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Akamatsu D, Serizawa F, Umetsu M, Suzuki S, Goto H, Unno M, Kamei T. Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy. Ann Vasc Surg 2024; 101:148-156. [PMID: 38159719 DOI: 10.1016/j.avsg.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/31/2023] [Accepted: 10/22/2023] [Indexed: 01/03/2024]
Abstract
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.
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Affiliation(s)
| | - Fukashi Serizawa
- Department of Surgery, Tohoku University Hospital, Sendai, Japan
| | - Michihisa Umetsu
- Department of Surgery, Tohoku University Hospital, Sendai, Japan
| | - Shunya Suzuki
- Department of Surgery, Tohoku University Hospital, Sendai, Japan
| | | | - Michiaki Unno
- Department of Surgery, Tohoku University Hospital, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Hospital, Sendai, Japan
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Lu SW, Niu KY, Pai CP, Lin SH, Chen CB, Lo YT, Lee YC, Seak CJ, Yen CC. Novel Prediction Score for Arterial-Esophageal Fistula in Patients with Esophageal Cancer Bleeding: A Multicenter Study. Cancers (Basel) 2024; 16:804. [PMID: 38398195 PMCID: PMC10886662 DOI: 10.3390/cancers16040804] [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: 01/12/2024] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
PURPOSE To develop and internally validate a novel prediction score to predict the occurrence of arterial-esophageal fistula (AEF) in esophageal cancer bleeding. METHODS This retrospective cohort study enrolled patients with esophageal cancer bleeding in the emergency department. The primary outcome was the diagnosis of AEF. The patients were randomly divided into a derivation group and a validation group. In the derivation stage, a predictive model was developed using logistic regression analysis. Subsequently, internal validation of the model was conducted in the validation cohort during the validation stage to assess its discrimination ability. RESULTS A total of 257 patients were enrolled in this study. All participants were randomized to a derivation cohort (n = 155) and a validation cohort (n = 102). AEF occurred in 22 patients (14.2%) in the derivation group and 14 patients (13.7%) in the validation group. A predictive model (HEARTS-Score) comprising five variables (hematemesis, active bleeding, serum creatinine level >1.2 mg/dL, prothrombin time >13 s, and previous stent implantation) was established. The HEARTS-Score demonstrated a high discriminative ability in both the derivation and validation cohorts, with c-statistics of 0.90 (95% CI 0.82-0.98) and 0.82 (95% CI 0.72-0.92), respectively. CONCLUSIONS By employing this novel prediction score, clinicians can make more objective risk assessments, optimizing diagnostic strategies and tailoring treatment approaches.
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Affiliation(s)
- Sz-Wei Lu
- Department of Emergency Medicine, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan;
- Department of Emergency Medicine, Tri-Service General Hospital SongShan Branch, National Defense Medical Center, Taipei 105, Taiwan
| | - Kuang-Yu Niu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (K.-Y.N.); (Y.-C.L.)
| | - Chu-Pin Pai
- Division of Thoracic Surgery, Department of Surgery, Lotung Poh-Ai Hospital, Yilan 265, Taiwan;
| | - Shih-Hua Lin
- Department of Gastroenterology and Hepatology, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan;
| | - Chen-Bin Chen
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan; (C.-B.C.); (C.-J.S.)
| | - Yu-Tai Lo
- Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
| | - Yi-Chih Lee
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (K.-Y.N.); (Y.-C.L.)
| | - Chen-June Seak
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan; (C.-B.C.); (C.-J.S.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chieh-Ching Yen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan; (K.-Y.N.); (Y.-C.L.)
- Department of Emergency Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan; (C.-B.C.); (C.-J.S.)
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
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Gavali H, Mani K, Furebring M, Olsson KW, Lindström D, Sörelius K, Sigvant B, Torstensson G, Andersson M, Forssell C, Åstrand H, Lundström T, Khan S, Sonesson B, Stackelberg O, Gillgren P, Isaksson J, Kragsterman B, Gidlund KD, Horer T, Sadeghi M, Wanhainen A. Semi-Conservative Treatment Versus Radical Surgery in Abdominal Aortic Graft and Endograft Infections. Eur J Vasc Endovasc Surg 2023; 66:397-406. [PMID: 37356704 DOI: 10.1016/j.ejvs.2023.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 04/30/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Abdominal aortic graft and endograft infections (AGIs) are rare complications following aortic surgery. Radical surgery (RS) with resection of the infected graft and reconstruction with extra-anatomical bypass or in situ reconstruction is the preferred therapy. For patients unfit for RS, a semi-conservative (SC), graft preserving strategy is possible. This paper aimed to compare survival and infection outcomes between RS and SC treatment for AGI in a nationwide cohort. METHODS Patients with abdominal AGI related surgery in Sweden between January 1995 and May 2017 were identified. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria were used for the definition of AGI. Multivariable regression was performed to identify factors associated with mortality. RESULTS One hundred and sixty-nine patients with surgically treated abdominal AGI were identified, comprising 43 SC (14 endografts; 53% with a graft enteric fistula [GEF] in total) and 126 RS (26 endografts; 50% with a GEF in total). The SC cohort was older and had a higher frequency of cardiac comorbidities. There was a non-significant trend towards lower Kaplan-Meier estimated five year survival for SC vs. RS (30.2% vs. 48.4%; p = .066). A non-significant trend was identified towards worse Kaplan-Meier estimated five year survival for SC patients with a GEF vs. without a GEF (21.7% vs. 40.1%; p = .097). There were significantly more recurrent graft infections comparing SC with RS (45.4% vs. 19.3%; p < .001). In a Cox regression model adjusting for confounders, there was no difference in five year survival comparing SC vs. RS (HR 1.0, 95% CI 0.6 - 1.5). CONCLUSION In this national AGI cohort, there was no mortality difference comparing SC and RS for AGI when adjusting for comorbidities. Presence of GEF probably negatively impacts survival outcomes of SC patients. Rates of recurrent infection remain high for SC treated patients.
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Affiliation(s)
- Hamid Gavali
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Mia Furebring
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Karl Wilhelm Olsson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Birgitta Sigvant
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Vascular Surgery, Karlstad Central Hospital, Karlstad, Sweden
| | - Gustav Torstensson
- Department of Surgery, Helsingborg Regional Hospital, Helsingborg, Sweden
| | - Manne Andersson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, County Hospital Ryhov, Ryhov, Jönköping County, Sweden
| | - Claes Forssell
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Håkan Åstrand
- Department of Surgery, County Hospital Ryhov, Ryhov, Jönköping County, Sweden
| | - Tobias Lundström
- Department of Surgery and Urology, Eskilstuna Hospital, Eskilstuna, Sweden
| | - Shahzad Khan
- Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden
| | - Björn Sonesson
- Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden
| | - Otto Stackelberg
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Gillgren
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Södersjukhuset, Stockholm, Sweden
| | - Jon Isaksson
- Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden
| | - Björn Kragsterman
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgery, Västerås Central Hospital, Västerås, Sweden
| | - Khatereh Djavani Gidlund
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mitra Sadeghi
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden
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Hou XF, Liu LX, Zhao ZX, Yang JY. A case report and literature review of an aortoduodenal fistula complicated by intestinal Ascaris lumbricoides. Asian J Surg 2023; 46:4042-4043. [PMID: 37105813 DOI: 10.1016/j.asjsur.2023.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Affiliation(s)
- Xiao-Fan Hou
- Qinghai University Medical College, Xining, 810007, Qinghai Province, China
| | - Lin-Xun Liu
- Department of General Surgery, Qinghai Provincial People's Hospital, Xining, 810007, Qinghai Province, China
| | - Zhan-Xue Zhao
- Department of General Surgery, Qinghai Provincial People's Hospital, Xining, 810007, Qinghai Province, China
| | - Jin-Yu Yang
- Department of General Surgery, Qinghai Provincial People's Hospital, Xining, 810007, Qinghai Province, China.
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Ozawa H, Ohki T, Shukuzawa K, Chono Y, Omori M, Baba T, Hara M, Tachihara H. Evolution of open aneurysmorrhaphy for management of sac expansion after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2023; 77:760-768. [PMID: 36306936 DOI: 10.1016/j.jvs.2022.10.024] [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: 06/10/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We evaluated the perioperative and mid-term clinical outcomes of open aneurysmorrhaphy (OA) for the treatment of sac expansion after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. METHODS OA involves sac exposure without dissection of the proximal or distal neck, sacotomy and ligation of back-bleeding vessels, preservation of the prior stent graft, and tight closure of the sac around the stent graft. We performed a retrospective review of all patients who had undergone OA for nonruptured sac expansion after standard EVAR at our institution between January 2015 and June 2021. The primary end points were 30-day mortality and aneurysm-related death. The secondary end points were postoperative complications, overall survival, freedom from reintervention, and sac regrowth rate. RESULTS A total of 28 patients had undergone OA. Their mean age was 76.9 ± 6.7 years. The median sac diameter at OA was 79 mm (interquartile range [IQR], 76-92 mm). The median duration from the index EVAR to OA was 82 months (IQR, 72-104 months). Preoperative computed tomography angiography confirmed a type II endoleak (EL) in 20 patients, 1 of whom had had a coexisting type Ia EL; a type IIIb EL was identified in 1 patient. Concomitant endovascular procedures had been performed in six patients to treat a type I or III EL or reinforce the proximal and distal seals. The OA technique has been modified since 2017, with the addition of more aggressive dissection of the sac and complete removal of the mural thrombus to further decrease the sac diameter. Postoperative complications occurred in two patients and included abdominal lymphorrhea and failed hemostasis of the common femoral artery requiring surgical repair in one patient each. The 30-day mortality was 0%. During the median follow-up of 36 months (IQR, 14-51 months), the overall survival was 92.7% and 86.9% at 12 and 36 months, respectively, without any aneurysm-related death. In the late (2017-2021) treatment group, the median sac diameter immediately after OA was smaller than that in the early (2015-2016) treatment group (early group: median, 50 mm; IQR, 39-57 mm; vs later group: median, 41 mm; IQR, 32-47 mm; P = .083). Furthermore, in the late group, the sac regrowth rate was lower (early group: median, 0.36 mm/mo; IQR, 0.23-0.83 mm/mo; vs late group: median, 0 mm/mo; IQR, 0-0.11 mm/mo; P = .0075) and the freedom from reintervention rate was higher (late group: 94.7% at both 12 and 36 months, respectively; early group: 71.4% and 53.6% at 12 and 36 months, respectively; log-rank P = .070). CONCLUSIONS Our results have shown that OA for the management of post-EVAR sac expansion is feasible with acceptable mid-term outcomes. Aggressive dissection and tight plication of the sac might be imperative for better mid-term outcomes after OA.
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Affiliation(s)
- Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiko Chono
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Baba
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Hara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromasa Tachihara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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6
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Traina L, Mucignat M, Rizzo R, Gafà R, Bortolotti D, Passaro A, Zamboni P. COVID-19 induced aorto duodenal fistula following evar in the so called "negative" patient. Vascular 2023; 31:189-195. [PMID: 34919005 DOI: 10.1177/17085381211053695] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Since October 2019, SARS-CoV-2 pandemic represents a challenge for the international healthcare system and for the treatment and survival of patients. We normally focus on symptomatic patients, and symptoms can range from the respiratory to the gastrointestinal system. In addition, we consider patients without fever and respiratory symptoms, with both a negative RT nasopharyngeal swab and lung CT, as a "Covid-19 negative patient." In this article, we present a so called Covid-19 "negative" patient, with an unsuspected vascular clinical onset of the viral infection. METHODS An 80 y.o. man, who previously underwent endovascular aortic repair for an infrarenal abdominal aortic aneurysm, presented to our department with an atypical presentation of an aorto-enteric fistula during the pandemic. While in hospital, weekly nasopharyngeal swab tests were always negative for SARS-CoV-2. However, the absence of aortic endograft complications, the gross anatomy of duodenal ischemic injury, and the recent history of the patient who lived the last months in Bergamo, the Italian city with the highest number of COVID-19 deaths, lead the senior Author to suspect an occult SARS-CoV-2 infection. The patient underwent to resection of the fourth portion of the duodenum and the first jejunal loop, with subsequent duodenum-jejunal latero-lateral anastomosis and the direct suture of the aortic wall. The intestinal specimen was investigated as suspected SARS-CoV-2 bowel infection by the means of immune-histochemistry (IHC). An ileum sample obtained in the pre-COVID-19 era was used as a control tissue. RESULTS The histological analysis of the bowel revealed sustained wall ischemia and liponecrosis of the duodenal wall, with intramural blood vessels thrombosis. Blood vessel endotheliitis and neo-angiogenesis were also observed. Finally, the IHC was strongly positive for SARS-CoV-2 RNA and for HLA-G presence, with a particular concentration both in blood vessels and in the intestinal villi. The control tissue sample was not positive for both SARS-CoV-2 and HLA-G. CONCLUSIONS Coronavirus pandemic continues to be an international challenge and more studies and trials must be done to learn its pathogenesis and its complications. As for thromboembolic events caused by SARS-COV-2, vascular surgeons are involved in treatment and prevention of the complications of this syndrome and must be ready with general surgeons to investigate atypical and particular cases such as the one discussed in this article.
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Affiliation(s)
- Luca Traina
- Unit of Vascular and Endovascular Surgery, 18560Azienda Ospedaliero Universitaria di Ferrara - Arcispedale S.Anna, Ferrara, Italy
| | - Marianna Mucignat
- Unit of Vascular and Endovascular Surgery, 18560Azienda Ospedaliero Universitaria di Ferrara - Arcispedale S.Anna, Ferrara, Italy.,Department of Translational Medicine for Romagna, and Vascular Diseases Center, University of Ferrara, Ferrara, Italy
| | - Roberta Rizzo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Roberta Gafà
- Department of Translational Medicine for Romagna, and Vascular Diseases Center, University of Ferrara, Ferrara, Italy
| | - Daria Bortolotti
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Angelina Passaro
- Department of Translational Medicine for Romagna, and Vascular Diseases Center, University of Ferrara, Ferrara, Italy
| | - Paolo Zamboni
- Department of Translational Medicine for Romagna, and Vascular Diseases Center, University of Ferrara, Ferrara, Italy
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Busch M, Stahl K, Fuge J, Schrimpf C, RIttgerodt N, Greer M, Mederacke YS, Haverich A, Wedemeyer H, Heidrich B, Schneider A, Lenzen H, Mederacke I. Out of sight for the endoscopist? Gastrointestinal bleeding after aortic repair. Scand J Gastroenterol 2022; 57:1112-1119. [PMID: 35527697 DOI: 10.1080/00365521.2022.2062258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIM Secondary Aortoenteric Fistulas (sAEF) are difficult to diagnose and usually result in fatal gastrointestinal (GI) bleeding following aortic repair. Outcomes are largely dependent on a timely diagnosis, but AEFs remain challenging to identify endoscopically and are usually diagnosed on computed tomography (CT) scans. The aim of our study was optimize diagnosis of AEF by identifying patients developing GI bleeding after aortic repair, investigate their clinical course and identify factors specific to different bleeding sources. METHODS A retrospective, single-center study capturing all patients developing upper or lower GI bleeding after aortic surgery between January 2009 and March 2020 was performed. Electronic health records were screened for diagnostic codes of the relevant procedures. Bleeding was classified into three groups: AEF with demonstrable fistula, ischemic - macroscopic ulceration plus histological confirmation or imaging and "other" due to other recognized conventional cause, such as peptic ulcer disease. RESULTS 47 GI bleeding episodes in 39 patients were identified. Of these, 10 episodes (21%) were caused by AEF, 16 (34%) by ischemic ulceration and 21 (45%) due to other causes. Patients with AEF exhibited more frequent hemodynamic instability requiring vasopressors and had higher mortality, while ischemic ulcerations were associated with more recent operation or hypotensive episode. CONCLUSIONS GI bleeding complications are uncommon following aortic surgery. AEF and ischemic ulceration are however frequent bleeding causes in this cohort. In patients presenting with fulminant bleeding, primary CT-scanning should be considered.
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Affiliation(s)
- Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Claudia Schrimpf
- Department for Heart-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Department for Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nina RIttgerodt
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Young-Seon Mederacke
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department for Heart-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Benjamin Heidrich
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Andrea Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Henrike Lenzen
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ingmar Mederacke
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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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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9
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Bacopanos E, Jansen S, Hockley J. Aortoduodenal Fistula from Duodenal Stenting for Malignant Gastric Obstruction. EJVES Vasc Forum 2022; 57:1-4. [PMID: 36249716 PMCID: PMC9563612 DOI: 10.1016/j.ejvsvf.2022.08.002] [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: 03/21/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Aortoduodenal fistula (ADF) is a rare cause of upper gastrointestinal (GI) bleeding and is usually fatal without intervention. A high index of suspicion is required to identify and successfully manage this condition. Report Three cases of ADF following duodenal stent insertion for gastric outflow obstruction secondary to metastatic adenocarcinoma are presented. All presented with upper GI bleeding and underwent emergency percutaneous endovascular aortic stent graft repair (EVAR), with temporary aortic balloon occlusion in one case. All were successful in achieving haemostasis. The first case, although initially complicated by acute stent thrombosis of the right iliac limb, was discharged to a rehabilitation facility and survived for two years. The second patient died two days after the procedure from sepsis related complications. The third was discharged home six days post-procedure with a three month follow up. Conclusion A high suspicion for ADF in patients with previous duodenal stents is required for prompt diagnosis and management. EVAR may increase short to midterm life expectancy. Aortoduodenal fistula following duodenal stent for malignant gastric obstruction Cases underwent percutaneous endovascular stent graft repair and achieved haemostasis In cases of ADF secondary to duodenal stenting, tube endografting may prolong life.
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10
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Fatal Case of a Contained Ruptured of the Infrarenal Aorta due to Simultaneous Primary Aortocaval Fistula and Aortoenteric Fistula. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03071-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AbstractWe report an extremely rare case of primary aortocaval fistula with simultaneous development of an aortoenteric fistula in a 68-year-old man. The patient developed under oral anticoagulation a spontaneous intracaval aortic rupture. An emergency intervention was performed with a covering of the fistula with an aorto-uniiliac stent graft and a femoro-femoral crossover bypass. One week later, the patient was transferred to our institution with the diagnosis of a psoas abscess and a suspected concomitant aortoenteric fistula. We performed a complete explantation of the endograft and implanted it after extensive debridement an aortobiiliac bypass, made of bovine pericardium. The postoperative course was complicated, first by bleeding from the left iliac anastomosis, and then by bleeding from the proximal aortic anastomosis. The entire graft was explanted and an axillo-femoral bypass was implanted. The patient then developed a multi-organ failure and died 3 months later. If possible, an extended surgical debridement and resection of all infected tissue with in situ reconstruction is the gold standard. However, with this therapy, there is still a high risk of reinfection. Long-term antibiotic management is mandatory.
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First case report of gastric outlet obstruction due to aortofemoral bypass Dacron graft erosion of the duodenum treated with neo aortoiliac system procedure. Int J Surg Case Rep 2022; 97:107400. [PMID: 35917604 PMCID: PMC9403085 DOI: 10.1016/j.ijscr.2022.107400] [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] [Received: 05/07/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Gastric outlet obstruction is an uncommon complication of surgical treatment of aortoiliac occlusive disease with aortofemoral bypass. The most frequent presenting feature of duodenal erosion due to aortic synthetic graft is upper gastrointestinal bleeding, which can range from a minor "herald" bleed to exsanguinating hemorrhage. CASE PRESENTATION A 64-year-old male patient with an aortofemoral Dacron bypass due to aortoiliac occlusive disease TASC II D with a chronic graft infection required emergency resection of the right limb of the Dacron graft two years ago. The patient developed abdominal pain, postprandial vomiting and progressive weight loss with an upper gastrointestinal endoscopy that showed Dacron graft material eroding into the fourth portion of the duodenum generating a gastric outlet obstruction without aortoenteric fistula and ulceration in the duodenal mucosa. CLINICAL DISCUSSION The treatment goals of aortoenteric fistula are to control hemorrhage, treat infection, maintain adequate distal perfusion, graft explantation and aortic reconstructions like in this case. Traditional treatment of aortoenteric fistula is graft excision and establishing an anatomic autologous or an extra-anatomic synthetic bypass. Neo aortoiliac system procedure has shown to be the most effective and safest emerging technique today. CONCLUSION Aortoenteric fistula is a life-threatening condition associated with high morbidity and mortality and it can also pose a diagnostic dilemma. There are many presentations of aortoenteric fistula including gastric outlet obstruction syndrome. The neo aortoiliac system procedure is the ideal curative surgical approach in stable patients.
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12
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Castronovo EL, Bissacco D, Trimarchi S, Mezzetti R. Neoaortoiliac system in treating aortic graft infections: a single center long-term experience and review of the literature. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:160-168. [PMID: 35142460 DOI: 10.23736/s0021-9509.22.12063-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Aortic graft infection represents one of the most challenging and life-threatening complication of surgical and endovascular treatment of aortic pathologies. The aim of this study was to report the results of a single center with in-situ revascularization for the treatment of aortic graft infections using the neo-aorto-iliac system (NAIS) and to review the literature about this surgical technique. METHODS We retrospectively reviewed our aortic graft infection case series and in-situ revascularization using the neo-aorto-iliac system. The study was conducted from January 2009 to June 2020. The primary outcomes analyzed were early mortality (<30 days), late mortality (>30 days), reinfection rate. Secondary outcomes were the primary patency rate, the secondary patency rate, and the lower limb salvage rate. A literature review of the last twenty years was performed on international medical databases Pubmed (Medline), Scopus and Web of Science. RESULTS During study period, 12 patients, all male (median age of 69 years [range: 52-87 years]), underwent to infected graft explantation and revascularization by NAIS using femoral-popliteal veins. Six cases were complicated by aorto-enteric fistulas, five were duodenal and one was colon. Patients spent the immediate postoperative period in the Intensive Care Unit for a median time of 4 days (range: 0-9 days). The median length of hospital stay was 27.5 days (range: 1-66 days). The mean follow-up was 21.5 months (range: 0-120). The 30-day mortality rate was 25% (3 patients) due to postoperative complications. No patient dropped out of the follow-up protocol. The primary patency rate was 92% while the secondary patency rate was 100%. No patient underwent lower limb amputation. Persistence of infection occurred in 1 case (8.3%). Overall Kaplan-Meier survival estimates were 75% for 30 days, 50% for 1 year, 48% for 5 years. Literature analysis identified 19 case series. CONCLUSIONS The literature regarding NAIS has low statistical evidence due to retrospective design of the studies. Our results are in agreement with retrospective studies in the literature. When the surgical team is confident with NAIS, this technique should be considered the preferred method, considering an acceptable and comparable mortality rate with other techniques and a better rate of patency, resistance to graft degeneration, recurrent infections and amputation rate.
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Affiliation(s)
- Enza L Castronovo
- Unit of Vascular Surgery, San Marco Polyclinic, Zingonia, Bergamo, Italy -
| | - Daniele Bissacco
- Unit of Vascular Surgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Roberto Mezzetti
- Unit of Vascular Surgery, San Marco Polyclinic, Zingonia, Bergamo, Italy
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Tan N, Shi Y, Xu D, Wang J. Unusual cause of gastrointestinal bleeding in an 84-year-old woman: a miraculous survival from an aortoduodenal fistula repair. BMJ Case Rep 2021; 14:e244318. [PMID: 34518182 PMCID: PMC8438823 DOI: 10.1136/bcr-2021-244318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/04/2022] Open
Abstract
An 84-year-old woman presented acutely with dizziness, fatigue and a total of 800 mL of fresh per rectum (PR) bleeding. The significant history of abdominal aortic aneurysm repair 5 years ago included multiple episodes of endovascular leak around the stent associated with abscess of left psoas major, left abdominal wall abscess with sinus formation, appendicitis with abscess formation, and acute pancreatic and chronic cholecystitis with multiple gallstones in the 7 months prior to this presentation. During the preceding 7 months, the patient was stabilised with an intravenous proton pump inhibitor, blood transfusions and Intensive Care Unit (ICU) management for the assumed diagnosis of stress ulcers over multiple hospital admissions. Imaging with CT scan of the abdomen made the more accurate diagnosis of acute gastrointestinal haemorrhage caused by a fistula between the distal duodenum and aorta, which was later surgically confirmed. Removal of infected stents and axillobifemoral bypass were performed with a successful recovery.
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Affiliation(s)
- Nicole Tan
- Curtin Medical School, Curtin University Bentley Campus, Perth, Bentley, Australia
| | - Yi Shi
- Vascular Surgery, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Dan Xu
- Curtin Medical School, Curtin University Bentley Campus, Perth, Bentley, Australia
- Curtin School of Population Health, Curtin University Bentley Campus, Perth, Bentley, Australia
- Medical Education and General Practice, Sun Yan-sen University of Medical Sciences, Guangzhou, China
| | - Jinsong Wang
- Vascular Surgery, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
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14
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Aortoenteric Fistula after Endovascular Aneurysm Repair. Case Rep Vasc Med 2021; 2021:8828838. [PMID: 33680531 PMCID: PMC7906801 DOI: 10.1155/2021/8828838] [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: 04/28/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 11/18/2022] Open
Abstract
Aortoenteric fistula is a rare complication following endovascular abdominal aortic aneurysm repair. However, there is a significant morbidity and mortality associated with this complication. Patients can present with gastrointestinal hemorrhage, fever, or nonspecific features of chronic infection. Extra anatomic bypass with complete graft explanation is the standard management.
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15
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Aortoduodenal fistulas after endovascular abdominal aortic aneurysm repair and open aortic repair. J Vasc Surg 2021; 74:711-719.e1. [PMID: 33684467 DOI: 10.1016/j.jvs.2021.02.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 02/11/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In the present study, we have reported and compared aortoduodenal fistulas (ADFs) after endovascular abdominal aortic aneurysm repair (EVAR) vs after open aortic repair (OAR). METHODS We retrospectively analyzed the data from patients treated for ADFs from January 2015 to May 2020 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoints of the present study were 30-day and 1-year mortality. The secondary endpoints were major postoperative complications. RESULTS A total of 24 patients (20 men; median age, 69 years; range, 53-82 years) were admitted with ADFs after EVAR (n = 9) or OAR (n = 15). These patients accounted for ∼4.3% of all abdominal aortic aneurysm repairs in our hospital. The median interval from the initial aortic repair and the diagnosis of ADF was 68 months (range, 6-83 months) for the ADF-EVAR group and 80 months (range, 1-479 months) for the ADF-OAR group. Three patients in the ADF-EVAR group had refused surgical treatment owing to their high surgical risk. One patient in the ADF-OAR group had undergone removal of the aortic prosthesis without replacement. Of the remaining 20 patients, 12 (ADF-EVAR group, n = 4; ADF-OAR group, n = 8) had undergone in situ replacement of the aorta and 8 (ADF-EVAR group, n = 2; ADF-OAR group, n = 6) had undergone extra-anatomic reconstruction with aortic ligation. After a mean follow-up of 26 months, no patient had experienced early limb loss. However, one case of rupture of the venous graft (ADF-EVAR), one case of aortic stump blowout (ADF-OAR), and one case of a ureteroarterial fistula with a homograft (ADF-OAR) had occurred. Overall, the incidence of postoperative complications was significantly greater after ADF-OAR (93% vs 33%; P = .036). The most frequent bacteria involved in the blood cultures were Escherichia coli (25% of patients), and Candida spp. (61%) were the predominant pathogens found on intra-abdominal smears. The in-hospital mortality rates for the ADF-EVAR and ADF-OAR group were 22% and 13%, respectively. The corresponding 1 -year mortality rates were 22% and 33%. CONCLUSIONS Patients with ADFs after EVAR or OAR have limited overall survival. In addition to the similar therapeutic approaches, we found no significant differences in postoperative mortality between these two uncommon pathologic entities. In our study, the overall postoperative morbidity seemed greater for the ADF-OAR group.
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16
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Chen JF, Ochoa Chaar CI, Cardella J, Dardik A, Guzman RJ, Nassiri N. Emergent percutaneous chimney endovascular aortic repair of a secondary aortoenteric fistula in the setting of a solitary kidney. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:253-257. [PMID: 33997566 PMCID: PMC8095080 DOI: 10.1016/j.jvscit.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
Secondary aortoenteric fistula is a potentially lethal complication after aortic surgery. Traditional treatment consists of open graft excision with extra-anatomic bypass or in situ reconstruction. Patients who present in extremis, however, are generally poor candidates for re-do open aortic surgery. Endovascular repair has emerged as an alternative treatment modality for patients who would otherwise be unable to tolerate an extended operation. We report here a case of urgent endovascular repair of a juxtarenal secondary aortoenteric fistula via endovascular aneurysm repair with a renal artery chimney in a patient with a solitary kidney who presented in hemorrhagic and septic shock.
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Affiliation(s)
- Julia Fayanne Chen
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Jonathan Cardella
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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17
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Hassan A, Khan A, Huasen B, Banihani M. Aortoenteric fistula after endovascular mycotic aortic aneurysm exclusion: lessons learned during the COVID-19 era. BMJ Case Rep 2021; 14:e238875. [PMID: 33547124 PMCID: PMC10577721 DOI: 10.1136/bcr-2020-238875] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2021] [Indexed: 01/08/2023] Open
Abstract
We report a case of aortoenteric fistula 2 years following endovascular aortic aneurysm repair (EVAR) for mycotic aneurysm presenting as upper gastrointestinal bleeding. Initial CT angiogram did not reveal the bleeding or connection to bowel, but endoscopy was suspicious of endograft in the duodenum. Management required a multidisciplinary approach. To stabilise the patient and to control bleeding, a 'bridging' endograft extension was performed. This was followed by open surgical removal of the EVAR endograft and lower limb in situ revascularisation. During postoperative recovery, the patient developed atypical, staged multisystemic symptoms (cardiac, pulmonary and neurological). With increasing awareness of the COVID-19 pandemic, the patient was found SARS-CoV-2-positive, which explained the progression of his symptoms. This was also reflected on other case reports in literature later.
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Affiliation(s)
- Ahmed Hassan
- Vascular Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
| | - Aazeb Khan
- Vascular Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
| | - Bella Huasen
- Radiology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
| | - Mohamed Banihani
- Vascular Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
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18
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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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19
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Caradu C, Vosgin-Dinclaux V, Lakhlifi E, Dubuisson V, Ducasse E, Bérard X. Surgical Explantation of a Fenestrated Endovascular Abdominal Aortic Aneurysm Repair Device Complicated by Aorto-Enteric Fistula. EJVES Vasc Forum 2020; 50:12-18. [PMID: 33937899 PMCID: PMC8077032 DOI: 10.1016/j.ejvsvf.2020.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/12/2020] [Accepted: 12/09/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Alarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) device explantation. Infected fenestrated EVAR (FEVAR) exposes patients to even worse procedural risks. Report A 67 year old man with a prior history of FEVAR presented with impaired general condition, abdominal and back pain, and increased C reactive protein. Computed tomography angiography revealed a collection around the aortic graft bifurcation and 18F-fluorodeoxyglucose–positron emission tomography (FDG-PET) revealed increased FDG uptake at this level, confirmed by labelled white blood cells, all favouring graft infection. A thoracophrenolumbotomy was performed and revealed an aorto-enteric fistula which was treated by small bowel resection. The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed. The thoracic aorta was cross clamped above the coeliac trunk for complete graft excision. Meanwhile, the right kidney was perfused with 4°C Ringer lactate solution. In situ reconstruction was accomplished with a bifurcated antimicrobial graft sutured below the superior mesenteric artery with re-implantation of the right renal artery. The patient was left with a laparostomy for definitive abdominal closure, restoration of the digestive tract, and omental wrap 72 hours later. Broad spectrum antibiotic therapy was initiated peri-operatively and reduced to sulfamethoxazole/trimethoprim for a total duration of six weeks after one sample was positive for Moraxella osloensis. Eleven months later, the patient was free from re-infection, with no fever or inflammatory syndrome. Discussion Total explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard when dealing with infected EVAR. As with type IV thoraco-abdominal aneurysm open repair, FEVAR device explantation requires additional protective measures to prevent visceral ischaemia and renal impairment. In agreement with the European Society for Vascular Surgery guidelines, such patients should be referred to dedicated vascular centres with expertise in surgical repair, anaesthetics, and post-operative intensive care. Alarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) explantation. Total explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard. FEVAR explantation requires additional protective measures to prevent visceral ischaemia and kidney impairment.
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Affiliation(s)
- Caroline Caradu
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | | | - Emilie Lakhlifi
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Vincent Dubuisson
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Eric Ducasse
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Bérard
- Vascular Surgery Department, Bordeaux University Hospital, Bordeaux, France
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20
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Gaines S, Babrowski TA, Skelly C, Milner R. Unique endovascular repair of an aortic pseudoaneurysm after staged approach for an aortoduodenal fistula. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:612-613. [PMID: 33163743 PMCID: PMC7599372 DOI: 10.1016/j.jvscit.2020.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Sara Gaines
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, Ill
| | - Trissa A Babrowski
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, Ill
| | - Christopher Skelly
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, Ill
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, Ill
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21
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Boisvert A, Gilbert N, Hivon P, Rheaume P. Q fever aortic infection causing an aortoduodenal fistula after endovascular aneurysm repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:487-489. [PMID: 33134625 PMCID: PMC7588805 DOI: 10.1016/j.jvscit.2020.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/12/2020] [Indexed: 11/18/2022]
Abstract
An aortoduodenal fistula is a rare complication of endovascular aortic aneurysm repair. Q fever infection is known for its vascular tropism, and arterial fistulas have been reported in association with Coxiella burnetii infections. We report the case of a 78-year-old patient who had developed an aortoduodenal fistula secondary to vascular Q fever 5 years after he had been treated with an aortic endograft. Explantation of the endograft, autogenous reconstruction using the neo-aortoiliac system procedure, and duodenal repair were performed as a curative surgical treatment of this serious vascular condition. At the 9-month follow-up examination, the patient showed no signs of recurrent vascular infection and was instructed to complete an 18-month antibiotic regimen.
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Affiliation(s)
- Annie Boisvert
- Division of Vascular Surgery, CHU de Québec, Quebec City, Quebec, Canada
- Correspondence: Annie Boisvert, MD, MSc, Division of Vascular Surgery, CHU de Quebec, 10 rue d’Espinay, Quebec City, Quebec G1L 3L5, Canada
| | - Nathalie Gilbert
- Division of Vascular Surgery, CHU de Québec, Quebec City, Quebec, Canada
| | - Pierre Hivon
- Division of Infectious Diseases and Microbiology, CHU de Québec, Quebec City, Quebec, Canada
| | - Pascal Rheaume
- Division of Vascular Surgery, CHU de Québec, Quebec City, Quebec, Canada
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22
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Bradley NA, Roxburgh C, Khan F, Guthrie G. Postimplantation syndrome in endovascular aortic aneurysm repair - a systematic review. VASA 2020; 50:174-185. [PMID: 33138736 DOI: 10.1024/0301-1526/a000913] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Postimplantation syndrome (PIS) following endovascular aortic aneurysm repair (EVAR) is a poorly understood phenomenon occurring in the early post-operative course. The underlying aetiology, risk factors, clinical sequalae, and treatment options, are largely unknown. The lack of any standardised diagnostic criteria limits current research in this field. The MEDLINE database was interrogated using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search strategy. Five search terms were used; "postimplantation syndrome" AND "aneurysm", AND "infection", AND "complications", AND "biomarkers", AND "outcomes". 19 studies were included in the review process, reporting a 17.4%-39.0% incidence of PIS. IL-6 was the most commonly elevated biomarker in PIS vs. non-PIS patients. There was a higher incidence of PIS in patients who received polyester rather than expanded-polytetrafluoroethylene (ePTFE) grafts. There was a lower rate of type 2 endoleaks observed in patients who developed PIS. Early major adverse cardiovascular events (MACE) were higher in PIS patients, however there were no studies reporting long-term MACE. Length of stay was higher in PIS patients. Current data support the role of IL-6 as being key to the development of PIS following EVAR. Further work describing the effect that PIS has on long-term clinical outcomes is needed. Lack of standardised diagnostic criteria limit the reporting of PIS between centres, the criteria proposed by this review may resolve this.
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Affiliation(s)
| | | | - Faisel Khan
- School of Medicine, University of Dundee, UK
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23
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Dzieciuchowicz Ł, Tomczak J, Strauss E, Oszkinis G. Mid-Term Results of Endovascular Aneurysm Sealing in the Treatment of Abdominal Aortic Aneurysm With Unfavorable Morphology. Vasc Endovascular Surg 2020; 55:39-49. [PMID: 33034263 DOI: 10.1177/1538574420965736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To report mid-term results of endovascular aneurysm sealing (EVAS) of abdominal aortic aneurysms (AAA) deemed unsuitable for a standard endovascular aneurysm repair (EVAR). METHODS A prospectively maintained database of 42 patients with EVAR-unfavorable anatomy treated by EVAS combined with chimney grafts in case of the proximal AAA neck shorter than 5 mm was analyzed. Early outcomes included final angiographic result, intra- and early post-operative deaths, and complications. Mid-term outcomes included all-cause mortality (ACM), aneurysm-related mortality (ARM), patency of the stents, occurrence of endoleaks, serious complications and graft failures defined as the AAA growth of more than 5 mm, type I endoleak, occlusion of the stent-graft or chimney graft, aorto-duodenal fistula, or aneurysm rupture. RESULTS The procedure was completed in all patients. Twenty-eight chimney grafts were implanted in 19 patients. Patients were followed for a median of 24 months (range 12-34 months). There were 2 intraoperative ruptures and 1 patient died in an early postoperative period. The cumulative ACM was 15, 21, and 36% at 12, 24, and 36 months, respectively, and the cumulative ARM was 8, 11, and 27% at 12, 24, and 36 months, respectively. Three out of 5 aneurysm-related deaths were due to a secondary aorto-duodenal fistula. The cumulative incidence of graft failure was 20, 27, and 42% at 12, 24, and 36 months, respectively. The cumulative incidence of an endoleak was 5, 9, and 23% at 12, 24, and 36 months, respectively. The graft failure increased significantly both ACM (p = .012) and ARM (p = .00003). The implantation of chimney grafts at the initial procedure increased ARM significantly (p = .008). The presence of an endoleak did not have any significant influence on ACM and ARM. CONCLUSION Patients treated with EVAS for AAAs with EVAR-unfavorable anatomy, especially those with chimney grafts, exhibit a high risk of graft failure and subsequent death.
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Affiliation(s)
- Łukasz Dzieciuchowicz
- Department of Vascular Surgery and Vascular Diseases, Institute of Medical Sciences, 49792University of Zielona Góra, Zielona Góra, Poland
| | - Jolanta Tomczak
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Ewa Strauss
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, 37807Poznan University of Medical Sciences, Poznań, Poland.,Institute of Human Genetics, Polish Academy of Sciences, Poznań, Poland
| | - Grzegorz Oszkinis
- Department of General and Vascular Surgery, University of Opole, Opole, Poland
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24
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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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Late Open Conversion Following Failure of EVAR and TEVAR: “State of the Art”. Cardiovasc Intervent Radiol 2020; 43:1855-1864. [DOI: 10.1007/s00270-020-02636-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
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26
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Tuma F, Crespi Z, Wolff CJ, Daniel DT, Nassar AK. Enterocutaneous Fistula: A Simplified Clinical Approach. Cureus 2020; 12:e7789. [PMID: 32461860 PMCID: PMC7243661 DOI: 10.7759/cureus.7789] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A “fistula” is an abnormal connection between two epithelial surfaces. Fistulae are named based on the two surfaces or lumens they connect to. Fistulae form due to loss of wall integrity from an underlying insult, leading to the penetrance of an adjacent organ or epithelized surface. Common causes of small bowel fistulae include sequelae of surgical intervention, foreign body, bowel diverticula, Crohn's disease, malignancy, radiation, and infection. A histopathological analysis displays acute and/or chronic inflammation due to the underlying pathology. A thorough history and physical examination are important components of patient evaluation. Generally, patients will present with non-specific constitutional symptoms in addition to local symptoms attributed to the fistula. In rare instances, symptoms may be severe and life-threatening. Initial laboratory workup includes complete blood count, comprehensive metabolic panel, and lactate level. Radiologic imaging is useful for definitive diagnosis and helps delineate anatomy. In practice, computed tomography (CT) is the initial imaging modality. The addition of intravenous or enteric contrast may be helpful in certain situations. Magnetic resonance imaging (MRI) may also be used in special circumstances. Invasive procedures, such as endoscopy, can assist in the evaluation of mucosal surfaces to diagnose pathology such as inflammatory processes. Appropriate management should include optimizing nutritional status, delineating fistulous tract anatomy, skincare, and managing the underlying disease. A non-operative approach is generally accepted as the initial approach especially in the acute/subacute setting. However, operative intervention is indicated in the setting of failed non-operative management. Successful management of small bowel fistulae requires a multidisciplinary team approach. To conclude, a small bowel fistula is a complex clinical disease, with surgical intervention being the most common cause in developed countries. The non-operative approach should be trialed before an operative approach is considered.
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Affiliation(s)
- Faiz Tuma
- General Surgery, Central Michigan University College of Medicine, Saginaw, USA
| | - Zachary Crespi
- Surgery, Central Michigan University College of Medicine, Mount Pleasant, USA
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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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28
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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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Chakfé N, Diener H, Lejay A, Assadian O, Berard X, Caillon J, Fourneau I, Glaudemans AWJM, Koncar I, Lindholt J, Melissano G, Saleem BR, Senneville E, Slart RHJA, Szeberin Z, Venermo M, Vermassen F, Wyss TR, de Borst GJ, Bastos Gonçalves F, Kakkos SK, Kolh P, Tulamo R, Vega de Ceniga M, von Allmen RS, van den Berg JC, Debus ES, Koelemay MJW, Linares-Palomino JP, Moneta GL, Ricco JB, Wanhainen A. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections. Eur J Vasc Endovasc Surg 2020; 59:339-384. [PMID: 32035742 DOI: 10.1016/j.ejvs.2019.10.016] [Citation(s) in RCA: 272] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Koda Y, Murakami H, Yoshida M, Matsuda H, Mukohara N. Secondary Aorto-enteric Fistula and Type II Endoleak Five Years after Endovascular Abdominal Aortic Aneurysm Repair. EJVES Short Rep 2019; 43:12-17. [PMID: 31193640 PMCID: PMC6536776 DOI: 10.1016/j.ejvssr.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/27/2019] [Accepted: 04/14/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction Secondary aorto-enteric fistula (AEF) after endovascular abdominal aortic aneurysm repair (EVAR) is a rare but potentially fatal disease. The aetiology and mechanisms are unclear. This study presents a patient who developed secondary AEF and type II endoleak five years after EVAR. Case A 73 year old man underwent successful EVAR with a bifurcated aortic stent graft for a 5.5 cm infrarenal abdominal aortic aneurysm. The aneurysm sac showed no change in size for three years, then shrank 20 mm to 3.5 cm by five years. After five years and eight months, the patient presented with fever and back pain. Enhanced CT demonstrated enlargement of the aneurysm sac, type II endoleak from the third and fourth right lumbar arteries, and air around the stent graft. An emergency operation was performed. The infected stent graft was removed by pushing up the stent graft to release the hooks from the wall of the aorta. A small fistula resembling a fish mouth measuring 1×1 cm was observed in the third part of the duodenum. The fistula was closed by direct suture, and in situ reconstruction was performed with an 18×9 mm standard polyethylene terephthalate graft. Culture of the explanted stent graft grew enterobacter. Intravenous antibiotic therapy was continued for six weeks and was stopped after confirming no recurrence of infection with computed tomography and laboratory testing. Two years later, there has been no recurrence of infection. Conclusion Long term surveillance is critical because AEF can occur even after initially successful EVAR. Secondary aorto-enteric fistula post endovascular abdominal aortic aneurysm repair can occur in the late phase of follow up. Staged omentopexy may be beneficial for prevention of recurrent infection. Type II endoleak can affect the development of secondary aorto-enteric fistula.
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Affiliation(s)
- Yojiro Koda
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Hyogo, Japan
| | - Hirohisa Murakami
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre, Himeji, Japan
| | - Masato Yoshida
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre, Himeji, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Nobuhiko Mukohara
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre, Himeji, Japan
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Gurien SD, Stright A, Garuthara M, Klein JDS, Rosca M. An iliac-appendiceal fistula causing gastrointestinal bleeding. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:107-109. [PMID: 31193446 PMCID: PMC6529689 DOI: 10.1016/j.jvscit.2018.12.008] [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: 08/31/2018] [Accepted: 12/14/2018] [Indexed: 12/11/2022]
Abstract
Aortoenteric fistulas are an uncommon cause of gastrointestinal bleeding, and iliac-appendiceal fistulas are an even rarer cause. We describe a case of an iliac-appendiceal fistula in a patient who presented several months after aortic reconstruction with gastrointestinal bleeding. An extensive workup revealed that the source of bleeding was localized to the appendiceal orifice. The patient underwent an appendectomy with a two-stage procedure involving the iliac graft for definitive repair and ultimately recovered well. Despite the rarity of aortoenteric and iliac-appendiceal fistulas causing gastrointestinal bleeding, keeping a high index of suspicion in patients with a prior vascular repair can prevent death.
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Affiliation(s)
- Steven D Gurien
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Adam Stright
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Melissa Garuthara
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Jonathan D S Klein
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Mihai Rosca
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
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Lirici MM, Tierno SM, Giudice R, Coscarella C, Graziani MG, Pogany G. Secondary aortoenteric fistula successfully treated with staged endovascular repair and duodenal resection without graft removal. MINIM INVASIV THER 2019; 29:114-119. [PMID: 30848980 DOI: 10.1080/13645706.2019.1581623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Secondary aorto-enteric fistulae (SAEF) are rare life-threatening complications that occur after abdominal aortic graft implant to treat aortic aneurysm or occlusive disease. Conventional treatments such as extra-anatomic bypass grafting with aortic ligation and subsequent graft removal with bowel repair are associated with a 25% to 90% operative mortality rate. In the emergency setting, patients unsuitable for major arterial surgery may benefit from a staged, less invasive approach. We present a case of SAEF treated with endoluminal deployment of a stent graft followed by duodenojejunal resection and anastomosis without further aortic reconstruction and graft removal.
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Affiliation(s)
- Marco Maria Lirici
- Department of General Surgery, San Giovanni Hospital Complex, Rome, Italy
| | | | - Rocco Giudice
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
| | - Carlo Coscarella
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
| | | | - Gabriele Pogany
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
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Kahlberg A, Grandi A, Loschi D, Vermassen F, Moreels N, Chakfé N, Melissano G, Chiesa R. A systematic review of infected descending thoracic aortic grafts and endografts. J Vasc Surg 2019; 69:1941-1951.e1. [PMID: 30606664 DOI: 10.1016/j.jvs.2018.10.108] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of this study was to collect and critically analyze the current evidence on the modalities and results of treatment of descending thoracic aortic surgical graft (SG) and endograft (EG) infection, which represents a rare but dramatic complication after both surgical and endovascular aortic repair. METHODS A comprehensive electronic health database search (PubMed/MEDLINE, Scopus, Google Scholar, and the Cochrane Library) identified all articles that were published up to October 2017 reporting on thoracic aortic SG or EG infection. Observational studies, multicenter reports, single-center series and case reports, case-control studies, and guidelines were considered eligible if reporting specific results of treatment of descending thoracic aortic SG or EG infection. Comparisons of patients presenting with SG or EG infection and between invasive and conservative treatment were performed. Odds ratio (OR) meta-analyses were run when comparative data were available. RESULTS Forty-three studies reporting on 233 patients with infected SG (49) or EG (184) were included. Four were multicenter studies including 107 patients, all with EG infection, associated with a fistula in 91% of cases, with a reported overall survival at 2 years of 16% to 39%. The remaining 39 single-center studies included 49 patients with SG infection and 77 with EG infection. Association with aortoesophageal fistula was significantly more common with EG (60% vs 31%; P = .01). In addition, time interval from index procedure to infection was significantly shorter with EG (17 ± 21 months vs 32 ± 61 months; P = .03). Meta-analysis showed a trend of increased 1-year mortality in patients with SG infection compared with EG infection (pooled OR, 3.6; 95% confidence interval, 0.9-14.7; P = .073). Surgical management with infected graft explantation was associated with a trend toward lower 1-year mortality compared with graft preservation (pooled OR, 0.3; 95% confidence interval, 0.1-1.0; P = .056). CONCLUSIONS Thoracic aortic EG infection is likely to occur more frequently in association with aortoesophageal fistulas and in a shorter time compared with SG infection. Survival is poor in both groups, especially in patients with SG infection. Surgical treatment with graft explantation seems to be the preferable choice in fit patients.
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Affiliation(s)
- Andrea Kahlberg
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy.
| | - Alessandro Grandi
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Diletta Loschi
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Frank Vermassen
- Department of Vascular and Thoracic Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Vascular and Thoracic Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Germano Melissano
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milan, Italy
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34
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Outcomes of Surgical Explantation of Infected Aortic Grafts After Endovascular and Open Abdominal Aneurysm Repair. Eur J Vasc Endovasc Surg 2019; 57:130-136. [DOI: 10.1016/j.ejvs.2018.07.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 07/17/2018] [Indexed: 12/31/2022]
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35
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Walter C, Taher F, Rieger H, Assadian A, Falkensammer J. Endograft Infection Due to Secondary Aortoenteric Fistula Treated With Custom-Made Bovine In Situ Aortic Bifurcation Graft. Vasc Endovascular Surg 2018; 53:165-169. [DOI: 10.1177/1538574418805868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Purpose: To increase awareness of the clinical presentation, diagnostic workup, and treatment options for endograft infections. Case Report: A 75-year-old male patient was admitted with suspected endograft infection 4 years after endovascular aortic aneurysm repair (EVAR). Although preoperative diagnostics showed no definitive signs of endograft infection, eventual surgical exposure of the endograft revealed signs of advanced inflammation, including the unexpected finding of an aortoduodenal fistula. Conclusion: A detailed evaluation of patient history and clinical examination, performed as a part of routine follow-ups, may be beneficial in identifying possible severe complications after EVAR early on. Regarding options for aortic reconstruction in case of endograft infection, bovine pericardium deserves consideration as a promising, feasible, and easily available graft material.
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Affiliation(s)
- Corinna Walter
- Department of Vascular and Endovascular Surgery, Wilhelminen hospital, Vienna, Austria
| | - Fadi Taher
- Department of Vascular and Endovascular Surgery, Wilhelminen hospital, Vienna, Austria
| | - Hannes Rieger
- Department of Pathology, Bacteriology, Wilhelminen hospital, Vienna, Austria
| | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Wilhelminen hospital, Vienna, Austria
| | - Jürgen Falkensammer
- Department of Vascular and Endovascular Surgery, Wilhelminen hospital, Vienna, Austria
- Medical School, Sigmund Freud Private University, Vienna, Austria
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36
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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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Wang SK, Fajardo A, Motaganahalli RL, Gupta AK. Successful Treatment of an Infected Zenith Fenestrated Endograft Without Explantation. Vasc Endovascular Surg 2018; 52:569-572. [PMID: 29734863 DOI: 10.1177/1538574418774663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Current surgical dogma for infected aortic endografts consists of complete explantation concurrent with revascularization via extra-anatomic bypass or in situ infection-resistant conduit. However, this treatment paradigm is associated with high rates of postoperative mortality and major morbidity. Therefore, patients with prohibitive operative risk are often not offered surgical intervention. In the following manuscript, we report the successful treatment of an 85-year-old gentleman with a fenestrated aortic endograft (Cook Medical, Bloomington, Indiana) infected secondary to the formation of an aortoenteric fistula with primary bowel repair, washout, and lifelong antibiotics and followed for nearly 2 years after intervention. Therefore, this nonexplantation approach can be considered for patients who may otherwise have no surgical recourse.
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Affiliation(s)
- S Keisin Wang
- 1 Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andres Fajardo
- 1 Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Raghu L Motaganahalli
- 1 Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alok K Gupta
- 1 Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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38
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Twenty-Year Experience with Aorto-Enteric Fistula Repair: Gastrointestinal Complications Predict Mortality. J Am Coll Surg 2017; 225:9-18. [DOI: 10.1016/j.jamcollsurg.2017.01.050] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 11/22/2022]
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