Stent-graft treatment for bleeding from a presumed aortoenteric fistula

Endovascular Management of Bleeding Aortoenteric Fistula May be Feasible as a Definitive Repair

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.

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

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.

Aortoduodenal Fistula after Abdominal Aortic Stent Graft Presenting with Extremity Abscesses

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.

Aortoenteric fistulae: present-day management

An aortoenteric fistula (AEF) is a communication between the aorta and an adjacent loop of the bowel. The three most useful diagnostic modalities for detecting AEF are abdominal computed tomography scan with intravenous contrast, esophagogastroduodenoscopy, and arteriography. The treatment of AEFs has improved in recent years, but despite the multiple surgical techniques reported, many of the patients do not survive or are left debilitated after treatment. Endovascular repair is an efficient and safe method to stabilize patients with life-threatening AEFs. The aim of this study is to provide a comprehensive and synthetic review of the latest advantages on the diagnosis and management of primary and secondary AEF.

Acutely Bleeding Aortoduodenal Fistula: Staged Endovascular and Open Surgical Repair

Secondary aortoduodenal fistula is an uncommon but potentially fatal complication that can occur after aortic reconstruction surgery and usually presents with upper gastrointestinal hemorrhage. Taking into account the accompanying multiple comorbidities of those patients, conventional open surgical repair carries with it significant mortality and morbidity rates. The purpose of this case report is to describe the successful combined endovascular and open surgical repair of an acutely ruptured aortoduodenal fistula in a 67-year-old male patient. Four months after the procedure, the patient remains well.

[Aortoenteric fistula to the sigmoid colon complicated with entero-grafto-cutaneous fistula]

We report a case of a 62-year-old man who presented to the emergency department with acute rectal bleeding. The patient had previous aortoiliac surgery with the utilization of an aorto-bifemoral vascular graft. Diagnosis of secondary aortoenteric fistula was made between the aortoiliac graft and sigmoid colon. This fistula had an entero-cutaneous component. After exploratory laparotomy resection of the sigma, extirpation of the entero-cutaneous fistula, excision of the graft, oversewing of the aortic stump, and extra-anatomical crossover bypass were successfully performed. This study reports a rare type of secondary aortoenteric fistula to the sigmoid colon complicated with an entero-grafto-cutaneous component and it describes an unusual and successful surgical treatment.

Outcome after endovascular stent graft repair of aortoenteric fistula: A systematic review

BACKGROUND

Aortoenteric fistula (AEF) is a critical clinical condition, which may present with gastrointestinal hemorrhage, with or without signs of sepsis. Conventional open surgical repair is associated with high morbidity and mortality. Endovascular stent graft repair has been attempted, but recurrent infection remains of major concern. We conducted a systematic review to assess potential factors associated with poor outcome after endovascular treatment.

METHODS

The English literature was searched using the MEDLINE electronic database up to April 2008. All studies reporting on the primary management of primary or secondary AEF with endovascular stent graft repair were considered.

RESULTS

Data were extracted from 33 reports that included 41 patients and were entered in the final analysis. Persistent/recurrent/new infection or recurrent hemorrhage developed in 44% of the patients, after a mean follow-up period of 13 months (range, 0.13-36). Secondary, as compared to primary, AEF had an almost threefold increased risk of persistent/recurrent infection. Evidence of sepsis preoperatively was found to be a factor indicating unfavorable outcome (P < .05). Persistent/recurrent/new infection after treatment was associated with worse 30-day and overall survival compared with those who did not develop sepsis (P < .05).

CONCLUSION

Endovascular stent graft repair of AEF was associated with a high incidence of infection or recurrent bleeding postoperatively. Evidence of sepsis preoperatively was indicating poor outcome.

Delayed visceral arterial hemorrhage following Whipple's procedure: minimally invasive treatment with covered stents

BACKGROUND

Delayed visceral arterial hemorrhage caused by inflammatory vessel erosion represents a rare but life-threatening complication after pancreatic head resection. Therapeutic options include reoperation or endovascular minimally invasive techniques such as embolization or stent graft placement. The present article describes our experiences with implantation of newly developed low-profile stent grafts.

METHODS

The findings of four patients with delayed visceral arterial hemorrhage are described. All patients were treated with placement of low-profile stent grafts. The patients' medical records, radiological reports, and images were retrospectively reviewed. Technical success was defined as immediate cessation of hemorrhage. Clinical success was defined as hemodynamic stability.

RESULTS

A total of seven stent grafts were implanted in four arteries. In detail, one stent graft was placed in the splenic artery of the first and second patients. In the third patient one stent graft was initially implanted in the common hepatic artery. The patient developed recurrent hemorrhages of the common hepatic artery, treated one time surgically and two times by deployment of a second and third stent graft. In the fourth patient two stent grafts were placed in the proper hepatic artery. Technical and clinical success was achieved at every procedure. Apart from recurrent hemorrhage of patient No. 3 there were no major complications.

CONCLUSIONS

Minimally invasive therapy using low-profile stent grafts is an effective and safe procedure for the treatment of delayed visceral arterial hemorrhage following Whipple's procedure. The technique is a promising alternative to standard procedures such as surgical repair or embolization.

Endovascular Treatment of a Bleeding Secondary Aorto-Enteric Fistula. A Case Report with 1-Year Follow-up

We report a patient with life-threatening gastrointestinal bleeding caused by a secondary aorto-enteric fistula. Because the patient had several comorbid conditions, we succesfully stopped the bleeding by endovascular placement of a bifurcated aortic stent-graft. The patient developed periaortic infection 4 months later, but he was managed with antibiotics. The patient is well 1 year after the procedure.

Endovascular repair of an anastomotic leak following open repair of abdominal aortic aneurysm

This report describes the case of an early postoperative anastomotic leak following elective open repair of an infrarenal abdominal aortic aneurysm which was successfully treated by endovascular stent-grafting. A 71-year-old man underwent open tube graft repair of abdominal aortic aneurysm. Twelve days later he presented with a contained leak from the distal anastomosis, which was confirmed on CT scan. This was successfully treated with a bifurcated aortic stent-graft. This case illustrates the usefulness of the endovascular approach for resolving this rare surgical complication of open repair of abdominal aortic aneurysm and the challenges associated with the deployment of such a device within an aortic tube graft.

Evolving strategies for the treatment of aortoenteric fistulas

BACKGROUND

Aortoenteric fistulas (AEFs) are a rare but often fatal cause of gastrointestinal bleeding. Operative repair of AEF has been historically associated with extremely high morbidity and mortality. We reviewed our experience of open surgical and endovascular treatment of AEF to compare outcomes over a contemporaneous time period.

METHODS

Over a 9-year period between January 1997 and January 2006, 16 patients (11 men and 5 women) were diagnosed with and treated for AEFs. Seven patients underwent open surgical repair, and nine, with anatomically suitable lesions, underwent endovascular repair. The outcome after treatment of these patients was investigated for survival, perioperative complications, length of hospital stay, and long-term disposition.

RESULTS

Three primary and 13 secondary AEFs were treated. The mean time from the initial aortic operation until AEF diagnosis was 5.9 years (range, 0.7-12.2 years) for patients with secondary AEFs. The overall 30-day mortality rate was 18.8%. One intraoperative death and one in-hospital death secondary to multisystem organ failure occurred in patients undergoing open repair. One in-hospital death related to persistent sepsis occurred in the endovascular group. The overall perioperative complication rate was 50.0%. Complications in the open group included sepsis, renal failure, bowel obstruction, and pancreatitis. Complications in the endovascular group were related to persistent sepsis. The mean in-hospital length of stay was significantly longer for patients undergoing open repair compared with endovascular repair (44.0 vs 19.4 days; P = .04). Four (80%) of five patients who were discharged from the hospital in the open group were placed in skilled nursing facilities, and seven (87.5%) of eight patients discharged in the endovascular group returned home. The median overall survival after hospital discharge was 23.1 months. There were no late aneurysm-related deaths or late deaths related to septic complications.

CONCLUSIONS

Patients with AEFs have limited overall survival. Endovascular therapy offers an alternative to open surgical repair, seems to be associated with decreased perioperative morbidity and mortality and a shorter in-hospital stay, and allows for acceptable survival given the presence of coexisting medical comorbidities. Furthermore, endovascular repair provides a therapeutic option to control bleeding and allow for continued intervention in a stabilized setting.

Endovascular repair for aorto-enteric fistula: a bridge too far or a bridge to surgery?

PURPOSE

To review our experience of endovascular treatment of aorto-enteric fistula (AEF).

METHODS

Between March 1999 and March 2005, 15 patients in five university and teaching hospitals in Belgium and The Netherlands were treated for AEF by endovascular repair. Twelve (80%) were male. The mean age was 67 years. Thirteen (87%) had had previous aortic or iliac surgery, 1.7-307 months before. All patients showed clinical or biochemical signs of bleeding. Eight (53%) were in shock, five (33%) had systemic signs of infection. Eight (53%) patients were treated in an emergency setting. Ten (67%) were treated with an aortouniiliac device, three (20%) with an aortobiiliac device, one with a tube graft and one with occluders only. All patients received antibiotics postoperatively for a prolonged period of time.

RESULTS

All AEF were successfully sealed, the 30-days mortality was nil. Mean hospital stay was 20 (2-81) days. One patient died 2.7 months later of postoperative complications, one died of lung cancer. Until now, there are no signs of reinfection in four (27%) patients (mean follow-up 15.7 (1-44) months). However, reinfection or recurrent AEF occurred in nine (60%) patients after 9.5 (0.61-31) months. Seven patients were reoperated successfully, two patients died after reintervention.

CONCLUSION

Endovascular sealing of AEF is a promising technique, which provides time to treat shock, local and systemic infection, and co-morbidity. This creates a better situation to perform open repair in the future with possibly better outcome. Danger of reinfection remains high. Endovascular sealing of AEF should, therefore, be seen as a bridge to open surgery when possible.

Staged endovascular stent-grafting and surgical treatment of a secondary aortoduodenal fistula

Secondary aortoenteric fistula is a dramatic, rather infrequent late complication occurring mostly after abdominal aortic surgery. Currently, graft excision and in situ bypass is considered the treatment of choice, but it is associated with significant mortality and morbidity. Herein, we describe the case of a secondary aortoduodenal fistula treated by staged endovascular stent-grafting and surgical closure of the fistula. Forty days after stent-grafting, Tc-99m-HMPAO labelled leukocyte scanning failed to identify leukocyte infiltration of the graft and there were no clinical signs of infection. At 8-month follow up, the patient was asymptomatic.

Emergency Endovascular Repair of an Aortoesophageal Fistula Caused by a Foreign Body

PURPOSE

To report stent-graft treatment of an aortoesophageal fistula caused by a foreign body.

CASE REPORT

A 32-year-old man was admitted with massive upper gastrointestinal bleeding 10 days after swallowing a fish bone. Computed tomography demonstrated a fistula from the proximal descending thoracic aorta to the mid esophagus. The bleeding was initially controlled by inflating a Sengstaken-Blakemore tube. A 28-mm x 16-cm Talent stent-graft was delivered transfemorally to repair the aortic defect; the esophageal injury was repaired primarily using a pedicled intercostal muscle flap via a right thoracotomy. Chest radiography at 12 months showed no migration of the stent-graft. Blood parameters of infection were normal; the patient remains well 18 months after stent-graft implantation.

CONCLUSIONS

This case illustrates stent-graft treatment of a life-threatening hemorrhage from an aortoesophageal fistula.

Endovascular Repair in the Presence of Aortic Infection

The purpose of this study is to describe our experience in the endovascular management of two cases of aortoenteric and aortoesophageal fistula that were unsuccessfully treated with an aortic stent graft because of recurrent infection. Although endovascular repair appears to be a promising therapeutic modality, in the presence of infection this technique should be considered on an individual basis. Failure of treatment should be expected in a significant number of cases during follow-up, particularly in patients with signs of sepsis. A review of the literature with positive and negative results has been included for a better understanding of this condition.

Endovascular repair of bleeding aortoenteric fistulas: a 5-year experience

PURPOSE

Aortoenteric fistula (AEF) is an uncommon but catastrophic complication that can occur either primarily or after aortic reconstruction. Untreated, it is uniformly fatal. Conventional surgical management is associated with a perioperative mortality rate of 25% to 90% and frequent major complications. We reviewed our experience with the endovascular treatment of both primary and secondary AEFs in an effort to determine whether endovascular repair is a less morbid alternative to traditional surgical treatment in select patients.

METHODS

In a 5-year period, seven high-risk patients who had bleeding and an AEF documented by means of radiology or endoscopy (2 primary, 5 secondary) were treated with coil embolization (1) or placement of an endovascular aortic stent graft (3 aortouniiliac, 2 tube, 1 bifurcated). One patient underwent computed tomography (CT)-guided percutaneous catheter drainage of an infected perigraft collection. The average follow-up period was 27 months (range, 11-66 months), and follow-up consisted of physical examination, complete blood count, and contrast-enhanced helical CT scanning at 3, 6, and 12 months and yearly thereafter. All patients were treated with intravenous antibiotics perioperatively and were prescribed life-long oral antibiotics on discharge.

RESULTS

There was one perioperative death (14%) caused by fungal sepsis. Persistent sepsis after stent-graft placement necessitated laparotomy and bowel resection in one patient. One patient had three bouts of recurrent sepsis that were successfully treated with a change of antibiotic. There were three late deaths (43%) unrelated to the procedure or AEF. Three patients (43%) were alive and well an average of 36 months (range, 23-67 months) after the procedure, with no clinical or radiologic evidence of recurrent bleeding or infection.

CONCLUSION

Endovascular management of AEFs is technically feasible and may be the preferred treatment in select patients with bleeding and no signs of sepsis. In the setting of gross infection, it may also be considered in high-risk patients as a bridge to more definitive treatment after hemodynamic stabilization and optimization.

Repair of secondary aortoesophageal fistula by endoluminal stent-grafting

PURPOSE

To describe a case of secondary aortoesophageal fistula that was treated with an endoluminal stent-graft.

CASE REPORT

A 58-year-old woman presented with hematemesis and melena. In 1974 she had an interposition graft repair of an aortic transection sustained during a traffic accident. At the examination in 1998, angiography demonstrated a mechanical disruption of the proximal anastomosis forming an aortoesophageal fistula. A 28-mm x 3.75-cm AneuRx stent-graft was introduced via a right femoral arteriotomy and deployed across the defect. Follow-up CT scans at 18 months showed exclusion of the false aneurysm with no evidence of infection; the patient remains well at >2 years after stent-graft implantation.

CONCLUSIONS

Endoluminal repair can be successful in achieving a satisfactory midterm outcome in cases of secondary aortoesophageal fistula.

Endovascular grafting of traumatic aortic aneurysms in contaminated fields

PURPOSE

To evaluate the potential of endovascular stent-grafts to treat traumatic aortic lesions in contaminated areas.

METHODS

Four patients (3 women; ages 26-78 years) underwent stent-grafting to repair an aortic rupture sustained in a motorcycle accident, aortic lacerations secondary to surgical treatment of spondylitis in 2 patients, and an aortobronchial fistula following surgical thoracic aortic repair 10 years earlier. Stent-grafts (2 Corvita, 1 Talent, and 1 Vanguard) were placed endoluminally into the infected areas via a transfemoral approach. Follow-up included erythrocyte sedimentation rate, white blood count, C-reactive protein, blood cultures, and computed tomography (CT).

RESULTS

The stent-grafts were successfully placed in all cases and excluded the aortic lesion. Under supportive antibiotic therapy, inflammation parameters returned to normal. CT imaging showed no evidence of paraprosthetic infection, nor were there any other complications over a follow-up that ranged from 3 to 34 months.

CONCLUSIONS

Endovascular therapy may be an alternative in the acute management of aortic ruptures in the setting of infection. Long-term results are required for definitive evaluation of the method.

Endovascular repair of an aortoduodenal fistula

PURPOSE

To demonstrate the utility of endovascular stent-graft repair for the management of an unusual aortoduodenal fistula.

METHODS AND RESULTS

A 23-year-old man with an aortoduodenal fistula secondary to tumor necrosis was treated with a Corvita endoluminal stent-graft after several failed surgical attempts to repair the defect. At 2-year follow-up, the patient was clinically and radiographically devoid of any evidence of occult stent-graft infection.

CONCLUSIONS

This case illustrates the usefulness of endovascular repair for the treatment of a primary aortoduodenal fistula. Endovascular repair should be included in the armamentarium for the management of difficult aortoduodenal fistulas.

Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis

PURPOSE

To describe the use of a stent-graft for emergent repair of life-threatening hepatic artery hemorrhage.

METHODS AND RESULTS

A 57-year-old man with a 17-year history of myxoid liposarcoma underwent surgery for a recurrent abdominal mass. Multivisceral resection including a Kausch-Whipple procedure with an extended right hemicolectomy was performed. Three weeks later, an episode of gastrointestinal bleeding prompted surgical repair of the hepatic artery, which had been eroded by infection due to a leaking bilioenteric anastomosis. After 3 weeks of programmed abdominal lavage, bleeding recurred. Angiography documented another rupture of the proximal hepatic artery. After an unsuccessful attempt at coil embolization, a Hemobahn stent-graft was implanted percutaneously during simultaneous cardiopulmonary resuscitation. Hemostasis was secured, and the patient recovered. Over the 10-month follow-up, no bleeding or infection has been observed at the site of the repair, and flow through the hepatic artery endograft remains satisfactory.

CONCLUSIONS

Percutaneous stent-graft placement can be employed for emergent treatment of visceral artery rupture in patients at high risk for conventional surgical repair.