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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
Conflict of Interest Disclosure Form
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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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