Improved outcomes in the recent management of secondary aortoenteric fistula.
OBJECTIVE
We reviewed the presentation, management, and late events in a recent experience with aortic graft-enteric communications (secondary aortoenteric fistula) to identify variables associated with poor outcomes.


METHODS
Since 1991, 29 patients (19 men, 10 women; mean age, 70) presented with a secondary aortoenteric fistula. The duration from aortic graft implantation to aortoenteric fistula development ranged from 8 months to 180 months (mean, 47 months). Presenting symptoms included gastrointestinal bleeding (n = 25), sepsis and retroperitoneal abscess (n = 3), and ruptured para-anastomotic aneurysm (n = 1). One third (10/29) of patients were hypotensive at presentation. Repair was accomplished by graft excision with axillobifemoral bypass (17 simultaneous, 8 staged), graft excision with in situ deep vein replacement (n = 2), or graft excision with rifampin-treated prosthetic replacement (n = 2). Mean follow-up was 51 months, and the incidence of late events was reported by life table methods.


RESULTS
The operative (< or = 30-day) mortality rate was 21%, with shock at presentation (P < .01), the need for preoperative transfusion (P < .01), and use of suprarenal aortic clamping during aortoenteric fistula repair (P = .03) associated with lethal outcome. Cumulative mortality related to aortoenteric fistula management was only 24% within an overall 5-year survival rate of 61%. Freedom from recurrent infection or amputation was 86% and 88% at 5 years, respectively, and assisted graft patency was 79%. Presence of staphylococcal species in 22% of patients and occasional operative findings of adjacent perigraft "biofilm" suggests that underlying indolent graft infection may contribute to the development of aortoenteric fistula in some cases.


CONCLUSIONS
Outcomes associated with aortoenteric fistula repair were surprisingly favorable in the absence of preoperative hemodynamic instability.
Armstrong
Paul A
PA
Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, Tampa, Fla 33606, USA.
Back
Martin R
MR
Wilson
Jeffrey S
JS
Shames
Murray L
ML
Johnson
Brad L
BL
Bandyk
Dennis F
DF
D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001012:Aorta, Abdominal; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007412:Intestinal Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000628:therapy; D011336:Probability; D011475:Prosthesis Failure; D016459:Prosthesis-Related Infections / Q000000981:diagnostic imaging / Q000628:therapy*; D018570:Risk Assessment; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000379:methods*
D000900:Anti-Bacterial Agents