Secondary aorto-enteric fistulae: Towards a more conservative approach

Abstract

Eight cases of secondary aorto-enteric fistulae are presented occurring 9 months to 10 years after aortic Dacron grafting. In four patients there was a simple fistula between the anastomosis and the adherent duodenum, three patients had clinically infected grafts and one had a false aneurysm that had ruptured into the bowel. The four patients with a simple fistula had direct suture repair of the defect. One developed a recurrent fistula at 2 months and was successfully repaired again by direct suture. All four patients remain well at a follow-up of 1-5 years. The other four patients had the grafts excised, with local regrafting in two cases, both patients remaining well at follow-up. One patient had an axillo-bifemoral graft, but died at 30 days of overwhelming sepsis. The final patient, a girl with diffuse aneurysmal disease, had the aortic stump oversewn but no reconstruction. She died at 9 months of aortic stump disruption. These results suggest that a more conservative approach to the operative correction of secondary fistulae should be used wherever possible.

In situ versus extra-anatomic reconstruction for primary infected infrarenal abdominal aortic aneurysms

“…However, infected prosthetic aortic graft management studies have noted a high incidence of complications for extra-anatomic bypass, including an 8% to 19% rate of aortic stump disruption, 17% to 27% rate of amputation, and an 8% to 22% rate of reinfection. [16][17][18][19][20][21] Although no aortic stump disruption nor reinfection developed in the 15 patients in group II, limb loss did occur in one patient during follow-up, for a 7% amputation rate. Concerning the potential risk of limb loss, in situ graft reconstruction may be optimal for management of infrarenal aortic aneurysms.…”

Infected Abdominal Aortic Grafts

“…They had 22% hospital mortality rate and 16 out of the 18 surviving patients were alive after five years of follow-up, but it is worth noting that when the graft was inserted in the presence of paraprosthetic graft infection, 60% of patients died. Their experience and those of others 19 suggest that this procedure may be safe in selected cases. The performance of the extra-anatomical bypass graft prior to graft removal is preferred by some.…”

Aortoiliac and aortofemoral bypass grafting are widely used operative treatment modalities of aortic reconstruction for both aortic occlusive disease and aneurysms of abdominal aorta. Graft occlusion,

“…Patients died because of persistant sepsis and recurrent aortoenteric fistulae. More recently Thomas and Baird, and Walker and Cooley presented their experience about patients with aortoenteric fistula involving suture line (11,12). Their results are encouraging for more conservative management in selected patients.…”