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Abu Jheasha AA, Ashhab M, Dukmak ON, Maraqa M, Emar M, Jubran F, Alhusseini R. Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report. Ann Med Surg (Lond) 2023; 85:4053-4059. [PMID: 37554889 PMCID: PMC10406025 DOI: 10.1097/ms9.0000000000000909] [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: 02/23/2023] [Accepted: 05/14/2023] [Indexed: 08/10/2023] Open
Abstract
UNLABELLED A double secondary aortoenteric fistula (AEF) occurs in a patient who has had significant aortic surgery and is characterized by a direct connection between the gastrointestinal (GI) tract and the aorta at two separate sites. IMPORTANCE During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. CASE PRESENTATION The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. CLINICAL DISCUSSION Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. CONCLUSIONS An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.
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Koda Y, Murakami H, Yoshida M, Matsuda H, Mukohara N. Secondary Aorto-enteric Fistula and Type II Endoleak Five Years after Endovascular Abdominal Aortic Aneurysm Repair. EJVES Short Rep 2019; 43:12-17. [PMID: 31193640 PMCID: PMC6536776 DOI: 10.1016/j.ejvssr.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/27/2019] [Accepted: 04/14/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction Secondary aorto-enteric fistula (AEF) after endovascular abdominal aortic aneurysm repair (EVAR) is a rare but potentially fatal disease. The aetiology and mechanisms are unclear. This study presents a patient who developed secondary AEF and type II endoleak five years after EVAR. Case A 73 year old man underwent successful EVAR with a bifurcated aortic stent graft for a 5.5 cm infrarenal abdominal aortic aneurysm. The aneurysm sac showed no change in size for three years, then shrank 20 mm to 3.5 cm by five years. After five years and eight months, the patient presented with fever and back pain. Enhanced CT demonstrated enlargement of the aneurysm sac, type II endoleak from the third and fourth right lumbar arteries, and air around the stent graft. An emergency operation was performed. The infected stent graft was removed by pushing up the stent graft to release the hooks from the wall of the aorta. A small fistula resembling a fish mouth measuring 1×1 cm was observed in the third part of the duodenum. The fistula was closed by direct suture, and in situ reconstruction was performed with an 18×9 mm standard polyethylene terephthalate graft. Culture of the explanted stent graft grew enterobacter. Intravenous antibiotic therapy was continued for six weeks and was stopped after confirming no recurrence of infection with computed tomography and laboratory testing. Two years later, there has been no recurrence of infection. Conclusion Long term surveillance is critical because AEF can occur even after initially successful EVAR. Secondary aorto-enteric fistula post endovascular abdominal aortic aneurysm repair can occur in the late phase of follow up. Staged omentopexy may be beneficial for prevention of recurrent infection. Type II endoleak can affect the development of secondary aorto-enteric fistula.
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Affiliation(s)
- Yojiro Koda
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Hyogo, Japan
| | - Hirohisa Murakami
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre, Himeji, Japan
| | - Masato Yoshida
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre, Himeji, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Nobuhiko Mukohara
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre, Himeji, Japan
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Saito H, Nishikawa Y, Akahira JI, Yamaoka H, Okuzono T, Sawano T, Tsubokura M, Yamaya K. Secondary aortoenteric fistula possibly associated with continuous physical stimulation: a case report and review of the literature. J Med Case Rep 2019; 13:61. [PMID: 30871625 PMCID: PMC6419421 DOI: 10.1186/s13256-019-2003-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/31/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Secondary aortoenteric fistula is a rare but fatal complication after reconstructive surgery for an aortic aneurysm characterized by abdominal pain, fever, hematochezia, and hematemesis, and the mortality rate is high. It has been suggested that it arises due to either continuous physical stimulation or prosthesis infection during primary surgery. We describe an aortoenteric fistula following reconstructive surgery for an abdominal aortic aneurysm together with postmortem pathological findings. CASE PRESENTATION A 59-year-old Japanese man who had undergone reconstructive surgery for an abdominal aortic aneurysm 20 months earlier presented with the chief complaint of hematochezia and malaise. Esophagogastroduodenoscopy and total colonoscopy revealed only colon diverticula with no bleeding. Contrast-enhanced computed tomography revealed gas within the aneurysm sac and adhesion between the replaced aortic graft and intestinal tract, suggesting a graft infection. After 18 days of antibiotic treatment, he suddenly went into a state of shock, with massive fresh bloody stool and hematemesis, followed by cardiac arrest. An autopsy revealed communication between the artery and the ileum through an ulcerative fistula at the suture line between the left aortic graft branch and the left common iliac artery. Pathological analysis revealed tight adherence between the arterial and intestinal walls, but no marked sign of infection around the fistula, suggesting that the fistula had arisen due to physical stimuli. CONCLUSIONS Pathological analysis suggested that the present secondary aortoenteric fistula arose due to physical stimuli. This reaffirms the importance of keeping reconstructed aortas isolated from the intestine after abdominal aortic aneurysm surgery.
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Affiliation(s)
- Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Miyagi Japan
| | - Yoshitaka Nishikawa
- Department of Internal Medicine, Hirata Central Hospital, Fukushima, Ishikawa Japan
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Kyoto Japan
| | - Jun-ichi Akahira
- Department of Pathology, Sendai Kousei Hospital, Sendai, Miyagi Japan
| | - Hajime Yamaoka
- Sendai Gastrointestinal Endoscopy Clinic, Sendai, Miyagi Japan
| | - Toru Okuzono
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Miyagi Japan
| | - Toyoaki Sawano
- Department of Surgery, Minamisoma Municipal General Hospital, Minamisoma, Fukushima Japan
- Department of Public Health, Fukushima Medical University School of Medicine, Fukushima, Fukushima Japan
| | - Masaharu Tsubokura
- Department of Public Health, Fukushima Medical University School of Medicine, Fukushima, Fukushima Japan
| | - Kazuhiro Yamaya
- Department of Cardiovascular Surgery, Sendai Kousei Hospital, Sendai, Miyagi Japan
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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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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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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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Janczak D, Chabowski M. An endovascular procedure (stent graft) in the treatment of a recurrent secondary aortoduodenal fistula. Hosp Pract (1995) 2014; 42:139-142. [PMID: 24779087 DOI: 10.3810/hp.2014.04.1111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A secondary aortoenteric fistula is a complication of earlier aortic grafting due to anaortic abdominal aneurysm. A primary aortoduodenal fistula (ADF) is a rare clinical entity that usually causes gastrointestinal bleeding that can be occult, intermittent, or massive. This article presents the case of a 68-year-old man with acute onset of a massive hematemesis and hematochezia.Eight years earlier he had undergone the implantation of an aortobifemoral prosthesis to treat an aortic aneurysm. The patient's condition was unstable, and it was during emergency surgery that the diagnosis of an ADF was made. An infected graft was removed in its entirety,and a new prosthesis was implanted. An omentoplasty with a pedunculated flap was performed.After 8 months, the patient had a recurrent AD F. He underwent another operation, but hemorrhaging from the aortic anastomosis occurred, so he required emergency surgery. Eventration occurred on the 14th postoperative day. The resection of the transversal colon was performed with a cecostomy for the decompression of the end-to-end anastomosis. Three months later the patient suffered a recurrent AD F. An aortobifemoral stent graft was implanted. Periaortal flow drainage was established for the irrigation of the retroperitoneal space. A microjejunostomy tube was also inserted. The patient recovered without any complications. This case represents an example of a rare serious complication of aortic abdominal aneurysm. This case report covers pathophysiology, diagnostic evaluation, and management of an aortoenteric fistula.
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Fístulas aorto-entéricas secundárias – caso clínico. ANGIOLOGIA E CIRURGIA VASCULAR 2013. [DOI: 10.1016/s1646-706x(13)70018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Farres H, Gonzales AJ, Garrett HE. Aortoduodenal fistula after endograft repair of abdominal aortic aneurysm secondary to a retained guidewire. J Vasc Surg 2012; 56:1413-5. [DOI: 10.1016/j.jvs.2012.05.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/09/2012] [Accepted: 05/09/2012] [Indexed: 11/28/2022]
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McPhee JT, Soybel DI, Oram RK, Belkin M. Primary aortoenteric fistula following endovascular aortic repair due to type II endoleak. J Vasc Surg 2011; 54:1164-6. [DOI: 10.1016/j.jvs.2011.04.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 04/20/2011] [Accepted: 04/21/2011] [Indexed: 11/29/2022]
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Fernández-Samos Gutiérrez R, Martínez Mira C, Alonso Argüeso G, Peña Cortés R, Alonso Alvarez M, Vaquero Morillo F. Fístula aortoentérica post-EVAR. Presentación de un caso y revisión de la literatura. ANGIOLOGIA 2011. [DOI: 10.1016/j.angio.2011.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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AAA stent-grafts: past problems and future prospects. Ann Biomed Eng 2010; 38:1259-75. [PMID: 20162359 DOI: 10.1007/s10439-010-9953-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 01/31/2010] [Indexed: 10/19/2022]
Abstract
Endovascular aneurysm repair (EVAR) has quickly gained popularity for infrarenal abdominal aortic aneurysm repair during the last two decades. The improvement of available EVAR devices is critical for the advancement of patient care in vascular surgery. Problems are still associated with the grafts, many of which can necessitate the conversion of the patient to open repair, or even result in rupture of the aneurysm. This review attempts to address these problems, by highlighting why they occur and what the failings of the currently available stent grafts are, respectively. In addition, the review gives critical appraisal as to the novel methods required for dealing with these problems and identifies the new generation of stent grafts that are being or need to be designed and constructed in order to overcome the issues that are associated with the existing first- and second-generation devices.
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Chenu C, Marcheix B, Barcelo C, Rousseau H. Aorto-enteric Fistula After Endovascular Abdominal Aortic Aneurysm Repair: Case Report and Review. Eur J Vasc Endovasc Surg 2009; 37:401-6. [DOI: 10.1016/j.ejvs.2008.11.037] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 11/24/2008] [Indexed: 11/28/2022]
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Saratzis N, Saratzis A, Melas N, Ktenidis K, Kiskinis D. Aortoduodenal Fistulas After Endovascular Stent-Graft Repair of Abdominal Aortic Aneurysms:Single-Center Experience and Review of the Literature. J Endovasc Ther 2008; 15:441-8. [DOI: 10.1583/08-2377.1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bergqvist D, Björck M, Nyman R. Secondary Aortoenteric Fistula after Endovascular Aortic Interventions: A Systematic Literature Review. J Vasc Interv Radiol 2008; 19:163-5. [PMID: 18341942 DOI: 10.1016/j.jvir.2007.10.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 10/05/2007] [Accepted: 10/08/2007] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Bergqvist
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala SE 751 85, Sweden.
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Ruby BJ, Cogbill TH. Aortoduodenal fistula 5 years after endovascular abdominal aortic aneurysm repair with the Ancure stent graft. J Vasc Surg 2007; 45:834-6. [PMID: 17398395 DOI: 10.1016/j.jvs.2006.11.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 11/14/2006] [Indexed: 10/23/2022]
Abstract
We report a case of aortoduodenal fistula 5 years after uncomplicated endovascular abdominal aortic aneurysm repair. The diagnosis was confirmed by abdominal computed tomography scan and esophagogastroduodenoscopy. The patient was successfully treated with primary duodenal repair, removal of the infected graft, in situ placement of a bifurcated graft, and omental interposition. Review of the literature identifies this as one of very few documented aortoduodenal fistulas after endovascular aneurysm repair. Fistulization occurred despite accurate stent graft placement without migration, endoleak, or aortic sac size enlargement on annual postoperative imaging studies.
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Affiliation(s)
- Blaine J Ruby
- Department of Surgery, Gundersen Lutheran Medical Center, La Crosse, WI 54601, USA
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