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El Beyrouti H, Treede H, Halloum N. Mechanism and Management of Aorto-Esophageal Fistulation after Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2024:S0890-5096(24)00834-3. [PMID: 39710190 DOI: 10.1016/j.avsg.2024.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 12/01/2024] [Accepted: 12/13/2024] [Indexed: 12/24/2024]
Abstract
An aorto-esophageal fistula (AOF) is a pathological communication between the thoracic aorta and the esophagus. It can induce life-threatening hematemesis, which is unique among the other types of gastrointestinal hemorrhage in that the vomiting is bright red and represents an arterial bleed. Nevertheless, it is notable that over 70% of cases are associated with thoracic aortic aneurysms, particularly as a postoperative complication following open surgery, and arguably more so following endovascular repair. As thoracic endovascular aortic repair becomes a more common practice, it is important to remain vigilant for an increase in the incidence of AOF. A thorough consideration of potential AOF etiologies is essential, as these must be substantiated by clinical, laboratory, and imaging tests. The available management options and the likelihood of success depend largely on the diagnosis made. The stability of the fistula wall is fundamental to determine treatment options and is particularly important in case of a potentially fatal AOF. The stability of the organ wall determines the complication risk, and therefore which treatment the patient is most likely to tolerate. A new AOF classification system will allow for better diagnosis and clearer assessment of treatment options.
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Affiliation(s)
- Hazem El Beyrouti
- Department of Vascular and Endovascular Surgery, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany; Department of Cardiac and Vascular Surgery, University Medical Centre Mainz, Johannes Gutenberg University, Mainz, Germany.
| | - Hendrik Treede
- Department of Cardiac and Vascular Surgery, University Medical Centre Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Nancy Halloum
- Department of Cardiac and Vascular Surgery, University Medical Centre Mainz, Johannes Gutenberg University, Mainz, Germany
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Fukumoto K, Saito Y, Yumikura T, Taoka M, Tanaka M, Okumura Y. A Case of Aortopulmonary Fistula with Post-Operative Aortic Pseudoaneurysm Diagnosed by Transesophageal Echocardiography. Int Heart J 2024; 65:963-966. [PMID: 39261029 DOI: 10.1536/ihj.24-127] [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] [Indexed: 09/13/2024]
Abstract
Tracheobronchial or esophageal fistula after aortic surgery has been reported sporadically in the literature, however, reports of an aortopulmonary fistula associated with a post-operative aortic pseudoaneurysm are rare. We experienced a case of refractory heart failure due to an aortopulmonary fistula associated with a post-operative aortic pseudoaneurysm. A 60-year-old man who had undergone aortic surgery 2 years earlier was hospitalized for congestive heart failure. He was diagnosed with refractory heart failure after 10 days of diuretic therapy failed to improve his condition. He underwent a contrast-enhanced computed tomography (CT) scan and was suspected to have pulmonary artery perforation of an aortic pseudoaneurysm at the anastomotic site of the ascending aortic surgery. Transesophageal echocardiography showed shunt blood flow from the aortic aneurysm into the right pulmonary artery, leading to a definitive diagnosis of aortopulmonary fistula with post-operative aortic pseudoaneurysm. Computed tomography angiography is commonly used to diagnose an aortic fistula; however, diagnosis is often difficult because of the subtle imaging findings. We highlight the usefulness of transesophageal echocardiography in providing a definitive diagnosis and detailed morphologic information on this pathophysiology.
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Affiliation(s)
- Katsunori Fukumoto
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yuki Saito
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Tetsuro Yumikura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Makoto Taoka
- Department of Cardiovascular Surgery, Nihon University School of Medicine
| | - Masashi Tanaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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Tsuchiya N, Inafuku H, Yogi S, Iraha Y, Iida G, Ando M, Nagano T, Higa S, Maeda T, Kise Y, Furukawa K, Yonemoto K, Nishie A. Direct visualization of postoperative aortobronchial fistula on computed tomography. World J Radiol 2024; 16:337-347. [PMID: 39239242 PMCID: PMC11372552 DOI: 10.4329/wjr.v16.i8.337] [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: 05/23/2024] [Revised: 08/06/2024] [Accepted: 08/15/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Postoperative aortobronchial fistula (ABF) is a rare complication that can occur in 0.3%-5.0% of patients over an extended period of time after thoracic aortic surgery. Direct visualization of the fistula via imaging is rare. AIM To investigate the relationship between computed tomography (CT) findings and the clinical signs/symptoms of ABF after thoracic aortic surgery. METHODS Six patients (mean age 71 years, including 4 men and 2 women) with suspected ABF on CT (air around the graft) at our hospital were included in this retrospective study between January 2004 and September 2022. Chest CT findings included direct confirmation of ABF, peri-graft fluid, ring enhancement, dirty fat sign, atelectasis, pulmonary hemorrhage, and bronchodilation, and the clinical course were retrospectively reviewed. The proportion of each type of CT finding was calculated. RESULTS ABF detection after surgery was found to have a mean and median of 14 and 13 years, respectively. Initial signs and symptoms were asymptomatic in 4 patients, bloody sputum was found in 1 patient, and fever was present in 1 patient. The complications of ABF included graft infection in 2 patients and graft infection with hemoptysis in 2 patients. Of the 6 patients, 3 survived, 2 died, and 1 was lost to follow-up. The locations of the ABFs were as follows: 1 in the ascending aorta; 1 in the aortic arch; 2 in the aortic arch leading to the descending aorta; and 2 in the descending aorta. ABFs were directly confirmed by CT in 4/6 (67%) patients. Peri-graft dirty fat (4/6, 67%) and peri-graft ring enhancement (3/6, 50%) were associated with graft infection, endoleaks and pseudoaneurysms were associated with hemoptysis (2/6, 33%). CONCLUSION Asymptomatic ABF after thoracic aortic surgery can be confirmed on chest CT. CT is useful for the diagnosis of ABF and its complications.
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Affiliation(s)
- Nanae Tsuchiya
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Hitoshi Inafuku
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Satoko Yogi
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Yuko Iraha
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Gyo Iida
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Mizuki Ando
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Takaaki Nagano
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Shotaro Higa
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Tatsuya Maeda
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Yuya Kise
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Kojiro Furukawa
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Koji Yonemoto
- Department of Biostatistics, School of Health Sciences, Faculty of Medicine, University of the Ryukyus, Okinawa 903-0215, Japan
| | - Akihiro Nishie
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
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Stanley B, Nguyen V, Sivasuthan G, Burstow M. Massive gastrointestinal bleed due to a primary aortoenteric fistula. BMJ Case Rep 2024; 17:e258320. [PMID: 38378584 PMCID: PMC10882345 DOI: 10.1136/bcr-2023-258320] [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: 02/22/2024] Open
Abstract
A man in his 60s attended emergency for acute-onset abdominal pain and haematemesis. Requiring resuscitation, a CT abdomen/pelvis revealed a primary aortoenteric fistula actively bleeding into the duodenum. His background included a previous severe Q-fever infection and a heavy smoking history. Despite attempts at resuscitation and an emergent surgical attempt at haemostasis, the patient did not survive the massive gastrointestinal haemorrhage.Even in less severe cases, management of aortoenteric fistulas is tricky. Blood cultures and angiographic imaging are important investigations in guiding surgical approach. The pathology tends to have a significant rate of mortality even at tertiary-level vascular surgical centres.
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Affiliation(s)
- Benjamin Stanley
- Logan Hospital, Logan, Queensland, Australia
- Griffith University School of Medicine and Dentistry, Gold Coast, Queensland, Australia
| | | | | | - Matthew Burstow
- Department of General Surgery, Logan Hospital, Logan, Queensland, Australia
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Sohail AH, Cohen K, Ho K, Cimaroli S, Brathwaite CEM, Shin P. Incidental aortocaval fistula in the setting of an unruptured abdominal aortic aneurysm. J Surg Case Rep 2023; 2023:rjad384. [PMID: 37416494 PMCID: PMC10319617 DOI: 10.1093/jscr/rjad384] [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: 05/04/2023] [Accepted: 06/15/2023] [Indexed: 07/08/2023] Open
Abstract
An aortocaval fistula, a rare abnormal vascular communication between the aorta and inferior vena cava, is most commonly associated with abdominal aortic aneurysms (AAAs). Other factors leading to aortocaval fistula formation include atherosclerosis, collagen vascular diseases, vasculitis, hematogenous infections, prior spinal surgery, malignancy and radiation exposure. In rare instances, aortocaval fistulas may be discovered incidentally on abdominal imaging. We report an unusual case of an incidental aortocaval fistula in a 93-year-old male patient with an unruptured AAA, presenting with shortness of breath, malaise and lethargy. The patient had no other obvious risk factors for aortocaval fistula formation. Multidetector computed tomography angiography helped identify the fistula, and the patient was eventually transferred to hospice for comfort measures. This case highlights the importance of detailed imaging and preoperative planning in managing aortocaval fistulas and associated AAAs.
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Affiliation(s)
- Amir H Sohail
- Department of Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Koral Cohen
- Correspondence address. Department of General Surgery, NYU Long Island School of Medicine, Mineola, NY, USA. Tel: 201-414-2434; Fax: 516-663-8707; E-mail:
| | - Kimberly Ho
- Department of Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Sawyer Cimaroli
- Department of Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
| | | | - Patrick Shin
- Department of Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
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Das S, Prakash S, Singh S, Shaikh O, Balasubramanian G. Aortoesophageal Fistula Occurring Due to Aortic Aneurysm. Cureus 2023; 15:e42148. [PMID: 37602018 PMCID: PMC10438792 DOI: 10.7759/cureus.42148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Upper gastrointestinal bleeding is a rare presentation of the aortoesophageal fistula (AEF) and is usually caused by thoracic aortic aneurysms. We present the case of a 61-year-old male who presented with chest pain and hematemesis. A chest X-ray showed a widened mediastinum. The patient underwent computed tomography angiography (CTA), which showed the presence of a large aneurysm in the aorta, which caused compression of the trachea, esophagus, and left pulmonary artery. Additionally, there was evidence of an AEF. It was decided to perform an emergency surgical intervention on the patient. However, the patient had multiple episodes of hematemesis and expired.
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Affiliation(s)
- Snehasis Das
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Sagar Prakash
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Shweta Singh
- Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Oseen Shaikh
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Gopal Balasubramanian
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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Jutidamrongphan W, Kritpracha B, Sörelius K, Chichareon P, Chongsuvivatwong V, Sungsiri J, Rookkapan S, Premprabha D, Juntarapatin P, Tantarattanapong W, Suwannanon R. Predicting Infection Related Complications After Endovascular Repair of Infective Native Aortic Aneurysms. Eur J Vasc Endovasc Surg 2023; 65:425-432. [PMID: 36336285 DOI: 10.1016/j.ejvs.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 09/26/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) as surgical treatment for infective native aortic aneurysm (INAA) is associated with superior survival compared with open surgery, but with the risk of infection related complications (IRCs). This study aimed to assess the association between baseline clinical and computed tomography (CT) features and the risk of post-operative IRCs in patients treated with EVAR for INAA. It also sought to develop a model to predict long term IRCs in patients with abdominal INAA treated with EVAR. METHODS All initial clinical details and CT examinations of INAAs between 2005 and 2020 at a major referral hospital were reviewed retrospectively. The images were scrutinised according to aneurysm features, as well as peri-aortic and surrounding organ involvement. Data on post-operative IRCs were found in the patient records. Cox regression analysis was used to derive predictors for IRCs and develop a model to predict five year IRCs after EVAR in abdominal INAA. RESULTS Of 3 780 patients with the diagnosis of aortic aneurysm or aortitis, 98 (3%) patients were treated with EVAR for abdominal INAAs and were thus included. The mean follow up time was 52 months (range 0 ‒ 163). The mean transaxial diameter was 6.5 ± 2.4 cm (range 2.1 ‒14.7). In the enrolled patients, 38 (39%) presented with rupture. The five year IRC rate in abdominal INAAs was 26%. Female sex, renal insufficiency, positive blood culture, aneurysm diameter, and psoas muscle involvement were predictive of five year IRC in abdominal INAA after EVAR. The model had a C-index of 0.76 (95% CI 0.66 - 0.87). CONCLUSION Pre-operative clinical and CT features have the potential to predict IRC after endovascular aortic repair in INAA patients. These findings stress the importance of rigorous clinical, laboratory, and radiological follow up in these patients.
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Affiliation(s)
| | - Boonprasit Kritpracha
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Karl Sörelius
- Department of Vascular Surgery, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ply Chichareon
- Cardiology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Jitpreedee Sungsiri
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Sorracha Rookkapan
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Dhanakom Premprabha
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Pong Juntarapatin
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Ruedeekorn Suwannanon
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
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