Aortoduodenal Fistula after Abdominal Aortic Stent Graft Presenting with Extremity Abscesses

Aortoduodenal fistulas after endovascular abdominal aortic aneurysm repair and open aortic repair

OBJECTIVE

In the present study, we have reported and compared aortoduodenal fistulas (ADFs) after endovascular abdominal aortic aneurysm repair (EVAR) vs after open aortic repair (OAR).

METHODS

We retrospectively analyzed the data from patients treated for ADFs from January 2015 to May 2020 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoints of the present study were 30-day and 1-year mortality. The secondary endpoints were major postoperative complications.

RESULTS

A total of 24 patients (20 men; median age, 69 years; range, 53-82 years) were admitted with ADFs after EVAR (n = 9) or OAR (n = 15). These patients accounted for ∼4.3% of all abdominal aortic aneurysm repairs in our hospital. The median interval from the initial aortic repair and the diagnosis of ADF was 68 months (range, 6-83 months) for the ADF-EVAR group and 80 months (range, 1-479 months) for the ADF-OAR group. Three patients in the ADF-EVAR group had refused surgical treatment owing to their high surgical risk. One patient in the ADF-OAR group had undergone removal of the aortic prosthesis without replacement. Of the remaining 20 patients, 12 (ADF-EVAR group, n = 4; ADF-OAR group, n = 8) had undergone in situ replacement of the aorta and 8 (ADF-EVAR group, n = 2; ADF-OAR group, n = 6) had undergone extra-anatomic reconstruction with aortic ligation. After a mean follow-up of 26 months, no patient had experienced early limb loss. However, one case of rupture of the venous graft (ADF-EVAR), one case of aortic stump blowout (ADF-OAR), and one case of a ureteroarterial fistula with a homograft (ADF-OAR) had occurred. Overall, the incidence of postoperative complications was significantly greater after ADF-OAR (93% vs 33%; P = .036). The most frequent bacteria involved in the blood cultures were Escherichia coli (25% of patients), and Candida spp. (61%) were the predominant pathogens found on intra-abdominal smears. The in-hospital mortality rates for the ADF-EVAR and ADF-OAR group were 22% and 13%, respectively. The corresponding 1 -year mortality rates were 22% and 33%.

CONCLUSIONS

Patients with ADFs after EVAR or OAR have limited overall survival. In addition to the similar therapeutic approaches, we found no significant differences in postoperative mortality between these two uncommon pathologic entities. In our study, the overall postoperative morbidity seemed greater for the ADF-OAR group.

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.

Septic embolism in the intensive care unit

Septic embolism encompasses a wide range of presentations and clinical considerations. From asymptomatic, incidental finding on advanced imaging to devastating cardiovascular or cerebral events, this important clinico-pathologic entity continues to affect critically ill patients. Septic emboli are challenging because they represent two insults—the early embolic/ischemic insult due to vascular occlusion and the infectious insult from a deep-seated nidus of infection frequently not amenable to adequate source control. Mycotic aneurysms and intravascular or end-organ abscesses can occur. The diagnosis of septic embolism should be considered in any patient with certain risk factors including bacterial endocarditis or infected intravascular devices. Treatment consists of long-term antibiotics and source control when possible. This manuscript provides a much-needed synopsis of the different forms and clinical presentations of septic embolism, basic diagnostic considerations, general clinical approaches, and an overview of potential complications.

Conservative treatment of an aortoesophagial fistula after endovascular stent grafting for a thoracic aortic aneurysm

Background

Aortoesophageal fistula (AEF) is an uncommon condition that presents a problem in therapy because of the high rate of morbidity and mortality associated with its surgical management and the uniformly fatal outcome of medical treatment. In this article we describe a case of secondary AEF after endoluminal stent grafting of the thoracic aorta, which was observed by only conservative management and followed up for 14 months with no signs of recurrent hemorrhage or chronic mediastinitis.

Case Report

A 54-year old man with hepatocellular carcinoma (HCC) was admitted to our hospital because of tarry stool. He had a history of traumatic aneurysm, and undergone segmental replacement with a stent graft three years ago. After admission, Esophagogastroduodenoscopy and computed tomography identified AEF. He was treated conservatively, because his stage of HCC was advanced. Oral intake was prohibited, and the patient received proton pump inhibitors, intravenous hyperalimentation and antibiotics. Afterwards, no signs of hemorrhage were observed. Although oral intake was resumed after that, another bleeding event or development of mediastinitis was not observed. Subsequently, He was received chemotherapy for advanced HCC, and we observed downstaging of his advanced HCC.

Conclusions

Although we observed 14 months survival in our case under conservative management of secondary AEF, it seems that the treatment of secondary AEF should do the operative management.

AAA stent-grafts: past problems and future prospects

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.

Is F 18 Fluorodeoxyglucose Positron Emission Tomography Too Sensitive for the Diagnosis of Vascular Endograft Infection?

We report a case of a false positive fluorodeoxyglucose positron emission tomography (FDG-PET) scan in a patient who presented with abdominal pain, and gastrointestinal bleeding accompanied by elevation of inflammatory markers, seven weeks after a proximal type I endoleak repair with a cuff extension. Aortoenteric fistula and endograft infection was ruled out by laparotomy. FDG-PET image may have a role in diagnosis of infection, but false positive results are possible and caution is necessary if other data are non-confirmatory.

[Aortoduodenal fistula revealed by acute fever with heavy and swollen red leg]

BACKGROUND

Aortoduodenal fistulas are rare and severe complications of aortic prostheses. The clinical picture usually includes digestive features and fever, unlike our observation where fistula was revealed by heavy and swollen leg with cutaneous septic abscesses but no digestive signs.

PATIENTS AND METHODS

A 59 year-old man who had undergone aortoiliac prosthetic repair of an aortic aneurysm 6 years earlier was hospitalized in a dermatology department for fever beginning three months previously associated with a heavy and swollen leg. Clinical and ultrasound examination revealed vascularised cutaneous nodules on the leg. Abdominal CAT showed left iliac venous compression caused by periprosthetic inflammation and particularly retroperitoneal fluid accumulation, gas bubbles in which suggested aortoduodenal fistula, which was confirmed during surgery. Aspirative puncture of abscesses was positive for E. Coli and Candida Glabatra.

DISCUSSION

Aortoduodenal fistula is a rare complication of vascular prostheses. Clinical features include digestive symptoms and fever. However, diagnosis may be difficult and delay surgery. Cutaneous manifestations appear later and are often associated with other symptoms; they are caused by septic emboli or vascular compression. Imaging methods may assist diagnosis, but surgical procedures provide confirmation and form the cornerstone of management.

Aortoenteric fistula as a late complication of thrombolysis and bare metal stenting for perioperative occlusion of aortofemoral bypass

We previously described the case of a 47-year-old man who experienced perioperative graft occlusion after infrarenal aortic endarterectomy and aortobifemoral expanded polytetrafluoroethylene bypass graft for occlusive disease. The patient was treated with local graft thrombolysis and stenting of an intimal flap at the level of the endarterectomized aorta next to the aortic anastomosis. An urgent laparotomy performed 6 years later showed aortic wall perforation by the stent with a large aortoenteric fistula. Surgical treatment included removal of the stent and the aortobifemoral graft, bowel repair, and extra-anatomic lower-limb revascularization by axillofemoral and cross-femoral bypass grafting. The patient was discharged 12 days later with no early complications. Although local thrombolysis and stenting may be a technically feasible technique instead of reoperation in early aortofemoral graft thrombosis, long-term results of this procedure may be affected by perigraft hematoma due to perioperative thrombolysis, increased risk of infection due to the prolonged intragraft cannulation, and risk of stent-related aortic injury, especially if an endarterectomy has been performed. All these issues may increase the risk of late aortoenteric fistula. More experience with hybrid, open/endovascular procedures, and more contemporary stent-based devices is needed to assess the efficacy and safety of this alternative treatment.