Endovascular treatment of aorto-enteric fistula...recurrent aortoenteric fistula as a...

Endovascular treatment of aorto-enteric

fistula

Athanasios D. Giannoukas, MD, MSc, PhD, FEBVS

Professor of Vascular Surgery

University of Thessaly Medical School

Chairman, Department of Vascular Surgery

University Hospital of Larissa, Greece

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Aorto-enteric fistula

• Abnormal communication between aortic and bowel

lumen necessitating immediate intervention

• Primary (incidence 0.02 – 0.07%) or secondary

(more often: <1%)

• GI bleeding alone or in combination with sepsis

Aorto-enteric fistula

Conventional surgical repair

• Primary: Aortic ligation and extra-anatomic bypass

• Secondary: extra-anatomic by-pass, graft excision

and aortic ligation or graft excision and in-situ aortic

reconstruction

High morbidity and mortality rates (>40%)

O’Mara CS et al. Am J Surg 1981;142:203

Bianchi P et al. Surg Today 2007;37:1053

CASE 1

Graft removal, aortic stump closure

with omentum and AxBF graft

Pt survived, 2yr-FU no evidence of

infection

Case 2

Case 2

Successful hybrid slanchnic

revascularization and thoracic &

abdominal endografting

Pt died 4 days later in the ICU due

to MOF

Aorto-enteric fistulaIn-situ surgical repair with homografts

• 57 patients treated with cryopreserved arterial homografts for

the in situ reconstruction of abdominal aortic infections.

• Thirty-day mortality was 9% (5 of 57 patients).

• Median follow-up was 36 months (range, 4-118 months);

• 3-year survival was 81%, and freedom from reoperation was

89%.

• Five patients (9%) required reoperation, in one patient each

for postoperative bleeding, acute cholecystitis, homograft

occlusion, homograft-duodenum fistula, and aneurysmal

degeneration.

• No recurrence of infection was reported.

Bisdas T et al. J Vasc Surg 2010;52:323

Batt M, et al. Contemporary management of infrarenal aortic graft

infection: early and late results in 82 patients.

Vascular 2012 Jun 1;20:129-137

• In situ reconstruction (ISR) in 63 patients with various conduits,

• Extra-anatomic reconstruction (EAR) in 11

• Conservative treatment in 5 and resection without reconstruction in 3.

• The perioperative mortality (33%) - similar for EAR and ISR

• Perioperative mortality higher in patients with secondary aortoenteric

fistula (P < 0.001) in those undergoing emergency aortic reconstruction

(P < 0.001) and in AGI caused by virulent organisms (P < 0.05).

• Fifteen (27%) of the surviving patients developed a recurrence of infection.

• EAR patients were more exposed to RI (P < 0.04).

• In conclusion, ISR may be more appropriate for AGI, but this study cannot

draw a conclusion relating to the optimal conduit for ISR.

Aorto-enteric fistularationale for endovascular treatment

• Patients with AEFs have limited overall survival.

• Endovascular therapy is associated with decreased

peri-operative morbidity and mortality and a shorter

in-hospital stay, and allows for acceptable survival

given the presence of coexisting medical co-

morbidities.

• Furthermore, endovascular repair provides a

therapeutic option to control bleeding and allows for

continued intervention in a stabilized setting.

Baril DT et al. J Vasc Surg 2006;44:250

Endovascular repair of

Aorto-enteric fistula

• Systematic review of English literature up to April

2008

• Endovascular repair of primary or secondary A-E

fistulae

• 33 reports with 41 pts

Antoniou GA, Koutsias S, Antoniou SA, Georgiakakis A, Lazarides M,

Giannoukas AD. J Vasc Surg 2009;49:782-9

Endovascular repair of

Aorto-enteric fistula

• Secondary as compared to primary AEF had an

almost three-fold increased risk

• Evidence of co-existing sepsis was factor of

unfavourable outcome (p< .05)

• Persistent/recurrent/new infection or haemorrhage

developed in 44% after a mean f-up of 13 mths

• Persistent/recurrent/new infection after treatment was

associated with worse 30-day and overall outcome

(p< .05)

Antoniou GA, Koutsias S, Antoniou SA, Georgiakakis A, Lazarides M,

Giannoukas AD. J Vasc Surg 2009;49:782-9

Endovascular repair of

Aorto-enteric fistula

Antoniou GA, Koutsias S, Antoniou SA, Georgiakakis A, Lazarides M,

Giannoukas AD. J Vasc Surg 2009;49:782-9

Aorto-enteric fistulaEVAR vs surgical repair

• Report on 25 pts during 12 year period

• Preoperative sepsis in 76% (19)

• EVAR: 8 pts – OR: 17 pts

• In-hospital mortality better in EVAR (0% VS 35%)

• Recurrence-free, sepsis-free & overall long-term

survival similar in both groups

• 2-year overall survival in pts with pre-op sepsis was

worse (24% vs. 50%)

Kakkos SK, Antoniadis PN, Clonaris C, Papazoglou KO, Giannoukas AD, Matsagas MI, Kotsis T,

Dervisis K, Gerasimidis T, Tsolakis IA, Liapis CD.

Presented at ESVS 2010 Annual meeting in Amsterdam

Eur J Vasc Endovasc Surg 2011;41:625-34

EVAR: Definite treatment or bridge therapy ?

Aorto-enteric fistulaEVAR vs surgical repair

Marone EM, Mascia D, Kahlberg A, Tshomba Y, Chiesa R.

Emergent endovascular treatment of a bleeding

recurrent aortoenteric fistula as a "bridge" to definitive

surgical repair. (case report)

J Vasc Surg.2012;55:1160-3

Since surgical treatment is technically demanding and

time consuming in emergent settings, endovascular

strategies to rapidly stop bleeding associated with AEF

may serve as a "bridge" to definitive open repair

Algorithm for the surgical

management of

aortoenteric fistula

✓ Endovascular treatment of primary and secondary AEF:

- may allow quick resolution of acute bleeding, avoid supra-celiac aorticcross-clamping, reduce surgical time, and stabilize the patient.

- where appropriate, seems to be superior with respect to early survivalcompared to open surgery for AEFs

✓ This benefit may be lost during long-term follow-up

✓ Life long administration of antibiotics seems to reduce re-infection incidence

✓ It is reasonable to suggest after an endovascular- first approach, as a bridging treatment, and definite open surgery in patients with good life expectancy to achieve the best long-term outcome

Case 3

ABF graft

Pt alive 3 year-FU without

evidence of infection

EVAR: Definite treatment?

May be

✓ No sepsis

✓ No gross abscess around the graft

✓ High risk - unstable – short life expectancy patients

One-stage: EVAR + bowel resection & repair +

Saccotomy and graft irrigation + coverage of aorta

with omentum + long-term antibiotics

Aorto-enteric fistulaEVAR vs surgical repair

Thanks for the attention

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