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Joseph KR, Singh J, Chin R, Lee A, Oborska Y, Mayorchak Y. A novel approach to surviving an acute aorto-oesophageal fistula: A case report. Int J Surg Case Rep 2024; 121:110035. [PMID: 39013248 DOI: 10.1016/j.ijscr.2024.110035] [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: 04/30/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/18/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Acute aorto-oesophageal fistula poses a significant mortality risk, requiring immediate and decisive medical intervention. This report highlights the critical need for innovation in emergency surgical responses. CASE PRESENTATION A 57-year-old male, with a history of aortic repair, presented with chronic anaemia and dysphagia. He suffered a cardiac arrest from massive hematemesis during surgery for an infected thoracic hematoma. Lacking a Stengsten-Blackmore tube, a 26Fr Foley catheter was used to control the bleeding. This measure stabilized the patient enough for a definitive endovascular repair with aortic stents, which successfully managed the bleeding. CLINICAL DISCUSSION The treatment objectives for this condition include initial control of oesophageal bleeding, followed by endovascular management to further control the bleeding, subsequently releasing the oesophageal control, and ultimately preventing infection through the administration of intravenous antibiotics. CONCLUSION This case illustrates the importance of adaptability and the use of unconventional methods in emergency situations, demonstrating that innovative solutions can be lifesaving in critical surgical emergencies.
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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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Sieber S, Busch A, Sargut M, Knappich C, Bohmann B, Karlas A, Friess H, Eckstein HH, Novotny A. A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience. Vasc Endovascular Surg 2024; 58:185-192. [PMID: 37608725 DOI: 10.1177/15385744231198363] [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] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details. PATIENTS AND METHODS All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality. RESULTS A total of twentytwo patients (68% male, median age 70 years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63 years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities. CONCLUSION Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.
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Affiliation(s)
- Sabine Sieber
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Albert Busch
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
- Division of Vascular and Endovascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technical University of Dresden, Dresden, Germany
| | - Mine Sargut
- Department of Surgery, Technical University of Munich Hospital Rechts der Isar Medical Clinic and Polyclinic II, Munich, Germany
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Angelos Karlas
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Technical University of Munich Hospital Rechts der Isar Medical Clinic and Polyclinic II, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), Technical University of Munich Hospital Rechts der Isar, Munich, Germany
| | - Alexander Novotny
- Department of Surgery, Technical University of Munich Hospital Rechts der Isar Medical Clinic and Polyclinic II, Munich, Germany
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Hosseinzadeh A, Zehra J, Davarpanah MA, Farsani MM, Gorji MG, Shahriarirad R. Aortoduodenal fistula and abdominal aortic aneurysm as a complication of Brucella Aortitis managed with Insitu aortic aneurysm repair: A case report. Clin Case Rep 2023; 11:e8269. [PMID: 38054195 PMCID: PMC10694090 DOI: 10.1002/ccr3.8269] [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: 07/11/2023] [Revised: 11/13/2023] [Accepted: 11/18/2023] [Indexed: 12/07/2023] Open
Abstract
Key Clinical Message Brucella aortitis should be one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fitulae and repair of infrarenal aortic aneurysm with synthetic graft can be used in clean scarred fistulae. Abstract Arterial aneurysms are very rare complications of Brucella infection. The purpose of this case report is to document a case of abdominal aortic aneurysm and primary aorto-duodenal fistula as a complication of Brucella infection, along with the management of brucella induced aortoenteric fistula with insitu synthetic graft. We report a 53-year-old man with a complaint of abdominal pain and melena. Radiological evaluation revealed an inflammatory abdominal aortic aneurysm and a primary aorto-duodenal fistula was identified during surgery. The patient underwent laparotomy, and surgical repair of the aneurysm with a bifurcated Dacron graft, while the entry of the aorto-duodenal fistula was closed with intra-aortic sutures. One month later, the patient tested positive for the Wright agglutination test (1:80) and Coomb's test (1:640) for brucella, and was treated with doxycycline, rifampicin, and ciprofloxacin for brucellosis. Though rare, brucella aortitis should be considered as one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fistula and repair of the infrarenal aortic aneurysm with synthetic graft could be considered in a clean scarred fistula.
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Affiliation(s)
- Ahmad Hosseinzadeh
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical ScienceShirazIran
| | - Jumana Zehra
- School of MedicineShiraz University of Medical ScienceShirazIran
| | | | | | - Meghdad Ghasemi Gorji
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical ScienceShirazIran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical ScienceShirazIran
- School of MedicineShiraz University of Medical ScienceShirazIran
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Narayanan A, Hanna J, Okamura-Kho A, Tesar J, Lim E, Peden S, Dean A, Taumoepeau L, Katib N, Lyons O, Khashram M. Management of secondary aorto-enteric fistulae: a multi-centre study. ANZ J Surg 2023; 93:2363-2369. [PMID: 37012584 DOI: 10.1111/ans.18441] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/12/2023] [Accepted: 03/19/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Secondary aorto-enteric fistulae (SAEF) are a rare, complex and life-threatening complication following aortic repair. Traditional treatment strategy has been with open aortic repair (OAR), with emergence of endovascular repair (EVAR) as a potentially viable initial treatment option. Controversy exists over optimal immediate and long-term management. METHODS This was a retrospective, observational, multi-institutional cohort study. Patients who had been treated for SAEF between 2003 and 2020 were identified using a standardized database. Baseline characteristics, presenting features, microbiological, operative, and post-operative variables were recorded. The primary outcomes were short and mid-term mortality. Descriptive statistics, binomial regression, Kaplan-Meier and Cox age-adjusted survival analyses were performed. RESULTS Across 5 tertiary centres, a total of 47 patients treated for SAEF were included, 7 were female and the median (range) age at presentation was 74 years (48-93). In this cohort, 24 (51%) patients were treated with initially with OAR, 15 (32%) with EVAR-first and 8 (17%) non-operatively. The 30-day and 1-year mortality for all cases that underwent intervention was 21% and 46% respectively. Age-adjusted survival analysis revealed no statistically significant difference in mortality in the EVAR-first group compared to the OAR-first group, HR 0.99 (95% CI 0.94-1.03, P = 0.61). CONCLUSION In this study there was no difference in all-cause mortality in patients who had OAR or EVAR as first line treatment for SAEF. In the acute setting, alongside broad-spectrum antimicrobial therapy, EVAR can be considered as an initial treatment for patients with SAEF, as a primary treatment or a bridge to definitive OAR.
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Affiliation(s)
- Anantha Narayanan
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Department of Vascular Surgery, Wellington Hospital, Wellington, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Joseph Hanna
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Amy Okamura-Kho
- Department of Vascular Surgery, Auckland Hospital, Auckland, New Zealand
| | - Joshua Tesar
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Eric Lim
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Sam Peden
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anastasia Dean
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Auckland Hospital, Auckland, New Zealand
| | - Lupe Taumoepeau
- Department of Vascular Surgery, Wellington Hospital, Wellington, New Zealand
| | - Nedal Katib
- Department of Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Oliver Lyons
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery, University of Otago, Otago, New Zealand
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Reddy SM, Lander AD, Stumper O, Botha P, Khan N, Pachl M. Esophago-Vascular Fistulae in Children: Five Survivors, Literature Review, and Proposal for Management. J Pediatr Surg 2023; 58:1969-1975. [PMID: 37208288 DOI: 10.1016/j.jpedsurg.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION Esophago-vascular fistulae in children are almost uniformly fatal with death occurring by exsanguination. We present a single centre series of five surviving patients, a proposal for management and literature review. MATERIALS AND METHODS Patients were identified from surgical logbooks, surgeon recollection and discharge coding data. Demographics, symptoms, co-morbidities, radiology, management and follow up details were recorded. RESULTS Five patients (1M, 4F) were identified. Four were aorto-esophageal and one caroto-esophageal. Median age at initial presentation was 44 (8-177) months. Four patients had cross sectional imaging prior to surgery. Median time from presentation to combined entero-vascular surgery was 15 (0-419) days. Four patients required repair on cardio-pulmonary bypass with four undergoing staged surgical procedures. All required combined esophageal and cardio-vascular surgery. Length of PICU stay following combined surgery was 4 (2-60) days and overall hospital stay was 53 (15-84) days. Median follow up was 51 (17-61) months. Two patients had esophageal atresia and trachea-esophageal fistula managed as neonates. Three had no co-morbidities. Four had esophageal foreign bodies:1 esophageal stent, 2 button batteries, 1 chicken bone. One patient had a complication following colonic interposition. Four patients required an esophagostomy at the time of definitive surgery. All patients were alive and well at last follow up with one having successful reconnection surgery. CONCLUSION In this series, outcomes were favourable. Multidisciplinary discussion and surgery are mandatory. If hemorrhage is controlled at presentation, then survival to discharge is possible but the magnitude of surgical intervention is both significant and very high risk. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Snighda M Reddy
- Department of Paediatric Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Anthony D Lander
- Department of Paediatric Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Oliver Stumper
- Department of Cardiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Phil Botha
- Department of Cardiac Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Natasha Khan
- Department of Cardiac Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Max Pachl
- Department of Paediatric Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK.
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Martino A, Di Serafino M, Orsini L, Giurazza F, Fiorentino R, Crolla E, Campione S, Molino C, Romano L, Lombardi G. Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review. World J Gastroenterol 2023; 29:4222-4235. [PMID: 37545636 PMCID: PMC10401659 DOI: 10.3748/wjg.v29.i27.4222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/11/2023] [Accepted: 05/09/2023] [Indexed: 07/13/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Francesco Giurazza
- Department of Interventional Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | | | - Enrico Crolla
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Severo Campione
- Department of Pathology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Carlo Molino
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
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Lee SA, Jeong SJ, Gwon JG, Han Y, Cho YP, Kwon TW. Clinical outcomes of in situ graft reconstruction in treating infected abdominal aortic stent grafts following endovascular aortic aneurysm repair: a single-center experience. Ann Surg Treat Res 2023; 104:339-347. [PMID: 37337602 PMCID: PMC10277176 DOI: 10.4174/astr.2023.104.6.339] [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: 02/21/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 06/21/2023] Open
Abstract
Purpose This study aimed to review our experience with the explantation of infected endovascular aneurysm repair (EVAR) grafts. Methods This single-center, retrospective, observational study analyzed the data of 12 consecutive patients who underwent infected aortic stent graft explantation following EVAR between January 1, 2010 and December 31, 2019, of which 11 underwent in situ graft reconstruction following graft removal. The presentation symptoms, infection route, original pathology of abdominal aortic aneurysms (AAA), graft materials, and clinical outcomes were analyzed. Results Six patients underwent total explantation, whereas 5 underwent removal of only the fabric portions. For in situ reconstructions, prosthetic grafts and banked allografts were used in 8 and 3 patients, respectively. Four mechanisms of graft infection were noted in 11 patients: 4 had bacteremia from systemic infections, 3 had persistent infections following EVAR of primary infected AAA, 3 had ascending infections from adjacent abscesses, and 1 had an aneurysm sac erosion resulting in an aortoenteric fistula. No infection-related postoperative complications or reinfections occurred during the mean 65.27-month (standard deviation, ±52.51) follow-up period. One patient died postoperatively because of the rupture of the proximal aortic wall pseudoaneurysm that had occurred during forceful bare stent removal. Conclusion Regardless of graft material, in situ graft reconstruction is safe for interposition in treating an infected aortic stent graft following EVAR. In our experience, the residual bare stent is no longer a risk factor for reinfection. Therefore, it is important not to injure the proximal aortic wall when removing the bare stent by force.
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Affiliation(s)
- Sang Ah Lee
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seon Jeong Jeong
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Gyo Gwon
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Won Kwon
- Department of Acute Care Surgery, Korea University Guro Hospital, Seoul, Korea
- Armed Forces Trauma Center, Korean Armed Forces Capital Hospital, Seongnam, Korea
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9
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Ćeranić D, Nikolić S, Lučev J, Slanič A, Bujas T, Ocepek A, Skok P. Fatal bleeding due to an aorto-esophageal fistula: A case report and literature review. World J Clin Cases 2022; 10:11493-11499. [PMID: 36387793 PMCID: PMC9649541 DOI: 10.12998/wjcc.v10.i31.11493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/27/2022] [Accepted: 09/23/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Aorto-esophageal fistula is an extremely rare cause of acute upper gastrointestinal bleeding (UGIB).
CASE SUMMARY We present a case of an 80-year-old woman with esophageal cancer who was admitted to our department with hemorrhagic shock due to UGIB. During the diagnostic procedure, emergency computed tomography angiography was performed and confirmed aorto-esophageal fistula. Interventional radiologists inserted a stent graft into the aorta, successfully closing the fistula. Unfortunately, the patient later died of heart failure following irreversible hemorrhagic shock. Autopsy confirmed the aorto-esophageal fistula, which formed 1 cm below the distal edge of the stent previously inserted into the esophagus for a malignant stricture.
CONCLUSION There are very rare causes of UGIB. Although clinical decisions are made during the diagnostic workup of these patients, we must be aware of the limitations of various therapeutic options, even the most contemporary.
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Affiliation(s)
- Davorin Ćeranić
- Department of Gastroenterology, Internal Medicine Clinic, University Medical Centre Maribor, Maribor 2000, Slovenia
| | - Sara Nikolić
- Department of Gastroenterology, Internal Medicine Clinic, University Medical Centre Maribor, Maribor 2000, Slovenia
| | - Jernej Lučev
- Department of Radiology, University Medical Centre Maribor, Maribor 2000, Slovenia
| | - Aleš Slanič
- Department of Radiology, University Medical Centre Maribor, Maribor 2000, Slovenia
| | - Tatjana Bujas
- Department of Pathology, University Medical Centre Maribor, Maribor 2000, Slovenia
| | - Andreja Ocepek
- Department of Gastroenterology, Internal Medicine Clinic, University Medical Centre Maribor, Maribor 2000, Slovenia
| | - Pavel Skok
- Department of Gastroenterology, Internal Medicine Clinic, University Medical Centre Maribor, Maribor 2000, Slovenia
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10
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Gadela T, Paravathaneni M, Manney D, Bandla H. A Rare Cause of Gastrointestinal Bleeding: Aorto-Enteric Fistula. Cureus 2022; 14:e27023. [PMID: 35989755 PMCID: PMC9386321 DOI: 10.7759/cureus.27023] [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] [Accepted: 06/29/2022] [Indexed: 11/30/2022] Open
Abstract
Aorto-enteric fistula is defined as an abnormal connection between the gastrointestinal system and the aorta. The patients who develop this condition usually have a grim prognosis and the cases are universally fatal unless intervened with an endovascular repair or open surgical repair. Given the rarity and the relative unfamiliarity of this condition, an understanding of the presentation, pathogenesis, and management is vital to prevent catastrophic complications.
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11
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Singh K, Guerges M, Rost A, Russo N, Aparajita R, Schor J, Deitch J. Endovascular Management of Bleeding Aortoenteric Fistula May be Feasible as a Definitive Repair. Ann Vasc Surg 2022; 83:378.e1-378.e5. [PMID: 35108559 DOI: 10.1016/j.avsg.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/02/2021] [Accepted: 01/22/2022] [Indexed: 11/26/2022]
Abstract
Aorto-enteric fistula (AEF) is a complication with devastating sequelae and significant morbidity. Although open surgery remains primary treatment endovascular approach may be used as a temporary bridge but rarely as a definitive therapy. We present a case of a patient who presented with a secondary AEF, due to hemodynamic instability we chose to treat the fistula with an aortic endograft. The patient underwent bowel resection due to bowel obstruction with omental patch over the aortic rent, 6 weeks of antibiotics. Patient is now at 8-year follow-up without evidence of infection. Although there is scarce literature on this topic, endovascular treatment of bleeding AEF may be feasible as a definitive option. Due to high risk of graft infection we recommend close observation and suppressive antibiotics.
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Affiliation(s)
- Kuldeep Singh
- Department of Vascular Surgery, Staten Island University Hospital SI, NY
| | - Mina Guerges
- Department of Vascular Surgery, Staten Island University Hospital SI, NY.
| | - Amy Rost
- Department of Vascular Surgery, Staten Island University Hospital SI, NY
| | - Nicholas Russo
- Department of Vascular Surgery, Staten Island University Hospital SI, NY
| | - Ritu Aparajita
- Department of Vascular Surgery, Staten Island University Hospital SI, NY
| | - Jonathan Schor
- Department of Vascular Surgery, Staten Island University Hospital SI, NY
| | - Jonathan Deitch
- Department of Vascular Surgery, Staten Island University Hospital SI, NY
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12
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Koo MPM, Bookun HR, Robinson D. Complex Hybrid Repair of a Secondary Aortoenteric Fistula. Vasc Health Risk Manag 2022; 18:329-333. [PMID: 35510033 PMCID: PMC9058014 DOI: 10.2147/vhrm.s363417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Secondary aortoenteric fistula is a rare, highly morbid and often difficult to diagnose, cause of gastrointestinal bleeding. It is associated with prior aortic surgery or placement of a synthetic aortic graft. Our case features staged hybrid endovascular stent-grafting, graft excision, aortoplasty using a bovine pericardial patch, extra-anatomical bypass and complex bowel repair. Case Report An 82-year-old man presented with gastrointestinal bleeding and Streptococcus Anginosus bacteraemia, with previous aorto-bi-iliac bypass surgery for left common iliac occlusive disease 15 years ago. Computed tomography angiography (CTA), gastroscopy, colonoscopy, capsule endoscopy and enteroscopy identified no bleeding source. Repeat CTA showed gas locules and stranding around the graft and the third part of the duodenum, concerning for fistulous communication. On the next day, a Zenith TX2 thoracic 28x80mm stent-graft was deployed into the infrarenal aorta. On laparotomy, a fistula was present between the Dacron graft and fourth part of the duodenum. The Dacron graft was excised, followed by aortic patching with bovine pericardium. A right-to-left femoral-femoral crossover graft was constructed. CT at one-month post-laparotomy showed no signs of perigraft endoleak and interval resolution of gas locules. He was transferred to a rehabilitation facility on the 34th post-operative day with a multidisciplinary follow-up arranged. Discussion Aortoduodenal fistula is a challenging entity to diagnose and should be suspected in patients with GI bleeding and prior aortic surgery. Endovascular repair alone is a less invasive option but with higher re-infection and late failure rates. Liberal use of appropriate imaging modalities, a judicious repair strategy, long-term follow-up and multidisciplinary approach are critical for its management.
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Affiliation(s)
- Mei Ping Melody Koo
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
- Correspondence: Mei Ping Melody Koo, Email
| | - Hansraj Riteesh Bookun
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Domenic Robinson
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
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Beijer E, Scholtes V, Nederhoed J, Lely R, Hoksbergen A. Endovascular treatment of aortic stump rupture after extra-anatomical aortoduodenal fistula repair is not a definite treatment: a case report and review of literature. EJVES Vasc Forum 2022; 55:38-41. [PMID: 35497326 PMCID: PMC9046796 DOI: 10.1016/j.ejvsvf.2022.03.004] [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: 03/20/2021] [Revised: 02/13/2022] [Accepted: 03/09/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Endovascular treatment of an aortic stump rupture is technically feasible. Whether this is a definitive treatment or a bridge to further surgery is unknown. Report Previously a Case of an aortic stump rupture following extra-anatomic repair of a recurrent aortoduodenal fistula (ADF), which was successfully treated endovascularly by placement of an Amplatzer® Vascular Plug was described. The patient survived this acute procedure, but four years later was admitted with fever and back pain. Imaging revealed progressive enlargement of the aortic stump. A re-exploration was performed with removal of the infected aortic stump including the Amplatzer plug. A new aortic stump was created together with resection of an adherent part of the duodenum. The patient was discharged after five months and was able to survive for two more years without any recurring vascular complications. Discussion This Case demonstrates that after four years, endovascular treatment was not a definitive treatment for aortic stump rupture. Endovascular treatment should be followed by definitive treatment when the patient is fit for surgery, especially in cases of ADF. If the patient is unfit for surgery, conservative treatment with culture based antibiotics is a reasonable alternative. Positive obstinacy lengthened the survival of this patient with eight years of reasonably good quality life. Aortic stump ruptures are frequently lethal and demand rapid treatment. Aortic stump ruptures can be treated endovascularly. Late aortic stump enlargement prompts for definitive surgical repair. In certain cases, endovascular treatment should be regarded as a bridge to further surgery.
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A Rare Case of Aortoenteric Graft Erosion Presenting as Candida glabrata Fungemia. Case Rep Vasc Med 2021; 2021:9002143. [PMID: 34824875 PMCID: PMC8610657 DOI: 10.1155/2021/9002143] [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: 08/26/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background An aortoenteric fistula (AEF) describes a communication of the aorta or aortic graft with an adjacent loop of the bowel. Aortic graft erosion is a rare complication of abdominal aortic aneurysm repair. We describe a case of a patient presenting with sepsis from Candida glabrata fungemia secondary to aortoenteric erosion without any symptoms or signs of gastrointestinal bleeding. This is a unique case of Candida glabrata fungemia from aortoenteric graft erosion. Case Summary. This patient is a 75-year-old male with a history of a prior aortobifemoral bypass graft in 2005. He presented with complaints of right paraspinal pain and chills. He had no symptoms of gastrointestinal bleeding or abdominal pain. His white blood cell count was 25,600/mcl (4,000–11,000/mcL) with left shift. The erythrocyte sedimentation rate was 11 mm/hr (0-38 mm/hr), and C-reactive protein was 95.5 mg/L (<=10.0 mg/L). Blood cultures were obtained and eventually grew Candida glabrata. A computed tomography angiogram (CTA) of abdomen and pelvis demonstrated inflammation surrounding the graft concerning for graft infection with additional inflammatory changes tracking down both femoral limbs. He underwent staged bilateral femoralaxillary bypass followed by the excision of aortobifemoral bypass. Conclusion Patients with aortoenteric erosion can present with sepsis in absence of gastrointestinal bleeding. Emergent computed tomography angiogram (CTA) of abdomen and pelvis should be performed to assess for aortic graft erosion or fistula. Empiric treatment with antibiotics should include antifungal agent like micafungin until the final culture is reported. The definite management is an extra anatomic bypass, followed by graft excision.
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Chen C, Kim JW, Shin JH, Kwon Y, Kim J, Lee IJ. Management of life-threatening aortoesophageal fistula: experiences learned from eight patients. Acta Radiol 2021; 62:447-452. [PMID: 32551870 DOI: 10.1177/0284185120933228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Aortoesophageal fistula (AEF) is a rare but fatal condition causing massive upper gastrointestinal bleeding. PURPOSE To report our experiences in the management of life-threatening AEF. MATERIAL AND METHODS A total of eight patients (seven men, one woman; mean age = 59.4 years; age range = 43‒76 years) presenting with AEF between 2005 and 2018 were recruited from three different Korean hospitals. The medical records of these patients were reviewed for patient demographics, clinical features, diagnostic and therapeutic modalities, and outcomes. RESULTS Two patients died as a result of massive hemorrhage before endovascular or surgical treatment could be undertaken. Of the six patients who were treated, five underwent endovascular interventions: embolization of the fistula using n-butyl cyanoacrylate (NBCA) and subsequent thoracic endovascular aortic repair (TEVAR) in two patients; TEVAR alone in two patients; and NBCA embolization alone in one patient. Among them, three patients who received TEVAR with or without NBCA embolization in a timely fashion recovered and were discharged. One patient who received delayed TEVAR died of disseminated intravascular coagulation, and one who received NBCA embolization alone died of hemorrhagic shock, both dying within three days of treatment. The remaining patient who underwent surgical aortic repair is alive after 13 years. CONCLUSION Rapid identification and surgical treatment are necessary to increase the likelihood of survival, if emergency surgery is feasible. TEVAR in a timely fashion facilitates hemodynamic stabilization by rapidly controlling hemorrhage and saves the patient's life.
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Affiliation(s)
- Chengshi Chen
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, PR China
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, PR China
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yohan Kwon
- Department of Radiology, Ajou University Hospital, Suwon, Republic of Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University Hospital, Suwon, Republic of Korea
| | - In Joon Lee
- Department of Radiology, National Cancer Center, Goyang, Republic of Korea
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Diagnostic and Management Difficulty of Bleeding Aorto-Duodenal Fistula Associated with Hodgkin's Lymphoma. Diagnostics (Basel) 2021; 11:diagnostics11030389. [PMID: 33668895 PMCID: PMC7996524 DOI: 10.3390/diagnostics11030389] [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: 01/17/2021] [Revised: 02/21/2021] [Accepted: 02/23/2021] [Indexed: 11/16/2022] Open
Abstract
Primary aorto-enteric fistula (AEF) resulting from abdominal malignancy is a rare and often fatal complication. The few reports to date are mostly secondary to solid tumors. We present a case of a patient with refractory Hodgkin's lymphoma who developed life-threatening AEF. We describe the diagnostic and therapeutic efforts, requiring a multi-disciplinary team of interventional radiology, gastroenterology, and transfusion medicine, resulting in a favorable outcome. Importantly, we offer several insights regarding the identification and management of high-risk patients, with an emphasis on pre-treatment considerations and urgent diagnosis and intervention.
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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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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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Joshi G, Ogbudinkpa C, Stecher J, Khoury RE, Resnick DJ, Jacobs CE, White JV, Schwartz LB. Treatment of Post-Evar Aortoduodenal Fistula Without Endograft Excision. Vasc Endovascular Surg 2020; 55:282-285. [PMID: 33047669 DOI: 10.1177/1538574420966455] [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: 01/17/2023]
Abstract
An 80 year-old gentleman presented with aortoduodenal fistula 2 months after uncomplicated endovascular aneurysm repair (EVAR). Upon laparotomy and fistula takedown, there was no active hemorrhage from the excluded aneurysm. It was theorized the fistula had originated from an occult type II endoleak which had since thrombosed. The duodenum was repaired primarily; the anterior defect in the aneurysm sac was packed and covered with omentum. The patient recovered uneventfully and remains well after 9 months. This is the first case, to our knowledge, of a post-EVAR aortoduodenal fistula successfully treated without endograft excision.
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Affiliation(s)
- Gaurang Joshi
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Chinelo Ogbudinkpa
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Johanna Stecher
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Rym El Khoury
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Daniel J Resnick
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Chad E Jacobs
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - John V White
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Lewis B Schwartz
- Department of Surgery, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
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20
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Shlomin VV, Nokhrin AV, Orzheshkovskaia IE, Bova VI, Nefedov AV, Mikhaĭlov IV, Bondarenko PB, Puzdriak PD, Dmitrievskaia NO. [Surgical treatment of a patient with traumatic rupture of the aortic arch and late oesophageal perforation]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:175-182. [PMID: 32597900 DOI: 10.33529/angio2020219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Described herein is a clinical case report regarding a patient presenting with traumatic rupture of the aortic isthmus with the development of a pseudoaneurysm occupying virtually the entire posterior mediastinum and measuring 20?10 cm in size. He was immediately treated as an emergency to undergo prosthetic reconstruction of the portion of the aortic arch and descending thoracic aorta by means of temporary bypass grafting with a synthetic graft in order to protect the visceral organs. The postoperative period was complicated by oesophageal perforation with the formation of an oesophago-paraprosthetic fistula, infection of the vascular graft, accompanied by the development of pleural empyema and mediastinitis. A second operative procedure was performed, consisting of subclavian-iliac bypass grafting on the right with a polytetrafluoroethylene graft measuring 20 mm in diameter, exclusion of the intrathoracic portion of the oesophagus, creation of a gastro- and oesophagostoma, retrieval of the vascular graft followed by suturing of the aorta, pleurectomy, decortication of the lung, and removal of the empyemic sac on the left. There was no evidence of ischaemia of the spinal cord or visceral arteries. One month postoperatively, he underwent a traumatological stage and 4 months thereafter plasty of the oesophagus with an isoperistaltic gastric pedicle, extirpation of the thoracic portion of the oesophagus, to be later on followed by closure of the oesophagostoma. The patient experienced no difficulties either while walking or during other physical activities, with the ankle-brachial index amounting to 0.9. With time, he developed difficult-to-correct pulmonary hypertension. Unfortunately, the patient eventually died of acute cardiopulmonary insufficiency 9 years after right-sided extra-anatomical subclavian-iliac bypass grafting.
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Affiliation(s)
- V V Shlomin
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - A V Nokhrin
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - I E Orzheshkovskaia
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - V I Bova
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - A V Nefedov
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - I V Mikhaĭlov
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - P B Bondarenko
- National Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - P D Puzdriak
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
| | - N O Dmitrievskaia
- Department of Vascular Surgery, Municipal Multimodality Hospital #2, Saint Petersburg, Russia
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21
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Beijer E, Scholtes VPW, Moerbeek P, Coveliers HME, Lely RJ, Hoksbergen AWJ. Endovascular treatment of aortic stump blow-out after extra-anatomical repair of aortoduodenal fistula: a case report and review of literature. CVIR Endovasc 2020; 3:21. [PMID: 32281006 PMCID: PMC7152582 DOI: 10.1186/s42155-020-00111-8] [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: 11/21/2019] [Accepted: 02/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An aortoduodenal fistula (ADF) is an unusual, but serious complication following surgical or endovascular aortic repair. The optimal treatment for ADF consists of removal of the infected graft with in situ or extra-anatomical repair and is associated with high mortality. Part of this mortality is caused by re-bleeding or aortic stump ruptures. Classical treatment of an aortic stump rupture involves immediate re-laparotomy, removal of infected tissue, aortic stump formation and reinforcement with soft tissue flaps. However, this invasive treatment is often difficult to perform and the condition of the patient frequently requires a more rapid response. We describe a case in which an aortic stump rupture was treated endovascularly by using an Amplatzer® Vascular Plug, which successfully stopped the bleeding. CASE PRESENTATION This report describes a 67-year-old man who was presented with persistent duodenal leakage (due to secondary duodenal perforation) after resection and open in-situ repair of an infected aorto-bi-femoral prosthetic graft. An extra-anatomical reconstruction was performed with an axillo-bi-femoral bypass, followed by excision of the prosthesis, aortic stump formation, partial duodenal resection and duodenojejunal reconstruction. Twelve weeks later, sudden severe hematemesis with severe hemodynamic instability occurred. Computed tomography angiography showed extravasation of blood from the aortic stump into the duodenal loop. Endovascular treatment of the aortic stump blow-out with an Amplatzer® Vascular Plug was performed, which successfully stopped the bleeding and stabilized the patient. The duodenal fistula was treated conservatively. Three months later, the patient was discharged to a rehabilitation clinic in a good clinical condition. The patient was still alive after a follow-up of 4 years. CONCLUSIONS Rapid treatment is requested in cases of aortic stump rupture. Re-laparotomy is practically never the most suitable solution and most of these aortic stump ruptures are fatal. Endovascular treatment could be a suitable alternative. Whether the endovascular treatment of aortic stump rupture is a definitive treatment or a bridge to surgery remains to be elucidated.
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Affiliation(s)
- E Beijer
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - V P W Scholtes
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - P Moerbeek
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - H M E Coveliers
- Department of Surgery, General City Hospital, Aalst, Belgium
| | - R J Lely
- Department of Radiology, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - A W J Hoksbergen
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
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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: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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23
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Liu CH, Fu CK. An Unusual Cause of Gastrointestinal Bleeding-Mycotic Aneurysm with Aortoduodenal Fistula. Am J Med Sci 2020; 359:314-315. [PMID: 32171467 DOI: 10.1016/j.amjms.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/13/2019] [Accepted: 01/09/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Chien-Hung Liu
- Division of Gastroenterology, Department of Internal Medicine, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC
| | - Chun-Kai Fu
- Division of Gastroenterology, Department of Internal Medicine, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC.
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Treatment of aortoesophageal fistula developed after thoracic endovascular aortic repair: a questionnaire survey study. Esophagus 2020; 17:81-86. [PMID: 31222679 DOI: 10.1007/s10388-019-00683-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/16/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Aortoesophageal fistula (AEF) is a life-threatening late complication that can occur after thoracic endovascular aortic repair (TEVAR). More data are required to identify the optimal treatment strategy for AEF developed after TEVAR. The aim of this study was to clarify the current status of surgical treatments for AEF developed after TEVAR and the outcomes of these treatments. METHODS The Japan Esophageal Society conducted a questionnaire survey targeting authorized or semi-authorized institutes at Authorized Institutes for Board Certified Esophageal Surgeons. Thirty-nine patients with AEF developed after TEVAR were identified from 15 institutes. Data on patient demographics, treatment performed, and survival rate were obtained by the questionnaire. The Kaplan-Meier method was used for survival analysis and differences in the survival rates. RESULTS Esophagectomy and aortic replacement were performed in 32 and 22 patients, respectively, and 22 underwent both procedures. Postoperative complications were observed in 24 patients (75.0%). Complications with Clavien-Dindo Grade III or higher were observed in 53.1% of patients. Operative and hospital mortality rates were 3.1% and 18.8%, respectively. The survival rate in patients who underwent esophagectomy was higher than in those who did not (P < 0.0001). The survival of patients who underwent both esophagectomy and aortic replacement was also higher than in those who did not (P < 0.0001). CONCLUSION Esophagectomy combined with aortic replacement can offer a long-term treatment strategy with higher survival rates in patients who develop AEF after TEVAR. Because of the high incidence of postoperative morbidity and mortality, these types of surgery should only be performed in centers with both experienced esophageal and cardiovascular surgical teams.
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25
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Successful Bridge Therapy with Initial Endovascular Repair for Arterioenteric Fistula Resulting from Pseudoaneurysm Rupture with Massive Gastrointestinal Hemorrhage after Pancreas Transplantation. Ann Vasc Surg 2019; 58:379.e15-379.e22. [PMID: 30711503 DOI: 10.1016/j.avsg.2018.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/09/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Abstract
Pseudoaneurysm after pancreas transplantation has a reported incidence of 1.4 to 8.0% and may be caused by perioperative infection. Subsequent pseudoaneurysm rupture is a rare cause of arterioenteric fistula. Only 28 cases of arterioenteric fistula after pancreas transplantation have been reported in the past 20 years. We experienced a rare case of arterioenteric fistula resulting from pseudoaneurysm rupture after pancreas transplantation. We successfully treated the arterioenteric fistula with multistaged bridge therapy composed of initial endovascular aneurysm repair, secondary isolation of the fistula, and definitive open repair with extraanatomic bypass. No complications occurred in 1 year of follow-up; this staged therapy seems feasible for patients with arterioenteric fistula.
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26
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Successful surgical repair of aorto-esophageal fistula due to fish-bone ingestion. Indian J Thorac Cardiovasc Surg 2019; 35:68-70. [PMID: 33060974 DOI: 10.1007/s12055-018-0704-5] [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: 05/07/2018] [Revised: 06/19/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022] Open
Abstract
Aorto-esophageal fistula is a rare and potentially lethal disease. The main causes are ruptured aortic aneurysm, foreign body ingestion, complication of surgical or endovascular repair of thoracic aortic aneurysm, and esophageal malignancy. We report a case caused by fish-bone ingestion. He underwent replacement of proximal descending aorta using circulatory arrest and trans-hiatal esophagectomy in the same sitting. A second-stage esophago-coloplasty was performed after 6 months for establishing digestive tract continuity.
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27
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Beuran M, Negoi I, Negoi RI, Hostiuc S, Paun S. Primary Aortoduodenal Fistula: First you Should Suspect it. Braz J Cardiovasc Surg 2017; 31:261-263. [PMID: 27737411 PMCID: PMC5062716 DOI: 10.5935/1678-9741.20160049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/30/2016] [Indexed: 01/16/2023] Open
Abstract
A 59 year-old patient was admitted with upper gastrointestinal bleeding. The clinical exam showed mild hypotension and blood samples revealed acute anemia (hemoglobin = 7.5 g/dl). Emergency computed tomography showed an infrarenal abdominal aortic aneurysm and extravasation of the arterial contrast material toward the digestive tract. The patient was transported to the operating room for emergency laparotomy, which showed an aortoduodenal fistula. After proximal and distal aortic vascular control, the two anatomical structures were dissected with duodenorrhaphy, patch repair of the aortic tear and omentum interposition. The postoperative recovery was uneventful, with discharge after 12 days.
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Affiliation(s)
- Mircea Beuran
- Carol Davila University of Medicine and Pharmacy Bucharest, General Surgery Department, Emergency Hospital of Bucharest, Romania
| | - Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, General Surgery Department, Emergency Hospital of Bucharest, Romania
| | | | - Sorin Hostiuc
- Carol Davila University of Medicine and Pharmacy Bucharest, Mina Minovici National Institute of Legal Medicine, Romania
| | - Sorin Paun
- Carol Davila University of Medicine and Pharmacy Bucharest, General Surgery Department, Emergency Hospital of Bucharest, Romania
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Spanos K, Kouvelos G, Karathanos C, Matsagkas M, Giannoukas AD. Current status of endovascular treatment of aortoenteric fistula. Semin Vasc Surg 2017; 30:80-84. [PMID: 29248124 DOI: 10.1053/j.semvascsurg.2017.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aortoenteric fistula (AEF) is one of the most challenging diagnostic and therapeutic entities in vascular surgery. AEF can occur either primarily involving the aorta and the gastrointestinal tract or, more commonly, secondary to previous aortic reconstructive surgery. Traditionally, the treatment of AEF includes graft excision and extra-anatomic bypass surgery or in situ graft replacement. However, recently endovascular repair has emerged as an alternative therapeutic option. In this article, we present published and current evidence for endovascular repair of primary and secondary AEF. When endovascular treatment is applied where appropriate, early outcomes seem to be superior compared to open surgery. This benefit may be lost during long-term follow-up, implying that a staged approach with early conversion to in situ grafting may realize the best patient survival and morbidity. Lifelong administration of antibiotics is associated with a reduction in re-infection. An endovascular approach used as a bridging procedure in unstable patients is recommended, followed by definitive open therapy, if feasible, in patients with good life expectancy.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - Christos Karathanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece.
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Uno K, Koike T, Takahashi S, Komazawa D, Shimosegawa T. Management of aorto-esophageal fistula secondary after thoracic endovascular aortic repair: a review of literature. Clin J Gastroenterol 2017; 10:393-402. [PMID: 28766283 DOI: 10.1007/s12328-017-0762-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/06/2017] [Indexed: 12/15/2022]
Abstract
Aorto-esophageal fistula (AEF) is a rare and lethal entity, and the difficulty of making diagnosis of AEF is well-known. As promising results in the short-term effectiveness of thoracic endovascular aortic repair (TEVAR) promote its usage, the occurrence of AEF after TEVAR (post-TEVAR AEF) increases as one of the major complications. Therefore, we provide a review concerning the management strategy of post-TEVAR AEF. Although its representative symptom was reported as the triad of mid-thoracic pain and sentinel hematemesis followed by massive hematemesis, the symptom-free interval between sentinel hemorrhage and massive exsanguination is unpredictable. However, the physiological condition represents a surgical contraindication. Accordingly, early diagnosis is important, but either CT or esophago-gastro-duodenoscopy rarely depicts a typical image. The formation of post-TEVAR AEF might be associated with the infection of micro-organisms, which is uncontrollable with anti-biotic administration. The current first-line strategy is combination therapy as follows, (1) to control bleeding by TEVAR in the urgent phase, and (2) radical debridement and aortic/esophageal re-construction in the semi-urgent phase. In view of the high mortality and morbidity rate, it is proposed that the choice in treatment strategies might be affected by patient`s condition, size of the wall defects and the etiology of AEF. Practically, we should keep in mind the importance of making an early diagnosis and, once a suspicious symptom has occurred in a patient with a history of TEVAR, the existence of post-TEVAR AEF should be suspected. A prospective registry together with more developed technologies will be needed to establish a future strategy.
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Affiliation(s)
- Kaname Uno
- Division of Gastroenterology, Tohoku University Hospital, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 981-8574, Japan. .,Department of Gastrointestinal and Community Medicine, Tohoku University, 16 Kuzehara Uchigo-mimaya cho, Iwaki, Fukushima, 973-8555, Japan.
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Hospital, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 981-8574, Japan
| | - Seiichi Takahashi
- Department of Gastrointestinal and Community Medicine, Tohoku University, 16 Kuzehara Uchigo-mimaya cho, Iwaki, Fukushima, 973-8555, Japan
| | - Daisuke Komazawa
- Department of Gastrointestinal and Community Medicine, Tohoku University, 16 Kuzehara Uchigo-mimaya cho, Iwaki, Fukushima, 973-8555, Japan
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Hospital, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 981-8574, Japan
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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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“In situ” endografting in the treatment of arterial and graft infections. J Vasc Surg 2017; 65:1824-1829. [DOI: 10.1016/j.jvs.2016.12.134] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/13/2016] [Indexed: 12/27/2022]
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Imran JB, Tsai S, Timaran CH, Valentine RJ, Modrall JG. Damage Control Endografting for the Unstable or Unfit Patient. Ann Vasc Surg 2017; 42:150-155. [PMID: 28242397 DOI: 10.1016/j.avsg.2016.10.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/07/2016] [Accepted: 10/12/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the elective setting, both open surgical and endovascular therapies may be reasonable treatment options for many vascular conditions. However, an unstable or unfit patient with a vascular emergency may be less able to tolerate a definitive open vascular operation. We now report the outcomes for "damage control" endografting for unstable or unfit patients with vascular emergencies as bridge therapy before definitive open therapy. METHODS A retrospective review of patients who underwent damage control endografting over a 9-year period (2005-2014) was performed. The primary inclusion criterion was the use of emergency damage control endografting as temporizing therapy to permit time for patient stabilization or optimization before definitive open repair. Patients who underwent endografting as planned definitive therapy were excluded. RESULTS Indications for damage control endografting included arterial bleeding or expanding hematoma related to infected pseudoaneurysms (n = 5), infected grafts (n = 3), or cancer (n = 1). Anatomic locations included the aorta (n = 3), common iliac artery (n = 2), common femoral artery (n = 2), common carotid artery (n = 1), and subclavian artery (n = 1). The median age was 56 years (interquartile range [IQR] 51-70). Five of our patients were male and 4 patients were female. Median follow-up was 8 months (IQR 3-11). Operative (30-day) mortality was 11%. A single patient died on postoperative day 12 after undergoing aortic and duodenal reconstruction related to an aortoenteric fistula. Using the damage control approach, clinical stabilization was achieved in 8 of the 9 patients (88%). One patient with a bleeding infected common femoral artery pseudoaneurysm continued to bleed and required emergent open surgical repair. Definitive open repair was completed in 8 of the 9 patients (88%) at a median time interval of 3 days (IQR 1-10). Planned open repair was not performed in a patient with exsanguinating carotid hemorrhage after the associated cancer was deemed unresectable. CONCLUSIONS Damage control endografting facilitates stabilization of the majority of unstable and unfit patients with vascular emergencies to allow definitive open repair under more favorable conditions. This technique should be employed rarely due to the expense, but it is a technique worthy of consideration in select patients.
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Affiliation(s)
- Jonathan B Imran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center and Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center and Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center and Dallas Veterans Affairs Medical Center, Dallas, TX
| | | | - John Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center and Dallas Veterans Affairs Medical Center, Dallas, TX.
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Atypical Aortoesophageal Fistula with Atypical and Delayed Presentation and Negative Imaging Studies. Case Rep Gastrointest Med 2016; 2016:7219034. [PMID: 27965903 PMCID: PMC5124669 DOI: 10.1155/2016/7219034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/30/2016] [Indexed: 12/30/2022] Open
Abstract
A 59-year-old man with past medical history of thoracic aortic aneurysm treated with thoracic endovascular aortic repair presented with melena for 2 weeks. Initial EGD did not reveal the source of bleeding and showed normal esophagus; abdominal arteriogram did not reveal a fistulous communication and initial CTA showed normal position of the aortic graft stent without endoleak. The sixth EGD revealed a submucosal tumor-like projection in the upper esophagus and stigmata of recent bleeding. Another thoracic endovascular aortic repair with stent was placed over the old graft for presumed aortoesophageal fistula. Poststent upper gastrointestinal series with contrast showed extravasation of the contrast from the esophagus and CTA showed fistulous tract between aorta and esophagus. The patient refused definitive surgical repair despite having infected aortic graft; jejunostomy tube was placed and life-long suppressive antibiotic treatment was given and the patient is doing well at 2-year follow-up.
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Kakkos SK, Bicknell CD, Tsolakis IA, Bergqvist D. Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis. Eur J Vasc Endovasc Surg 2016; 52:770-786. [PMID: 27838156 DOI: 10.1016/j.ejvs.2016.09.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 09/25/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs). METHODS This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type. RESULTS Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups). CONCLUSIONS Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.
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Affiliation(s)
- S K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Greece; Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK.
| | - C D Bicknell
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK
| | - I A Tsolakis
- Department of Vascular Surgery, University Hospital of Patras, Greece
| | - D Bergqvist
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Hashimoto M, Goto H, Akamatsu D, Shimizu T, Tsuchida K, Kawamura K, Tajima Y, Umetsu M. Long-Term Outcomes of Surgical Treatment with In Situ Graft Reconstruction for Secondary Aorto-Enteric Fistula. Ann Vasc Dis 2016; 9:173-179. [PMID: 27738458 DOI: 10.3400/avd.oa.16-00082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/01/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives: The optimal surgical management for secondary aorto-enteric fistula (sAEF) is controversial. Here, we report the long-term outcomes of a surgical treatment with in situ graft reconstruction for sAEF that was performed at our hospital. Methods: Between 2009 and 2012, 10 consecutive patients (8 males, 2 females, mean age 75.9 years) with sAEF were surgically treated with in situ graft reconstruction. Perioperative and long-term outcomes were reviewed retrospectively by medical records. Results: Clinical manifestations, including gastrointestinal bleeding, shock, sepsis, and back and abdominal pain, were observed during the treatment of the patients. In all the cases, the fistula was found between the duodenum or small intestine and the graft anastomosis, the graft itself, or pseudoaneurysm. Total graft excision and in situ graft reconstruction with omental coverage and digestive tract reconstruction was performed for all cases. There were two operative deaths because of multiple organ dysfunction syndrome and sepsis. The other patients showed no sAEF related complications, such as graft infection, and were alive during the 54-month mean follow-up period (33-76 months). Conclusion: According to our study, the long-term outcomes of surgical treatment with in situ graft reconstruction for sAEF were considered satisfactory. (This article is a translation of Jpn J Vasc Surg 2016; 25: 1-6.).
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Affiliation(s)
- Munetaka Hashimoto
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hitoshi Goto
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Daijirou Akamatsu
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Takuya Shimizu
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Ken Tsuchida
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Keiichiro Kawamura
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuta Tajima
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Michihisa Umetsu
- Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
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Abstract
Formation of an artery-to-ureter fistula (AUF) is a rare event caused by pelvic surgery or ureteral instrumentation. This presentation details the unique occurrence and treatment of simultaneous bilateral iliac artery-to-ureter fistulae. A 55-year-old man developed significant arterial hemorrhage during ureteral stent removal initially from the right and, subsequently, from the left side. Following expedient ureteral balloon tamponade, endovascular management via femoral approach with vein-covered stents was successful for each fistula without adverse long-term effects. Endoluminal therapy using autologous tissue-covered stents represents a simple, yet durable, treatment option in these challenging cases.
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Affiliation(s)
- Matthew R Uzieblo
- Department of Vascular Surgery, Washington University, St. Louis, MO 63110, USA.
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Sultan S, Heskin L, Oaikhinan K, Hynes N, Akhter Y, Courtney D. Endovascular Repair of Early Rupture of Dacron Aortic Graft. Vasc Endovascular Surg 2016; 39:183-90. [PMID: 15806280 DOI: 10.1177/153857440503900208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Complications after open aortic surgery pose a challenge both to the vascular surgeon and the patient because of aging population, widespread use of cardiac revascularization, and improved survival after aortic surgery. The perioperative mortality rate for redo elective aortic surgery ranges from 5% to 29% and increases to 70–100% in emergency situation. Endovascular treatment of the postaortic open surgery (PAOS) patient has fewer complications and a lower mortality rate in comparison with redo open surgical repair. Two cases of ruptured abdominal aortic aneurysm (AAA) were managed with the conventional open surgical repair. Subsequently, spiral contrast computer tomography scans showed reperfusion of the AAA sac remnant mimicking a type III endoleak. These graft-related complications presented as vascular emergencies, and in both cases endovascular aneurysm repair (EVAR) procedure was performed successfully by aortouniiliac (AUI) stent graft and femorofemoral crossover bypass. These 2 patients add further merit to the cases reported in the English literature. This highlights the crucial importance of endovascular grafts in the management of such complex vascular problems.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Ireland.
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Lyden SP, Tanquilut EM, Gavin TJ, Adams JE. Aortoduodenal Fistula after Abdominal Aortic Stent Graft Presenting with Extremity Abscesses. Vascular 2016; 13:305-8. [PMID: 16288707 DOI: 10.1258/rsmvasc.13.5.305] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Aortoenteric fistula (AEF) has been described after endovascular stent graft repair of abdominal aortic aneurysms (EVAR). AEF after EVAR has been associated with aneurysm growth, endoleak, migration, and aortic inflammation. We report a patient with an AEF presenting 2 years after EVAR with two abscesses in the right leg. A computed tomographic scan showed a gas-filled thrombus lining the right limb of his graft. At conversion, no endoleak, device migration, or residual aneurysm sac was found. AEF can occur after endoluminal stent graft (ELG) in the absence of aneurysm growth, endoleak, migration, or inflammation. AEF can cause ELG infection and extremity infection.
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Affiliation(s)
- Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA.
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Keunen B, Houthoofd S, Daenens K, Hendriks J, Fourneau I. A Case of Primary Aortoenteric Fistula: Review of Therapeutic Challenges. Ann Vasc Surg 2016; 33:230.e5-230.e13. [PMID: 26965800 DOI: 10.1016/j.avsg.2015.11.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 11/17/2015] [Accepted: 11/24/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUNDS Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity. CASE REPORT A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding. CONCLUSIONS Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction.
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Affiliation(s)
- Bram Keunen
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sabrina Houthoofd
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Kim Daenens
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium.
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Malik MU, Ucbilek E, Sherwal AS. Critical gastrointestinal bleed due to secondary aortoenteric fistula. J Community Hosp Intern Med Perspect 2015; 5:29677. [PMID: 26653698 PMCID: PMC4677592 DOI: 10.3402/jchimp.v5.29677] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/28/2015] [Accepted: 10/30/2015] [Indexed: 12/22/2022] Open
Abstract
Secondary aortoenteric fistula (SAEF) is a rare yet lethal cause of gastrointestinal bleeding and occurs as a complication of an abdominal aortic aneurysm repair. Clinical presentation may vary from herald bleeding to overt sepsis and requires high index of suspicion and clinical judgment to establish diagnosis. Initial diagnostic tests may include computerized tomography scan and esophagogastroduodenoscopy. Each test has variable sensitivity and specificity. Maintaining the hemodynamic status, control of bleeding, removal of the infected graft, and infection control may improve clinical outcomes. This review entails the updated literature on diagnosis and management of SAEF. A literature search was conducted for articles published in English, on PubMed and Scopus using the following search terms: secondary, aortoenteric, aorto-enteric, aortoduodenal, aorto-duodenal, aortoesophageal, and aorto-esophageal. A combination of MeSH terms and Boolean operators were used to device search strategy. In addition, a bibliography of clinically relevant articles was searched to find additional articles (Appendix A). The aim of this review is to provide a comprehensive update on the diagnosis, management, and prognosis of SAEF.
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Affiliation(s)
- Mohammad U Malik
- Department of Internal Medicine, Conemaugh Memorial Medical Center, Johnstown, PA, USA;
| | - Enver Ucbilek
- Division of Gastroenterology and Hepatology - Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amanpreet S Sherwal
- Department of General Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, USA
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Kilic A, Arnaoutakis DJ, Reifsnyder T, Black JH, Abularrage CJ, Perler BA, Lum YW. Management of infected vascular grafts. Vasc Med 2015; 21:53-60. [PMID: 26584886 DOI: 10.1177/1358863x15612574] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Infections of vascular grafts are associated with significant mortality and morbidity risk and cost an estimated $640 million annually in the United States. Clinical presentation varies by time elapsed from implantation and by surgical site. A thorough history and physical examination in conjunction with a variety of imaging modalities is often essential to diagnosis. For infected aortic grafts, there are several options for treatment, including graft excision with extra-anatomic bypass, in situ reconstruction, or reconstruction with the neo-aortoiliac system. The management of infected endovascular aortic grafts is similar. For infected peripheral bypasses, graft preservation techniques can be utilized, but in cases where it is not possible, graft removal and revascularization through uninfected tissue planes is necessary. Infected dialysis access can be surgically treated by complete or subtotal graft excision. Diagnosis, general management, and surgical approaches to infected vascular grafts are discussed in this review.
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Affiliation(s)
- Arman Kilic
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | | | - James H Black
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Bruce A Perler
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ying Wei Lum
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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42
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Contemporary Management of Secondary Aortoduodenal Fistula. Ann Vasc Surg 2015; 29:1614-8. [DOI: 10.1016/j.avsg.2015.06.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 11/20/2022]
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Liang H, Chen C, Liu W, Yu F. Definitive Treatment for Aortoesophageal Fistula by Endovascular Stent Graft. Indian J Surg 2015; 78:151-4. [PMID: 27303128 DOI: 10.1007/s12262-015-1383-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022] Open
Abstract
Aortoesophageal fistula (AEF) is a rare and dangerous complication of foreign body ingestion. Endovascular angioplasty has now become a useful option to control fatal hemorrhage, but it still remains controversial to whether endovascular stenting could be used as a definitive procedure or as a temporary measure before definitive surgical treatment. We have successfully treated two AEF cases using thoracic endovascular aortic repair (TEVAR) as definitive treatment to close aortic defect. The separate 2-year and 6-month follow-ups show that patients are in good condition.
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Affiliation(s)
- Hengxing Liang
- Cardio-thoracic Surgery Department in Xiangya, 2nd hospital of Central South University, 39 Central Remin Road, Changsha, Hunan 410011 China
| | - Chen Chen
- Cardio-thoracic Surgery Department in Xiangya, 2nd hospital of Central South University, 39 Central Remin Road, Changsha, Hunan 410011 China
| | - Wenliang Liu
- Cardio-thoracic Surgery Department in Xiangya, 2nd hospital of Central South University, 39 Central Remin Road, Changsha, Hunan 410011 China
| | - Fenglei Yu
- Cardio-thoracic Surgery Department in Xiangya, 2nd hospital of Central South University, 39 Central Remin Road, Changsha, Hunan 410011 China
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Zheng H, Troutman DA, Dougherty MJ, Calligaro KD. Repair of Aortoenteric Fistula Secondary to Graft Placement for Middle Aortic Syndrome. Ann Vasc Surg 2015; 29:596.e7-10. [DOI: 10.1016/j.avsg.2014.10.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 10/26/2014] [Accepted: 10/29/2014] [Indexed: 11/28/2022]
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Tagowski M, Vieweg H, Wissgott C, Andresen R. Aortoenteric fistula as a complication of open reconstruction and endovascular repair of abdominal aorta. Radiol Res Pract 2014; 2014:383159. [PMID: 25302119 PMCID: PMC4180205 DOI: 10.1155/2014/383159] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/05/2014] [Indexed: 11/17/2022] Open
Abstract
The paper intends to present a review of imaging characteristics of secondary aortoenteric fistula (AEF). Mechanical injury, infection, and adherence of a bowel segment to the aorta or aortic graft are major etiologic factors of AEF after open aortic repair. The pathogenesis of AEF formation after endovascular abdominal aortic repair is related to mechanical failure of the stent-graft, to stent graft infection, and to persistent pressurization of the aneurysmal sac. The major clinical manifestations of AEF comprise haematemesis, melaena, abdominal pain, sepsis, and fever. CT is the initial diagnostic modality of choice in a stable patient. However, the majority of reported CT appearances are not specific. In case of equivocal CT scans and clinical suspicion of AEF, scintigraphy, (67)Ga citrate scans or (18)F-FDG PET/CT is useful. Diagnostic accuracy of endoscopy in evaluation of AEF is low; nevertheless it allows to evaluate other than AEF etiologies of gastrointestinal bleeding. Without adequate therapy, AEF is lethal. Conventional surgical treatment is associated with high morbidity and mortality. The endovascular repair may be an option in hemodynamically unstable and high-risk surgical patients. We also illustrate an example of a secondary AEF with highly specific albeit rare radiologic picture from our institution.
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Affiliation(s)
- Marek Tagowski
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
| | - Hendryk Vieweg
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
| | - Christian Wissgott
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
| | - Reimer Andresen
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746 Heide, Germany
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Surgery for Secondary Aorto-Enteric Fistula or Erosion (SAEFE) Complicating Aortic Graft Replacement: A Retrospective Analysis of 32 Patients with Particular Focus on Digestive Management. World J Surg 2014; 39:283-91. [DOI: 10.1007/s00268-014-2750-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Martinez Aguilar E, Fernández Alonso S, Santamarta Fariña E, Fernández Alonso L, Atienza Pascual M, Centeno Vallespuga R. Estado actual sobre el diagnóstico y tratamiento de fístulas aortoentéricas. ANGIOLOGIA 2014. [DOI: 10.1016/j.angio.2014.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Akashi H, Kawamoto S, Saiki Y, Sakamoto T, Sawa Y, Tsukube T, Kubota S, Matsui Y, Karube N, Imoto K, Yamanaka K, Kondo S, Tobinaga S, Tanaka H, Okita Y, Fujita H. Therapeutic strategy for treating aortoesophageal fistulas. Gen Thorac Cardiovasc Surg 2014; 62:573-80. [PMID: 25156035 DOI: 10.1007/s11748-014-0452-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Indexed: 10/24/2022]
Abstract
PURPOSE The development fistulas between the thoracic aorta and the esophagus are highly fatal conditions. We aimed to identify a therapeutic strategy for treating aortoesophageal fistula (AEF) in this study, by investigating all AEF cases presented in this special symposium at the 65th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery. METHODS Forty-seven AEF patients were included in this study. The survivors and nonsurvivors at six and 18 months after diagnosis of AEF were classified into "Group A6", "Group D6", "Group A18", and "Group D18", respectively. Comparisons between Group A6 and Group D6 and between Group A18 and Group D18 were made with regard to therapeutic strategy. RESULTS Twenty-two (46.8 %) and 33 (70.3 %) of the 47 patients died within 6 and 18 months, respectively. The patients treated with omentum wrapping (p = 0.0052), esophagectomy (p = 0.0269) and a graft replacement strategy for the aorta (p = 0.002) were more frequently included in Group A6. The patients with the omentum wrapping (p = 0.0174) and esophagectomy (p = 0.0203) and graft replacement were more significantly included in Group A18. The results of the multivariate analysis indicated that the mortality rate at 6 and 18 months after diagnosis was significantly correlated with graft replacement (p = 0.0188) and esophagectomy (p = 0.0257), respectively. There were significant differences in the actuarial survival curves in patients who had omentum wrapping, graft replacement, and esophagectomy compared to patients who did not have these 3 therapeutic procedures. CONCLUSION The use of thoracic endovascular aortic repair alone for AEF should not be considered a definitive surgery. In contrast, esophagectomy, open surgery with aortic replacement using prostheses and homografts and greater omentum wrapping significantly improve the mid-term survival of AEF.
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Affiliation(s)
- Hidetoshi Akashi
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830, Japan,
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Yu HH, Wong HH, Wong DC, Cheung FK, Yien RL, Li MK. Endovascular treatment for secondary aortoduodenal fistula. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Harry H.Y. Yu
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - Ho-Hing Wong
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - Dennis C.T. Wong
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - Frances K.Y. Cheung
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - Renny L.C. Yien
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - Michael K.W. Li
- Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
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Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft. Case Rep Transplant 2013; 2013:171807. [PMID: 24455393 PMCID: PMC3886212 DOI: 10.1155/2013/171807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/05/2013] [Indexed: 12/13/2022] Open
Abstract
We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.
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