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Rezaei H, Ghasemi F, Johari HG, Gholami MA. A complicated case of primary aortojejunal fistula: A case report. Int J Surg Case Rep 2024; 120:109842. [PMID: 38851068 DOI: 10.1016/j.ijscr.2024.109842] [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: 03/17/2024] [Revised: 05/25/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Aortoenteric fistulas are rare and life-threatening pathology characterized by an abnormal connection between the aorta and the gastrointestinal tract. CASE PRESENTATION The patient is a 61-year-old male who initially presented with hypogastric pain, hematemesis, and melena. Computed tomography angiography (CTA) revealed an abdominal aorta aneurysm but not a fistula. Imaging modalities were inconclusive in the diagnosis. The patient became unstable hemodynamically and was transferred to the operation room. The definitive diagnosis of aortoenteric fistula was confirmed during surgical exploration. Urgent surgery was performed; however, the patient experienced a cascade of complications, including rebleeding, intestinal leakage, and hemodynamic instability due to aortic bleeding. Despite rigorous interventions, the patient expired due to multiple organ failure 53 days after the first repair surgery. CLINICAL DISCUSSION There is no definite imaging method due to the lack of guidelines, and the absence of exact findings has led to intraoperative diagnosis in up to 50 % of cases. This is one of the modalities of choice to examine suspected aortoenteric fistulas. Many authors prefer Computed tomography (CT) with intravenous contrast for suspected AEF despite its limitations in clarity. Others recommend CT angiography as the preferred modality. It is worth noting that, as reported in a comprehensive retrospective review, the mortality rate is approximately 46 % within 60 days after AEF repair surgery. CONCLUSION This report adds to the limited data about primary aortojejunal fistulas, an extremely rare type of aortoenteric fistulas which has been reported in only a few cases. Understanding the importance of promptly suspecting, diagnosing, and intervening is crucial, emphasizing the importance of sharing such cases for medical guidance and better patient outcomes.
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Affiliation(s)
- Hooman Rezaei
- Department of Surgery, School of Medicine, Namazi Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farnia Ghasemi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Hamed Ghoddusi Johari
- Thoracic and Vascular Surgery Research center, Shiraz University of Medical Sciences, Shiraz, Iran
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Weise LB, Crisostomo PR, Bechara CF, Soult MC. Iliac artery-enteric fistulas following failed pancreatic transplant. J Vasc Surg Cases Innov Tech 2024; 10:101427. [PMID: 38375348 PMCID: PMC10875587 DOI: 10.1016/j.jvscit.2024.101427] [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: 10/14/2023] [Accepted: 12/26/2023] [Indexed: 02/21/2024] Open
Abstract
Arterial-enteric fistulas occur from a multitude of causes, especially following surgical manipulation of vasculature. The development of an iliac artery-enteric fistula (IEF) occurs rarely in patients with failed pancreatic transplants. IEFs warrant urgent intervention due to the high mortality from hemorrhagic and septic shock. The diagnosis can be delayed by a lack of suspicion, the low sensitivity of diagnostic tests, and the nonspecific signs of fistulas on computed tomography. The management of IEFs is adapted from guidelines for arterial-enteric fistulas of other causes, with little consensus on ideal vascular reconstruction and postoperative antimicrobial management. The outcomes are limited to the short-term results from case reports and case series. We report two cases of IEFs in patients with a history of simultaneous pancreatic kidney transplant. Our patients underwent successful resolution of gastrointestinal bleeding and sepsis, with definitive management of fistula resection and interposition iliac artery bypass. The index of suspicion for IEFs should be high, and they should be considered as a source of anemia or gastrointestinal bleeding of an unknown source in patients with failed pancreatic transplant. Definitive management should be pursued in patients who can tolerate fistula resection, allograft explant, and arterial reconstruction.
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Affiliation(s)
- Lorela B. Weise
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
| | - Paul R. Crisostomo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
| | - Carlos F. Bechara
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
| | - Michael C. Soult
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Omran S, Gröger S, Bruder L, Bürger M, Kapahnke S, Haidar H, Konietschke F, Greiner A. Neoaortoiliac system and cryopreserved human allograft for the treatment of aortic graft infections. Vascular 2023; 31:850-857. [PMID: 35549485 PMCID: PMC10563369 DOI: 10.1177/17085381221091372] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report and compare neoaortoiliac system reconstruction and cryopreserved human allograft in treating aortic graft infections. METHODS We retrospectively analysed the data of the patients treated for aorto graft infections between January 2015 and May 2021 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoint of this study was the 30-day and 1-year mortality; secondary endpoints were major postoperative complications. RESULTS We retrospectively reviewed a series of 31 consecutive patients (28 males; median age 72 years, range, 50-87 years) with aortic graft infection treated with NAIS (n = 20, 65%) or cryopreserved allograft (n = 11, 36%). The clinical presentation included fever attacks in 18 (58%) patients, abdominal pain in 15 (48%) patients, haemodynamic instability in 6 (19%) patients, and haematemesis in 2 (7%) patients. The median operative time of the NAIS was longer than CHA without a statistically significant difference (458 min vs. 359 min, p = .505). The postoperative morbidity for all patients was 81%, with no significant difference between NAIS and CHA groups (85% vs. 73%, p = .638). There was no limb thrombosis of the new reconstructions. Limb loss occurred in 4 (13%) patients, including 2 (10%) NAIS patients and 2 (18%) CHA patients. One NAIS patient developed complications in the form of a distal (femoral) disruption of the vein 15 days after surgery. There were no significant differences between NAIS and CHA groups in ICU stay (12 vs 8 days, .984) but in hospitalization (22 vs 33, p = .033). The most common bacteria isolated were staphylococci strains in 15 (48%). In 13 (36%) patients, candida was positive. The in-hospital 30-day and 1-year mortality for all patients was 16% (5/31) and 29% (9/31), with no significant differences between NAIS and CHA at 30 days (25% vs. 0, p = .133) or 1 year (35% vs. 18%, .429). Five NAIS patients died during the hospital stay; three of them had end-of-life decisions. After a median follow-up of 16 months (1-66 months), 12 (39%) patients died, including 9 patients with NAIS and 3 with CHA reconstructions. The causes of death included overwhelming sepsis in 5 (42%) patients, graft disruption in one (8%) NAIS patient, non-small cell lung cancer in one (8%) patient, COVID-19 in one (8%) patient and unknown causes (8%) in one. CONCLUSIONS Non-staged neoaortoiliac system reconstruction and cryopreserved human allografts show comparable short- and midterm results for treating aortic graft infections. However, both procedures remain challenging with high morbidity and mortality rates.
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Affiliation(s)
- Safwan Omran
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Steffen Gröger
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Leon Bruder
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Matthias Bürger
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Haidar Haidar
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Frank Konietschke
- Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Charité – Universitätsmedizin Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
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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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Rüütmann AM, Kals J. Primary and secondary aortoenteric fistulas in a patient with abdominal aortic aneurysm. Int J Surg Case Rep 2023; 107:108344. [PMID: 37220677 DOI: 10.1016/j.ijscr.2023.108344] [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: 04/19/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION Aortoenteric fistulas (AEF) are infrequent malignant complications of abdominal aortic aneurysms (AAA). We present a unique case of a patient with recurring AAA fistulisations. PRESENTATION OF CASE During oncologic treatment, a 63-year-old male was incidentally diagnosed with infrarenal AAA and assigned follow-up but was hospitalised with anaemia and elevated inflammation markers 14 months later. A CT-angiography scan detected an AAA enlargement, but no extravasation (negative FOBT). Another CTA-scan displayed a pseudoaneurysm and ruptured AAA 10 days later. During a total laparotomy, an enlarged pulsating inflammatory conglomerate without active leakage was detected, with a 2 cm duodenal defect (PAEF). The AAA was resected and replaced by a linear silver-coated Dacron graft. 3,5 years after PAEF, the patient was hospitalised with abdominal pain and haematemesis. He underwent gastroscopies, coloscopies, CT- and CTA-scans - all without significant findings. Only after the capsule-endoscopy detected a jejunal ulcer, the PET-scan visualized active regions in the jejunum and the aortic graft. A total laparotomy was performed; previous stapler-lined jejuno-jejunal anastomosis had adhered to the silver-coated Dacron graft (SAEF). The Dacron graft was removed and replaced with a linear xenograft from bovine pericardium. DISCUSSION No evidence-based recommendations prefer endovascular aneurysm repair (EVAR) over open repair, leaving the strategy dependent on local preferences. Whether EVAR or initial xenograft usage would have shown surpassing results, is speculative, as no graft material/type has proved long-term pre-eminence. CONCLUSIONS This case displays AEF's complex treatment and challenging diagnosis. Multimodal diagnostic and strategic approaches should be considered for best patient outcome.
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Affiliation(s)
- Anna Maria Rüütmann
- Faculty of Medicine, University of Tartu, 8 Puusepa Street, Tartu 51014, Estonia.
| | - Jaak Kals
- Department of Vascular Surgery, Tartu University Hospital, 8 Puusepa Street, Tartu 51014, Estonia; Surgery Clinic, Institute of Clinical Medicine, University of Tartu, 8 Puusepa Street, Tartu 51014, Estonia.
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Omran S, Gröger S, Shafei B, Schawe L, Bruder L, Haidar H, Greiner A. Outcomes of Candida and Non-Candida Aortic Graft Infection. Vasc Endovascular Surg 2023; 57:97-105. [PMID: 36148827 PMCID: PMC9846377 DOI: 10.1177/15385744221129236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate and compare the outcomes of Candida- and non-Candida-associated aortic graft infections. METHODS We retrospectively analyzed the data from patients treated for aortic graft infection from 2015 to 2021 in our hospital. RESULTS A total of 66 patients (56 men; median age, 69 years; range, 50-87 years) were admitted with aortic graft infection, including 21 (32%) patients in the Candida group and 45 (68%) in the non-Candida group. The average time between initial operation and presentation of aortic graft infection was 50 months (range, 1-332 months). Graft-enteric fistulas (GEFs) were more often in the Candida group (57% vs 27%, P = .017). The most proven causative fungal specimen was C. albicans in 16 (76%) patients. Non-albicans Candida was found in 9% of all patients and 29% of the Candida patients. The median ICU length of stay was longer in the Candida group than non-Candida (10 vs 9 days, P = .012). Additionally, the median hospital length of stay was longer in the Candida group (33 vs 22 days, P = .048). There were no statistically significant differences between Candida and non-Candida groups according to the in-hospital mortality (24% vs 24%, P = .955), and 1-year mortality (38% vs 38%, P = .980). CONCLUSIONS Patients with bacterial and fungal aortic graft infections have high rates of morbidity and mortality. We found no significant differences in postoperative morbidity and mortality between Candida and non-Candida patients. However, the ICU and hospital length of stay were longer in the Candida group.
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Affiliation(s)
- Safwan Omran
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany,Safwan Omran, Department of Vascular
Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu
Berlin, and Berlin Institute of Health, Charité––Universitätsmedizin Berlin,
Hindenburgdamm 30, Berlin 12203, Germany.
| | - Steffen Gröger
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Bashaer Shafei
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Larissa Schawe
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Leon Bruder
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Haidar Haidar
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
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Kasa K, Hirukawa H, Fukuda S, Asami F, Katsu M, Yamamoto K, Yoshi S. A Case Series of Secondary Aortoenteric Fistula after Open Aortic Aneurysm Repair: Timing and Technique of Surgery. Ann Vasc Dis 2022; 15:324-328. [PMID: 36644267 PMCID: PMC9816031 DOI: 10.3400/avd.cr.22-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/21/2022] [Indexed: 11/06/2022] Open
Abstract
Secondary aortoenteric fistula (sAEF) is a rare but serious complication after open aortic aneurysm repair (OAR). Although there is no consensus on the treatment strategy for sAEF, acute management of bleeding and infection control greatly affect the outcome. We report five cases of sAEF following OAR from 2016 to 2021. One patient died of sepsis following graft infection, whereas the others had relatively good outcomes. No recurrence of infection or fistula has been observed over an average follow-up period of 29.8 months. Timely management of bleeding and infection with surgical intervention resulted in favorable outcomes in our patients.
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Affiliation(s)
- Kentaro Kasa
- Department of Surgery, Tachikawa General Hospital, Nagaoka, Niigata, Japan,Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan,Corresponding author: Kentaro Kasa, MD. Department of Surgery, Tachikawa General Hospital, 1-24 Asahioka, Nagaoka, Niigata 940-8621, Japan Tel: +81-258-33-3111, Fax: +81-258-33-8811, E-mail:
| | - Hiroshi Hirukawa
- Department of Surgery, Tachikawa General Hospital, Nagaoka, Niigata, Japan
| | - Shintaro Fukuda
- Department of Surgery, Tachikawa General Hospital, Nagaoka, Niigata, Japan
| | - Fuyuki Asami
- Department of Cardiovascular Surgery, Tachikawa General Hospital, Nagaoka, Niigata, Japan
| | - Masatake Katsu
- Department of Cardiovascular Surgery, Tachikawa General Hospital, Nagaoka, Niigata, Japan
| | - Kazuo Yamamoto
- Department of Cardiovascular Surgery, Tachikawa General Hospital, Nagaoka, Niigata, Japan
| | - Shinpei Yoshi
- Department of Cardiovascular Surgery, Tachikawa General Hospital, Nagaoka, Niigata, Japan
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Liu C, Ding X, Zuo X. A Rare Cause of Repeated Life-Threatening Gastrointestinal Bleeding. Gastroenterology 2022; 163:e31-e32. [PMID: 35863522 DOI: 10.1053/j.gastro.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/02/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Chao Liu
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, People's Republic of China
| | - Xiangjiu Ding
- Department of Vascular Surgery, General Surgery, Qilu Hospital, Shandong University, Jinan, People's Republic of China
| | - Xiuli Zuo
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, People's Republic of China.
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Mesenteric approach in pancreas-preserving partial duodenectomy for aortic graft-duodenal fistula: a case report. Clin J Gastroenterol 2022; 15:920-923. [DOI: 10.1007/s12328-022-01665-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/15/2022] [Indexed: 10/16/2022]
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11
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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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12
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Feliciano DV, Schwaitzberg SD, DuBose JJ. Aortoduodenal fistula after repair of a stab injury to the abdominal aorta. Trauma Surg Acute Care Open 2022; 7:e000882. [PMID: 35128070 PMCID: PMC8785199 DOI: 10.1136/tsaco-2022-000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Joseph J DuBose
- Department of Surgery, Dell Seton Medical Center at The University of Texas, Austin, Texas, USA
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13
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Omran S, Raude B, Schawe L, Carstens JC, Angermair S, Berger C, Konietschke F, Treskatsch S, Greiner A. Isolated Ruptured Paravisceral Penetrating Aortic Ulcers. Ann Vasc Surg 2021; 81:138-147. [PMID: 34780950 DOI: 10.1016/j.avsg.2021.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/11/2021] [Accepted: 09/19/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The goal of this study is to investigate the clinical presentation, treatment options, and outcomes of the patients with isolated ruptured paravisceral penetrating aortic ulcers (PV-PAU). METHODS All patients presenting with acute aortic syndrome from 2015 to 2020 were screened, of which patients with isolated ruptured PV-PAU were included in this retrospective study. Study endpoints were the assessment of treatment options, technical success, and clinical outcome. Outcome measures included major perioperative complications and mortality. RESULTS Sixteen patients (11 men; median age 68; IQR 60 - 75 years) presented with isolated ruptured PV-PAU were included in this study. The median follow-up was 25 months (range 1 - 51). Ruptured PV-PAUs represented 12.3% of the ruptured aortic aneurysms in all locations. PV-PAUs were found in segment A (n = 8, 50%), segment B (n = 5, 31%), and segment C (n = 3, 19%). PV-PAUs showed a mean protrusion distance of 27±10 mm, a mean neck diameter of 21 ± 7 mm, and maximal aortic diameter of 50 ± 11 mm. Five patients (31%) showed hemodynamic instability on admission and needed intense fluid resuscitation. Of those, 2 patients needed urgent laparotomy with a fast transabdominal supraceliac aortic clamping, one needed an aortic balloon occlusion to obtain rapid aortic control. The open aortic repair was the most frequently performed surgery (11/16, 69%), followed by hybrid procedures (3/16) and parallel graft chimney technique (2/16). Two patients died during the follow-up, calculating for in-hospital and 1-year mortality rates of 6 - 12%, respectively. The postoperative morbidity rate was 31%. Postoperative complications included acute renal failure (31%), pneumonia (25%), and 1case of ischemic colitis (6%). No spinal cord ischemia was reported. CONCLUSIONS Ruptured PV-PAU is a rare and challenging diagnostic and therapeutic entity. Open aortic repair seems to be a reliable option in treating patients with isolated ruptured PV-PAUs. Hybrid procedures and parallel stent-graft techniques can only be used in selected patients.
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Affiliation(s)
- Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany.
| | - Ben Raude
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
| | - Larissa Schawe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
| | - Jan Christoph Carstens
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
| | - Stefan Angermair
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Christian Berger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Frank Konietschke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
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14
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Buerger M, Kapahnke S, Omran S, Müller V, Hinterseher I, Greiner A, Frese JP. [Aortic Complications Related to Mycobacterium bovis after Intravesical Bacille Calmette-Guérin Therapy - a Systematic Review]. Zentralbl Chir 2021; 146:506-520. [PMID: 34666364 DOI: 10.1055/a-1592-1709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Aortic complications after intravesical Bacillus Calmette-Guérin (BCG) application are a rare complication of the treatment of non-muscle invasive bladder cancer. The aim of this systematic review was to perform a descriptive analysis of previously published studies and to discuss the particular challenges of diagnosis and treatment of this rare complication. MATERIAL AND METHODS A literature search was performed in PubMed (1949-2021) and Web of Science (1900-2021) using the search terms "mycobacterium" OR "bovis" OR "BCG" AND "aorta" OR "aneurysm". In a staged review process, publications with the following inclusion criteria were included in data analysis: original paper, full-text availability in English or German and aortic complication after intravesical BCG instillation. We focused on the analysis of BCG-specific medical history data as well as treatment strategies in relation to patient outcome and the occurrence of graft infections during follow-up. RESULTS A total of 60 individual cases were described in 55 published articles. BCG-induced mycotic aortic aneurysms can occur in all segments of the thoracoabdominal aorta, but the infrarenal aortic segment was most commonly affected (65% of cases). The most common configuration was saccular outpouchings (65%). Concomitant infections in other tissues were typical (65%). Patients with mycotic aneurysm presented with or without consecutive aortic rupture in 28% and 63%, respectively. Diagnosis was based on a combination of pathological and microbiological examinations. A common treatment algorithm was surgical infection treatment (85%) and antitubercular therapy (83%). Performed simultaneously, they resulted in a long-term survival of 81%. Graft infection after initial aortic repair with alloplastic material (n = 40) developed in ten patients (25%) during follow-up. DISCUSSION Diagnosis of mycotic aneurysms or vascular complications after intravesical BCG application is exceptionally challenging and a high level of suspicion is required. Diagnosis is based on obtaining sample material of affected regions and the combination of patient's history, clinical presentation and pathological or microbiological examinations. Currently, no consensus guideline for optimal medical treatment options of aortic complications secondary to BCG instillation exists. The combination of surgical treatment and supportive antitubercular therapy seems to achieve the best results. Since the risk of prosthetic infection after the use of alloplastic materials remains high (25%), we strongly suggest evaluating autologous or allogenic aortic replacement during initial aortic repair.
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Affiliation(s)
- Matthias Buerger
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Kapahnke
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Safwan Omran
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Verena Müller
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Irene Hinterseher
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Greiner
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Paul Frese
- Klinik für Gefäßchirurgie, Charité Universitätsmedizin Berlin, Berlin, Germany
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15
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Omran S, Gröger S, Schawe L, Berger C, Konietschke F, Treskatsch S, Greiner A, Angermair S. Preoperative and ICU Scoring Models for Predicting the In-Hospital Mortality of Patients With Ruptured Abdominal Aortic Aneurysms. J Cardiothorac Vasc Anesth 2021; 35:3700-3707. [PMID: 34493435 DOI: 10.1053/j.jvca.2021.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study's objective was to compare several preoperative and intensive care unit (ICU) prognostic scoring systems for predicting the in-hospital mortality of ruptured abdominal aortic aneurysms (RAAAs). DESIGN Retrospective cohort study. SETTING Single tertiary university center. PARTICIPANTS The study comprised 157 patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 157 patients (82% male) presented with RAAA at Charité University Hospital from January 2011 to December 2020. The mean age was 74 years (standard deviation ten years). In-hospital mortality was 29% (n = 45), of whom nine patients (6%) died en route to the operating room, 13 (8%) on the operating table, and 23 (15%) in the ICU. A total of 135 patients (86%) were admitted to the ICU. All six models demonstrated good discriminating performance between survivors and nonsurvivors. Overall, the area under the curve (AUC) for RAAA preoperative scores was greater than those for ICU scores. The largest AUC was achieved with the Vascular Study Group of New England (VSGNE) RAAA risk score (AUC = 0.87 for all patients, AUC = 0.84 for patients admitted to the ICU), followed by Hardman Index (AUC = 0.83 for all patients, AUC = 0.81 for patients admitted to the ICU), and Glasgow Aneurysm Score (AUC = 0.74 for all patients, AUC = 0.83 for patients admitted to the ICU). The largest AUC for ICU scores (only patients admitted to the ICU) was achieved with Simplified Acute Physiology Score II (0.75), followed by Sepsis-related Organ Failure Assessment (0.73), and Acute Physiology and Chronic Health Evaluation II (0.71). CONCLUSIONS Preoperative and ICU scores can predict the mortality of patients presenting with RAAA. In addition, the discriminatory ability of preoperative scores between survivors and nonsurvivors was larger than that for ICU scores.
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Affiliation(s)
- Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany.
| | - Steffen Gröger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Larissa Schawe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Christian Berger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Frank Konietschke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Stefan Angermair
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
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