Table 40.1  Treatment options for the invasive management of aortoenteric fistula

1.Extra-anatomic bypass with resection of the infected prosthesis   · Staged

  · Simultaneous

2.Resection with in situ reconstruction

 · Antibiotic (rifampicin)-soaked graft with omental wrap

 · Homograft

 · Autologous vein

 · PTFE

3. Endovascular repair

 · As a bridging procedure

 · As a definitive solution

problem is how to deal with the aortic stump, which must be closed, preferably with double sutures. This may, however, not be possible if the distance to the renal arteries is too short. The stump is preferably covered with some vascularized tissue, and most frequently an omental pedicle has been used. Some authors advocate removal of the graft and an in situ reconstruction with expanded polytetrafluorethylene (ePTFE) graft or an antibioticbonded polyester graft (often with rifampicin)7,8 or in situ autologous vein.2,9 Table 40.1 summarizes the treatment options for the invasive management of aortoenteric fistula. [Q5: B] Recently a new therapeutic option has become available and that is endovascular repair. This is especially attractive as a bridging procedure bringing a hemodynamically unstable patient into a stage where graft removal and reconstruction can be made in a controlled way.10 In very fragile patients endovascular treatment may also be the only and final solution of a serious problem.

The prognosis is poor, with a high postoperative mortality, often several complications should the patient survive, and a risk for aortic stump blow out, which very few patients survive. Results have improved over recent years, but aortoenteric fistula still is a very serious and challenging complication.10 The 5-year survival rate is between 50% and 60%.3,7,10

References

 1. Bergqvist D, Bjorck M, Nyman R. Secondary aortoenteric fistula after endovascular aortic interventions: a systematic literature review. J Vasc Interv Radiol. 2008;19:163-165.

 2. Moore RD, Tittley JG. Laparoscopic aortic injury leading to delayed aortoenteric fistula: an alternative technique for repair. Ann Vasc Surg. 1999;13:586-588.

 3. Bergqvist D, Bjorkman H, Bolin T, et al. Secondary aortoenteric fistulae – changes from 1973 to 1993. Eur J Vasc Endovasc Surg. 1996;11:425-428.

 4. Nagy SW, Marshall JB. Aortoenteric fistulas. Recognizing a potentially catastrophic cause ofV gastrointestinal bleeding. Postgrad Med. 1993;93:211-212, 215–216, 219–222.

 5. Muller BT, Abbara S, Hennes N, Sandmann W. Diagnosis and therapy of second aortoenteric fistulas: results of 16 patients. Chirurg. 1999;70:415-421.

 6. Geroulakos G, Lumley JS, Wright JG. Factors influencing the long-term results of abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 1997;13:3-8.

 7. Hayes PD, Nasim A, London NJ, et al. In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the leicester experience (1992 to 1998). J Vasc Surg. 1999;30:92-98.

 8. Young RM, Cherry KJ Jr, Davis PM, et al. The results of in situ prosthetic replacement for infected aortic grafts. Am J Surg. 1999;178:136-140.

 9. Franke S, Voit R. The superficial femoral vein as arterial substitute in infections of the aortoiliac region. Ann Vasc Surg. 1997;11:406-412.

10.Bergqvist D, Bjorck M. Secondary arterioenteric fistulation – a systematic literature analysis.

Eur J Vasc Endovasc Surg. 2009;37:31-42.

Part IX

Vascular Access