Management Options of Aorta-Enteric Fistula in a Hostile Abdomen
Emily Lagergren, MD, Thomas Dodson, MD, William Jordan, MD, Yazan Duwayri, MD.
Emory University, Atlanta, GA, USA.
Background: Aorto-enteric fistulas (AEF) represent a rare but lethal subset of aortic graft infections. The most commonly described repairs of AEF involves excision of the infected graft, in situ abdominal aortic reconstruction or extra-anatomical bypass with subsequent graft excision, and bowel repair. Recurrent AEF after aortic graft removal is a rare problem and poses challenges in management. We present the successful treatment of two patients who presented with gastrointestinal hemorrhage secondary to delayed aortic stump blowout after resection of infected aortic grafts.
Methods and Results: The first patient is a 55-year-old gentleman who is status post multiple abdominal aortic operations including aorto-bifemoral and aortomesenteric bypasses for aortic dissection and malperfusion, open repair of aortic anastomotic pseudoaneurysm, and subsequent excision of infected aortic grafts with bilateral axillary femoral bypasses. He presented with hematemesis. Imaging was consistent with AEF. The patient’s prior extensive surgical history precluded a transabdominal approach. The aortic stump was debrided and reclosed via left thoracoabdominal incision. The fistula was separated and enteric coverage managed with an omental flap. The patient was discharged home on the twentieth postoperative day.
The second patient is a 68-year-old gentleman who has a past surgical history significant for open aortic aneurysm repair for rupture, right axillary bifemoral bypass with graft excision and duodenal repair for aortoduodenal erosion, enterocutaneous fistulae repairs, and complex abdominal wall reconstruction. He presented with hemorrhagic shock. Imaging was consistent with an AEF. Due to his complex surgical history and instability at presentation, the AEF was occluded with coils. Despite initial success, the aortoenteric fistula recurred 15 months later with coil erosion into the duodenum. Given his hemodynamic stability, he underwent visceral and renal artery debranching via a left thoracoabdominal exposure with ligation of the supraceliac aorta. He was discharged on his 10th postoperative day.
Conclusion: While the ideal surgical management of AEF is graft explantation via a trans-abdominal incision and in situ aortic reconstruction, hostile abdomens in patients with redo aortic surgery can preclude this treatment. Endovascular management with coil embolization is a safe alternative in unstable patients. Retroperitoneal and thoracoabdominal exposure of the aortic stump provides a controlled approach to the visceral aorta via virgin territory to safely separate the aorta from the eroding bowel.
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