Adjuncts to the Management of Graft Aorto-Enteric Erosion and Fistula with in situ Reconstruction

Mauriac, P; François, M.; Marichez, Arthur; Dubuisson, Vincent; Pugès, Mathilde; Stenson, Kristina; Ducasse, Éric; Caradu, Caroline; Bérard, Xavier

doi:10.1016/j.ejvs.2021.06.018

Cited by 7 publications

(8 citation statements)

References 23 publications

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“…Secondary AEFs are a rare vascular condition. Due to the significant comorbidities, these patients usually exhibit an acute presentation, and AEFs are associated with considerable perioperative mortality up to 50% [ 6 , 11 ]. Despite a number of proposed therapeutic approaches, a clear therapeutic plan is yet to be defined.…”

Section: Discussionmentioning

confidence: 99%

“…The incidence of secondary AEFs following open abdominal aortic aneurysm (AAA) and endovascular aneurysm repair (EVAR) ranges between 0.36–1.6% [ 5 ]. Chronic graft infection or physical stimulation through aortic pulsation pressure has been suggested to contribute to the formation of secondary AEFs [ 6 ]. Clinical presentation can vary, including gastrointestinal bleeding and signs of chronic infection such as weakness, fever or weight loss.…”

Section: Introductionmentioning

confidence: 99%

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Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center

Oikonomou

Pfister

Kasprzak

et al. 2022

JCM

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Objectives: To present our experience with various therapeutic approaches for the treatment of secondary aortoenteric fistulas following open and endovascular aortic aneurysm repair. Methods and Materials: A retrospective data analysis of patients treated for secondary aortoenteric fistulas in a single vascular institution between January 2005 and December 2018 was performed. Analyzed parameters included patients’ demographics, clinical presentation, diagnostic work-up, perioperative data and repair durability during follow-up. Results: Twenty-three patients with aortoenteric fistulas were treated in the target period. The fistulous connection was located in 21 cases (91.3%) in the duodenum and in two cases (8.7%) in the small intestine. Average time between the initial procedure and detection of the aortoenteric fistula was 69.4 ± 72.5 months. The most common presenting symptom was gastrointestinal bleeding (n = 12, 52.2%), followed by symptoms suggestive of chronic infection (n = 11, 47.8%). Open surgical repair was performed in 19 patients (bridging in 3 patients), and endovascular repair was carried out in two cases and one patient underwent a hybrid operation. One patient underwent abscess drainage due to significant comorbidities. Mean follow-up was 35.1 ± 35.5 months. In-hospital mortality and overall mortality were 43.5% (10/23) and 65.2% (15/23), respectively. Patients presenting with bleeding had a significantly higher perioperative mortality rate in comparison to patients presenting with chronic infection (66.7% (8/12) and 18.2% (2/11), respectively, p = 0.019). Patients who underwent stent-graft implantation for control of acute life-threatening bleeding showed significantly better perioperative survival in comparison to patients that were acutely treated with an open procedure (66.6%, (4/6) and 0% (0/6), respectively, p = 0.014). Perioperative mortality was also higher for ASA IV patients (71.4%, 5/7), when compared to ASA III Patients (31.2%, 5/16), although this did not reach statistical significance (p = 0.074). Conclusion: Treatment of secondary aortoenteric fistulas is associated with a high perioperative mortality rate. Patients who survive the perioperative period following open surgical repair in the absence of hemorrhagic shock show acceptable midterm results during follow-up. Stent-graft implantation for bleeding control in patients presenting with life-threatening bleeding seems to be associated with lower perioperative mortality rates.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center

Oikonomou

Pfister

Kasprzak

et al. 2022

JCM

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“…13,14 Rapid source control is recommended in the management of sepsis, 15,16 but open aortic surgery in a septic patient can result in endothelial dysfunction and massive third space losses, which, in combination with pre-operative haemorrhagic shock, can contribute to mortality rates up to 40%. 17 Traditional surgical management with open repair (OAR) has consisted of explantation of the infected graft, with extraanatomic bypass (EAB) or in-situ aortic reconstruction (ISR), 8,18 and is associated with a hospital mortality of 25%-90%. 9 In recent years, endovascular repair (EVAR) has emerged as a potentially safe and efficient method to stabilize critical patients.…”

Section: Introductionmentioning

confidence: 99%

“…Treatment must balance sepsis control and haemostasis in patients who may present in extremis —the lethal combination of systemic infection and haemorrhage 13,14 . Rapid source control is recommended in the management of sepsis, 15,16 but open aortic surgery in a septic patient can result in endothelial dysfunction and massive third space losses, which, in combination with pre‐operative haemorrhagic shock, can contribute to mortality rates up to 40% 17 . Traditional surgical management with open repair (OAR) has consisted of explantation of the infected graft, with extra‐anatomic bypass (EAB) or in‐situ aortic reconstruction (ISR), 8,18 and is associated with a hospital mortality of 25%–90% 9 .…”

Section: Introductionmentioning

confidence: 99%

Management of secondary aorto‐enteric fistulae: a multi‐centre study

Narayanan

Hanna

Okamura-Kho

et al. 2023

ANZ Journal of Surgery

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BackgroundSecondary 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.MethodsThis 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.ResultsAcross 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).ConclusionIn 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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“…Due to the complexity and urgency, the perioperative risk of severe complications (multi-organ failure and ultimately death) is reported to be up to 21%-75%. 3,[19][20][21] However, prognosis without treatment remains fatal with a mortality of 100%. 15,22 The majority of publications constitute individual case reports and small clinical case series with up to 50 patients.…”

Section: Introductionmentioning

confidence: 99%

A Modern Series of Secondary Aortoenteric Fistula – A 19-Year Experience

Sieber,

Busch,

Sargut

et al. 2023

Vasc Endovascular Surg

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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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Adjuncts to the Management of Graft Aorto-Enteric Erosion and Fistula with in situ Reconstruction

Cited by 7 publications

References 23 publications

Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center

Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center

Management of secondary aorto‐enteric fistulae: a multi‐centre study

A Modern Series of Secondary Aortoenteric Fistula – A 19-Year Experience

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