title: Late gastrointestinal bleeding after infrarenal aortic grafting: a 16-year experience.
abstract: OBJECTIVE
  To review the manifestation and management of gastrointestinal (GI) bleeding caused by secondary aortoenteric fistula (AEF) after infrarenal aortic grafting.
  
  
  METHODS
  Between 1991 and 2006, nine patients underwent emergency treatment for secondary AEF localized in the duodenum (78%), ileum (11%), or sigmoid colon (11%). Three (33%) patients suffered hypovolemic shock. There were two (22%) real fistulas and seven (78%) paraprosthetic fistulas. Graft infection was confirmed in four (45%) patients and four (45%) had proximal sterile pseudoaneurysms. Surgical management consisted of graft removal with (n = 5) or without simultaneous extra-anatomic bypass (n = 1), in situ Dacron graft interposition (n = 3), ileo-duodenorrhaphy (n = 8), sigmoidectomy with colostomy (n = 1), and segmentary ileectomy (n = 1). Endografting was used only as a temporary measure to control bleeding in two patients.
  
  
  RESULTS
  The mortality rate was 55% (n = 5). There were no intraoperative deaths, but 75% of the septic patients, 66% of those with preoperative hemodynamic instability, 50% of those with pseudoaneurysms, and 100% of those who required bowel resection died during the early postoperative period. Moreover, all of the surviving patients suffered early postoperative morbidity, resulting in prolonged intensive care unit stay and hospitalization.
  
  
  CONCLUSIONS
  Secondary AEF is life-threatening, difficult to treat, and associated with high morbidity and mortality, especially in patients with sepsis or hemodynamic instability and those requiring bowel resection.
authors.affiliation: Department of Vascular Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, Milan, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Bianchi
authors.forename: Ilias
authors.initials: I
authors.lastname: Dalainas
authors.forename: Fabio
authors.initials: F
authors.lastname: Ramponi
authors.forename: Daniela
authors.initials: D
authors.lastname: Dell'Aglio
authors.forename: Renato
authors.initials: R
authors.lastname: Casana
authors.forename: Giovanni
authors.initials: G
authors.lastname: Nano
authors.forename: Giovanni
authors.initials: G
authors.lastname: Malacrida
authors.forename: Domenico G
authors.initials: DG
authors.lastname: Tealdi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017541:Aneurysm, False / Q000601:surgery*; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D004378:Duodenal Diseases / Q000150:complications / Q000601:surgery; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D006801:Humans; D007077:Ileal Diseases / Q000150:complications / Q000601:surgery; D015994:Incidence; D007412:Intestinal Fistula / Q000150:complications / Q000601:surgery; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D011475:Prosthesis Failure; D012086:Reoperation; D012189:Retrospective Studies; D012810:Sigmoid Diseases / Q000150:complications / Q000601:surgery; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016157:Vascular Fistula / Q000150:complications / Q000601:surgery