The Management of Aortoduodenal Fistula by In Situ Replacement of the Infected Abdominal Aortic Graft

Abstract

Conventional surgical wisdom dictates the complete removal of infected abdominal aortic graft, oversewing of the aorta, and restoration of lower limb bloodflow by extra-anatomic bypass grafting. Dissatisfied with this approach because of the high incidence of local complications, mortality, and loss of limb, 20 patients with secondary aortoduodenal fistula had duodenal repair, excision of the old graft, and placement of a new graft in the same location. A similar technique was used in three patients with erosion of an aortic graft into the jejunum. Length of follow-up averaged 5.2 years, and was more than 1 year in each instance. Of the eighteen patients who survived the repair, three have had early recurrent rupture or false aneurysm of the proximal aortic anastomosis, with consequent death in two, but fifteen patients (83%) have had no further related problem. There was no loss of limb. Use of greater omentum as a protective barrier seemed helpful. Optimal antibiotic usage, and the idea that varying degrees of graft infection require different approaches, require further definition. In conclusion, in situ graft replacement is the correct operative strategy in this challenging group of patients.

Infected Abdominal Aortic Grafts

“…12 Our amputation rate was also comparable to that reported in the literature. [6][7][8][9][10][11] Walker et al 18 have recommended in situ grafting for secondary aorto-enteric fistula. 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.…”

Management of aortic graft infections – the present strategy and future perspectives

“…In 1987, Walker (50) reported the fi rst cases of in situ repair of AGI by replacing the infected grafts with Dacron grafts. The results of this method were very bad with more than 25 % mortality rate and more than 30 % reinfection rate.…”

Current Management of Vascular Infections

“…[21,22] Bacteremia develops in advanced graft infections. Graft infection due to S. epidermidis typically presents months to years after graft implantation with anastomotic aneurysm, graft-cutaneous sinus tract or perigraft cavity with fluid.…”