Staged Surgery for Chronic Primary Aortoduodenal Fistula in a Septic Patient

Abstract

Aortoenteric fistula is one of the most challenging problems that confront the vascular surgeons. Controversy remains over the optimal treatment because of the continued publication of series with high mortality, amputation, and aortic disruption rates. A positive preoperative blood culture is the best predictor of mortality with increased amputation rates due to infection of the extra-anatomic bypass. Therefore, in selected cases with sepsis, a prudent management protocol is required. We report a 68-yr-old male presenting with a chronic primary aortoduodenal fistula extensively involving the duodenum and Gram-negative sepsis. We planned a staged operation. Initially, an emergency laparotomy and control of the aorta allowed stabilization of the patient, identification of the fistula, and direct in situ placement of the prosthetic graft followed by an en bloc resection of the aneurysm and the surrounding structures. After he recovered from sepsis and had been stabilized, a staged extra-anatomic bypass followed by transabdominal removal of the temporarily placed graft was done. This management plan will allow the highest success rate and may be a prudent management protocol for these difficult cases.

Aortoenteric Fistulae: Present-Day Management

“…An estimated 80% of secondary AEFs affect the duodenum, mostly the third and fourth parts (the horizontal and ascending duodenum). 24 Perigraft soft tissue edema, fluid, and ectopic gas may be normal CT findings immediately after surgery. However, after 3-4 weeks, any ectopic gas is abnormal and should be considered a sign of perigraft infection and possibly fistulization to the bowel.…”

A Rare Cause of Gastrointestinal Hemorrhage: Secondary Aortoenteric Fistula

“…Aorta enteric fistula is the development of fistula between the aorta and the gastrointestinal tract. Two types of aortaenteric fistulas have been described: Primary aortaenteric fistula (PAEF) and secondary aortaenteric fistula (SAEF) (8,9). PAEF is rare, and its incidence has been reported between 0.04% and 0.07% in large autopsy series (8)(9)(10).…”

“…Rare causes of PAEF include radiation, carcinoma, mycotic aneurysm, septic aortitis due to salmonella infection, diverticular abscess, duodenal ulcer, and foreign bodies (8)(9)(10). In PAEF, fistula formation usually develops between the aorta and the 3rd and 4th sections of the duodenum (9,11,12). The annual incidence of SAEF is about 1% (0.6-2) (13).…”

“…Two types of aortaenteric fistulas have been described: Primary aortaenteric fistula (PAEF) and secondary aortaenteric fistula (SAEF) (8,9). PAEF is rare, and its incidence has been reported between 0.04% and 0.07% in large autopsy series (8)(9)(10). In PAEF, fistula typically occurs due to aneurysm developing as a result of atherosclerosis and mostly in elderly patients.…”

Primary Aortoduodenal Fistula – A Rare Clinical Entity

“…With surgical intervention, survival ranges from 18–93%. 6 , 7 , 13 – 18 As many as 40% of operated cases develop complications, and the overall postoperative mortality rate is greater than 30%. 3 , 6 PADFs associated with infected aneurysms have a worse prognosis, with a postoperative mortality rate exceeding 50%.…”