Liver

BACKGROUND

The residual stump after excision of an infected aortic graft may be subject to acute disruption-blowout-because of recurrence of infection or fatigue due to the mechanical stress. We present an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump.

METHODS

We excised the falciform ligament by giving attention to avoid any bleeding from the liver. The aortic stump was reinforced with synthetic, monofilament, nonabsorbable polypropylene sutures and the falciform ligament of the liver was plicated inside the stump and further sutured with polypropylene sutures.

RESULTS

After 5 months, he is in excellent condition. His laboratory examination is normal, he has stopped taking antibiotics, gained his initial weight, and recovered full activity.

CONCLUSIONS

We presented an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump after excision of an infected aortobiiliac synthetic graft. This technique can be an alternative option in patients with weak arterial wall or extended bacterial local infection in the retroperitoneal area which renders the aortic wall tissue extremely stiff to be folded and sutured. This technique may enhance the mechanical integrity of the stump.

Endovascular treatment of aortic stump blow-out after extra-anatomical repair of aortoduodenal fistula: a case report and review of literature

BACKGROUND

An aortoduodenal fistula (ADF) is an unusual, but serious complication following surgical or endovascular aortic repair. The optimal treatment for ADF consists of removal of the infected graft with in situ or extra-anatomical repair and is associated with high mortality. Part of this mortality is caused by re-bleeding or aortic stump ruptures. Classical treatment of an aortic stump rupture involves immediate re-laparotomy, removal of infected tissue, aortic stump formation and reinforcement with soft tissue flaps. However, this invasive treatment is often difficult to perform and the condition of the patient frequently requires a more rapid response. We describe a case in which an aortic stump rupture was treated endovascularly by using an Amplatzer® Vascular Plug, which successfully stopped the bleeding.

CASE PRESENTATION

This report describes a 67-year-old man who was presented with persistent duodenal leakage (due to secondary duodenal perforation) after resection and open in-situ repair of an infected aorto-bi-femoral prosthetic graft. An extra-anatomical reconstruction was performed with an axillo-bi-femoral bypass, followed by excision of the prosthesis, aortic stump formation, partial duodenal resection and duodenojejunal reconstruction. Twelve weeks later, sudden severe hematemesis with severe hemodynamic instability occurred. Computed tomography angiography showed extravasation of blood from the aortic stump into the duodenal loop. Endovascular treatment of the aortic stump blow-out with an Amplatzer® Vascular Plug was performed, which successfully stopped the bleeding and stabilized the patient. The duodenal fistula was treated conservatively. Three months later, the patient was discharged to a rehabilitation clinic in a good clinical condition. The patient was still alive after a follow-up of 4 years.

CONCLUSIONS

Rapid treatment is requested in cases of aortic stump rupture. Re-laparotomy is practically never the most suitable solution and most of these aortic stump ruptures are fatal. Endovascular treatment could be a suitable alternative. Whether the endovascular treatment of aortic stump rupture is a definitive treatment or a bridge to surgery remains to be elucidated.

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

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.

Successful Bridge Therapy with Initial Endovascular Repair for Arterioenteric Fistula Resulting from Pseudoaneurysm Rupture with Massive Gastrointestinal Hemorrhage after Pancreas Transplantation

Pseudoaneurysm after pancreas transplantation has a reported incidence of 1.4 to 8.0% and may be caused by perioperative infection. Subsequent pseudoaneurysm rupture is a rare cause of arterioenteric fistula. Only 28 cases of arterioenteric fistula after pancreas transplantation have been reported in the past 20 years. We experienced a rare case of arterioenteric fistula resulting from pseudoaneurysm rupture after pancreas transplantation. We successfully treated the arterioenteric fistula with multistaged bridge therapy composed of initial endovascular aneurysm repair, secondary isolation of the fistula, and definitive open repair with extraanatomic bypass. No complications occurred in 1 year of follow-up; this staged therapy seems feasible for patients with arterioenteric fistula.

Total retroperitoneal approach to aortic reconstruction: A novel technique for aorto-enteric fistulae and graft infections

Aorto-enteric fistulae pose a challenging negative outcome of aortic intervention. Treatment involves graft excision, and recently, more enthusiasm has met in situ revascularization over extra-anatomic bypass. This has been traditionally performed through the transperitoneal approach via a midline abdominal incision. We propose an exclusively total retroperitoneal technique in managing this complication with regard to both the vascular and alimentary tract technical aspects of the procedure. This involves exclusion and bypass of the affected segment followed by en-mass resection of the affected segment with the duodenum, and finally, bowel anastomosis. We present a case of an aorto-enteric fistulae illustrating classical radiological findings treated via a flank incision and retroperitoneal technique after a temporizing endovascular stent placement at an outside institution. Peri-operative course was uneventful. The retroperitoneal approach has been shown to be equivalent to its transperitoneal counterpart in many aspects of treating aortic disease. It has also been shown to be superior in others, including but not limited to, faster return of bowel function, decreased respiratory complications, less blood loss and shorter length of stay in the intensive care unit (ICU) and hospital. We recommend adding this approach to every vascular surgeons operative armamentarium when it comes to managing aorto-enteric fistulae. This might be especially helpful in avoiding re-operative planes, thus minimizing blood loss and iatrogenic bowel injury, better aortic exposure, and adequate access to the duodenum.

New therapeutic options provided by off-label deployment of stent graft for tailored arteriovenous access salvage: Two cases

A tailored therapy to patient requirements by combining endovascular and surgical steps can be necessary to prolong the life of a vascular access. Stent grafts play a growing role for the therapy of dialytic access complications. Randomized multi-center trials, however, support the on-label use of stent grafts in the treatment of graft venous outflow and in-stent restenosis. The main contraindication to their use is an ongoing infection. We report two cases of new off-label application of Viabahn (Gore, flagstaff, USA) stent graft. In the first case, the failure of a radiocephalic early cannulation graft was treated by stent graft placement on the arterial inflow anastomosis, when emergent angiographic examination revealed the previously unknown high takeoff of the radial artery from the axillary artery. At 13-month follow-up, the target lesion remained untreated. In the second case, elbow stent graft occlusion with extended thrombosis occurred in a right radiocephalic fistula after 3 years of unassisted patency. Being the last option for vascular access, successful endovascular recanalization was carried out. After 3 months, however, the clinical setting relapsed. A two-stage hybrid strategy with vascular surgeon was arranged due to ongoing signs of local infection. Flow was restored by emergent thromboaspiration associated with a new stent graft placement as a endovascular bridge to subsequent surgical treatment. After 2 days, the overlapped stent grafts were excised as planned. Surgical rerouting was completed by polytetrafluoroethylene prosthetic bridge implantation across the elbow. At 4 months, the follow-up remained uneventful. In selected instances, the off-label use of stent grafts may expand the therapeutic options of the vascular access team.

Current status of endovascular treatment of aortoenteric fistula

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.

Secondary aortoduodenal fistula and the unrecognised herald bleed

A 65-year-old man with history of aortobifemoral surgery 4 years ago was admitted to hospital after sudden abdominal pain. Initially misdiagnosed as renal colic, he was treated with analgesics, and while on observation he started with haematemesis, rapidly responding to volume infusion. Upper gastrointestinal endoscopy showed fresh blood in the stomach with no visible active bleeding. CT scan showed an important contrast extravasation from the aorta to the third duodenal portion, restarting haemodynamic instability and a cardiac arrest. Cardiopulmonary resuscitation (CPR) manoeuvres followed by intense fluid resuscitation and urgent laparotomy with a fast transabdominal supracoeliac aortic clamping was performed. After multiple blood and plasma unit transfusion and intravenous norepinephrine, two more cardiac arrests were recovered. Unfortunately, after aggressive management, the patient rapidly deteriorated and deceased on the table. Aortoduodenal fistula is a rare entity causing life-threatening bleeding. Its diagnosis requires high clinical suspicion and surgery offers the only hope for survival.

A Rare Cause of Primary Aortoenteric Fistula: Streptococcus parasanguinis Aortitis

Primary aortoenteric fistula is a rare cause of upper gastrointestinal bleed but can lead to significant mortality if the diagnosis is delayed. Aortitis, characterized by inflammation of the aortic wall, is a rare cause of aortoenteric fistula. We present a case report of a 72-year-old male patient with infectious aortoenteric fistula secondary to Streptococcus parasanguinis, along with a review of the literature. This case demonstrates the importance of early diagnosis and aggressive surgical treatment of aortoenteric fistulae and recognizing infectious aortitis as a potential etiology.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Late Stent Graft Infection after the Emergency Endovascular Repair of a Secondary Iliac Artery-Enteric Fistula Treated with Graft Removal and In Situ Aortic Reconstruction Using Femoral Veins

An arterioenteric fistula is a devastating and life-threatening condition that requires urgent treatment. Less-invasive endovascular treatment has emerged as an alternative to conventional open repair, but postoperative graft infection remains a major concern. We herein report a case of late stent graft infection after emergency endovascular repair of a secondary iliac artery-enteric fistula. The patient was a 63-year-old male who presented with a fever, who had undergone successful endovascular stent grafting for a secondary common iliac artery-enteric fistula 29 months prior. The diagnosis of a stent graft infection was confirmed via computed tomography. He underwent graft removal and in situ reconstruction with femoral vein grafts. At 6-month follow-up, the patient is in a good general condition without any symptoms.

Primary aortoduodenal fistula with a history of distal gastrectomy

Case

A 69‐year‐old man was transferred to our hospital because of an aortoduodenal fistula with hematemesis and pre‐shock vital signs. He had a history of alcoholism, malnutrition, and distal gastrectomy and Billroth I reconstruction. Endovascular aneurysm repair was successfully carried out; however, the presence of comorbidities affected further radical treatment.

Outcome

The patient survived for 2 months postoperatively.

Conclusion

Endovascular aneurysm repair is a useful first‐line treatment for high‐risk aortoduodenal fistula patients; however, it requires improvement for long‐term outcomes in complicated high‐risk cases.

Late Leakage of the Aortic Stump After Removal of an Infected Graft: Successful Surgical Treatment

The residual stump after excision of an infected aortic graft may be subject to acute blowout due to chronic mechanical stress on a weak arterial wall. We present a case of late aortic stump disruption that required revision after 12 months from graft removal. Our strategy consisted of avoiding reexposure of the pararenal aorta by creating a new supraceliac stump with healthy aortic wall after antegrade visceral debranching. This case confirms the need for long-term surveillance of aortic stumps. The use of a supraceliac approach minimizes the risk of intraoperative blowout and postoperative disruption.

Use of Aortic Occluders and Endovascular Plugs in a 2-step Hybrid Treatment of Secondary Aortoenteric Fistulas

Aortoenteric fistula (AEF) is a dreadful complication of abdominal aortic surgery. Surgical treatment is associated to high mortality and requires urgent graft removal with extra-anatomic or in situ reconstruction. Other authors suggest the use of stent grafts, both as a stand-alone procedure or as a bridge solution before open repair. We reviewed the results of a cohort of patients that presented at our institution with an AEF and were treated with a novel 2-step endovascular-open surgical procedure. The first step consisted in immediate endovascular occlusion of the infrarenal graft with deployment, below the renal arteries, of an aortic occluder and/or endovascular plugs. After occlusion of the infrarenal graft, extra-anatomic reconstruction (axillofemoral bypass) was performed. The second step consisted in the removal of the infrarenal graft with aortic stump ligation and took place after a few days recovery to allow improvement of patients' condition. A total of 5 selected patients were treated. Endovascular aortic occlusion was achieved in all cases with the deployment of 1 (3 patients) or 2 (2 patients) devices. The mean interval between the first and the second step was 7 days (min 4-max 13). Complete removal of the aortic graft was possible in all patients. One patient died on the first postoperative day due to multiorgan failure (1 of 5, 20%). Mean survival after discharge was 24 months (min 6-max 36). One patient died at 6 months because of aortic stump blowout. In our initial experience, endovascular aortic occlusion seems an effective option to prevent fatal enteric bleeding and a valuable first-step treatment for selected cases of AEF.

Secondary aorto-enteric fistula presenting over a 2-month period with recurrent gastrointestinal bleeding

A female in her sixties presented with recurrent gastrointestinal bleeding over a two-month period requiring multiple hospital admissions. Inconclusive upper and lower gastrointestinal endoscopies in addition to an initial negative CT angiogram initially left the diagnosis uncertain. A subsequent catastrophic bleed prompted a further CT angiogram that demonstrated a fistula between the aorta and third part of the duodenum with active contrast extravasation. Emergency surgery was carried out but ultimately the patient did not survive.

A rare and forgotten diagnosis of gastrointestinal bleeding: primary aortoduodenal fistula

Upper gastrointestinal (UGI) bleeding is a common medical condition among adults. Bleeding is mainly caused by the gastric or proximal duodenum, but rarely by the distal duodenum. Aortoduodenal fistula is one of the causes of UGI bleeding that results in a life-threatening condition if not treated properly. It is commonly observed in patients who have undergone previous aortic surgery and rarely occurs in patients without a history of aortic surgery. Diagnosis of aortoenteric fistula is difficult unless there is a high level of clinical suspicion. In this article, we aim to present a patient with aortoduodenal fistula and discuss the clinical presentation, as well as the diagnostic and therapeutic options of this disease.