Aortoenteric fistula as a late complication of thrombolysis and bare metal stenting for perioperative occlusion of aortofemoral bypass

We previously described the case of a 47-year-old man who experienced perioperative graft occlusion after infrarenal aortic endarterectomy and aortobifemoral expanded polytetrafluoroethylene bypass graft for occlusive disease. The patient was treated with local graft thrombolysis and stenting of an intimal flap at the level of the endarterectomized aorta next to the aortic anastomosis. An urgent laparotomy performed 6 years later showed aortic wall perforation by the stent with a large aortoenteric fistula. Surgical treatment included removal of the stent and the aortobifemoral graft, bowel repair, and extra-anatomic lower-limb revascularization by axillofemoral and cross-femoral bypass grafting. The patient was discharged 12 days later with no early complications. Although local thrombolysis and stenting may be a technically feasible technique instead of reoperation in early aortofemoral graft thrombosis, long-term results of this procedure may be affected by perigraft hematoma due to perioperative thrombolysis, increased risk of infection due to the prolonged intragraft cannulation, and risk of stent-related aortic injury, especially if an endarterectomy has been performed. All these issues may increase the risk of late aortoenteric fistula. More experience with hybrid, open/endovascular procedures, and more contemporary stent-based devices is needed to assess the efficacy and safety of this alternative treatment.     

Emergent endovascular treatment of a bleeding recurrent aortoenteric fistula as a "bridge" to definitive surgical repair

We report the case of a 59-year-old man who developed a recurrent aortoenteric fistula (AEF) following previous aorto-bifemoral bypass grafting and subsequent AEF open repair with aorto-bifemoral graft excision and extra-anatomic reconstruction. The patient was treated emergently by means of endovascular plug deployment via a left brachial approach into the infrarenal aortic stump, obtaining recovery of hemodynamic stability. Five days later, he underwent elective relaparotomy, aortic plug removal, infrarenal aortic ligature, and duodenal repair. Endovascular strategies to rapidly stop bleeding associated with recurrent AEF may serve as a "bridge" to definitive open repair, as in the case discussed herein. Even if rare, recurrent AEF following previous prosthetic aortic graft excision and extra-anatomic revascularization represents a dreadful event. Since surgical treatment is technically demanding and time consuming in emergent settings, we present an "unconventional" endovascular option to obtain quick cessation of aortic bleeding.     

Aortic sepsis: is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.     

Aortoduodenal fistula and associated rupture of abdominal aortic aneurysm after endoluminal stent graft repair

The main complications of endovascular repair of abdominal aortic aneurysms are vascular leaks and rupture, although infection and aortoduodenal fistulas have also been reported rarely. We report a case of aortoduodenal fistula with separate retroperitoneal rupture of an abdominal aortic aneurysm after endovascular stent graft repair. The initial implantation was uneventful, without any leaks at 1 month. The patient underwent open repair and did well. To our knowledge, this is the first case report of aortoduodenal fistula and associated retroperitoneal rupture of the aneurysm after endovascular stent graft repair of an abdominal aortic aneurysm.     

Neurologic complications of reoperative and emergent abdominal aortic reconstruction

Patients undergoing emergent and reoperative abdominal aortic reconstructions are at increased risk for ischemic neurologic complications. Between 1986 and 1992 five patients sustained ischemic injuries to the spinal cord, nerve roots, or lumbosacral plexus. Four patients underwent reoperative aortic procedures including removal of an infected aortobifemoral graft and extra-anatomic bypass (n=3) and aortofemoral graft revision for primary graft failure (n=1). A fifth patient had a ruptured common iliac aneurysm repaired with an aortobifemoral graft. Three patients undergoing reoperative aortic procedures developed lower extremity paraparesis, patchy sensory deficits, and bowel and bladder dysfunction. Physical examination and electromyography localized the injury to the level of the cauda equina or lumbosacral plexus. The other patient in this group developed incomplete T12 paraplegia. Surgical reconstruction resulted in internal iliac exclusion in all four patients. The incidence of neurologic deficits during this study period was 18% (3/17) in patients requiring aortofemoral graft excision for infection. The patient undergoing aneurysm repair was noted to have paraplegia after surgery and died on the fourth postoperative day. Autopsy revealed evidence of multiple emboli to the kidneys, bowel, and spinal cord. Neurologic deficits after reoperative and emergent abdominal aortic reconstructions are uncommon but devastating complications. Of particular concern is the incidence of neurologic deficits after removal of aortofemoral grafts with disruption of collateral flow to the spinal cord and nerve roots. Consideration should be given to maintaining retrograde perfusion of at least one internal iliac artery via common femoral artery reconstruction in these patients.Presented at the Nineteenth Annual Meeting of the Peripheral Vascular Surgery Society, Seattle, Wash., June 5, 1994.     

Penetrating aortic ulcer with severe gastrointestinal bleeding

Primary aortointestinal fistula is a rare reason for gastrointestinal bleeding and mainly caused by a communication between the digestive tract and an aortic aneurysm. The penetrating aortic ulcer has been recently recognized as an independent pathological entity. It may penetrate through the aortic wall, leading to fistula into adjacent organs. We report the case of a 78-year-old woman who was admitted to our department with massive gastrointestinal hemorrhage. Endoscopy did not reveal the cause of hemorrhage. The diagnosis was made by computed tomography showing a primary aortoduodenal fistula without aortic aneurysm. The patient was successfully operated on. During urgent operation we found the penetrating atherosclerotic ulcer as the cause of the aortoduodenal communication. Primary aortoenteric fistula has a fatal outcome unless it is diagnosed accurately and urgently treated by surgical intervention. Contrast-enhanced computed tomography is the primary imaging modality to specify the diagnosis.     

Complicated duodeno-biliary fistula in bleeding duodenal ulcer: case report an literature review

Upper gastrointestinal tract bleedings may represent the first clinical evidence of peptic ulcer and the related surgical emergency is still characterized by a high mortality rate. The presence of multiple complications, rare but possible in case of duodenal ulcer, such as the fistulization in the common bile duct alone or associated to others, can significantly increase the difficulty in the treatment. The Authors report a particularly complex case of a 77 years old male diabetic patient, with chronic bronchopaty, urgently admitted to our department for hematemesis. Soon after his hemodynamic stabilization, the patient was submitted to surgery which showed a duodenal ulcer with penetration/fistulization in the common bile duct associated to a perforation of the gallbladder with intra-hepatic abscess and erosion of the gastro-duodenal artery. Despite unfavourable outcome the case gave us the starting point for a review of the literature primarily related to the rarer biliary complications of duodenal ulcer. Bleeding ulcers today are usually treated by an interdisciplinary approach comprehensive of endoscopy, interventional radiology and, only rarely, surgery. The choice among the available options depends on the clinical presentation of the patient. Despite diagnostic and therapeutic progresses, peptic ulcer may still rarely have a dramatic presentation and be associated to uncommon and difficult anatomical aspects whose diagnosis and treatment may be not easy at all. The knowledge of all the aspects of peptic ulcer pathophysiology is therefore essential for the treatment of these patients.     

Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage "elephant trunk" repair

Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage "elephant trunk" repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1-64 months). Twelve patients (five women and seven men) with a mean age of 69 +/- 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.     

Infection of an Abdominal Aortic Stent Graft with Suprarenal Attachment

Stent grafting for treatment of abdominal aortic aneurysm can lead to infectious complications. The purpose of this report is to describe a case involving a patient with an aortobiliac stent graft, a horseshoe kidney, and coronary artery disease who presented suprarenal aortic infection requiring removal of the stent graft and in situ reconstruction using an arterial homograft. The discussion deals with management of infected vascular material and reconstruction techniques.     

Renal transplantation in patients with abdominal aortic aneurysm—a new surgical approach

An increasing number of abdominal aortic aneurysms occurs in renal failure patients because of an accelerated atherosclerosis process associated with uraemia. When technically feasible, endovascular repair of an abdominal aortic lesion should be considered as the treatment of choice. If a surgical repair is suggested, there are several options to select from. Since November 1999, we performed simultaneous aortic reconstruction using fresh arterial allograft and kidney transplantation in five uraemic patients with asymptomatic abdominal aortic aneurysm. The operative and postoperative course of four patients passed without major complications. One patient had ischaemic colitis early after the operation, which required a partial resection of the colon. One patient died 6 weeks after the operation due to non-vascular causes. In conclusion, the advantage of our single-phase procedure is that both diseases are treated simultaneously during a single hospital stay. Moreover, with our procedure, the risk of vascular graft infection in patients with chronic immunosuppression is low.     

Sigmoid colon exteriorization after ruptured abdominal aortic aneurysm

A 74-year-old man in shock was transferred to our hospital. A ruptured abdominal aortic aneurysm was diagnosed by computed tomography and an emergency operation was thereafter performed. At operation, a massive hematoma was encountered in the retroperitoneal space and a standard aneurysmectomy with bifurcated graft replacement was carried out. At the end of the operation, signs of sigmoid colonic ischemia were recognized, including mild discoloration and bowel spasm. After considering the recovery or deterioration from colonic ischemia, we chose to exteriorize the sigmoid colon. On the 4th postoperative day, patchy ischemic areas of an elevated sigmoid colon were noticed to worsen and as a result, we were forced to perform a sigmoid colectomy with end colostomy. Thereafter, the patient developed multisystem organ failure, but he recovered gradually. The patient was discharged from the hospital 3 months after the initial operation. As a complication after surgery for abdominal aortic aneurysms, colonic ischemia remains a serious problem, especially in cases of ruptured AAA. It is generally better to avoid an operation for both abdominal aortic aneurysms and a colon resection at the same time. In this case, an exteriorization of the sigmoid colon was selected for the 1st operation in order to treat a ruptured abdominal aortic aneurysm. This surgical modality was found to be useful for making a correct diagnosis of colonic ischemia before the perforation, while a 2nd look operation for colonic ischemia could thus be performed under conditions of a reduced risk of infection to the prosthetic graft. These operative procedures were considered to be important factors in saving the patient's life.     

The endovascular management of open aortic surgery complications with emergency stent-graft repair in high-risk patients

The aim of the study was to demonstrate the utility of endovascular stent-graft repair for emergency management of aorto-iliac surgery complications. Between 1997 and 2004, in our institute, 201 patients underwent transluminal endovascular graft placement. In 3 patients (1.4%), previously submitted to conventional aortic surgery, endovascular treatment was carried out due to the occurrence of late complications: 1 secondary aortocaval fistula, 1 impending rupture of aortic pseudoaneurysm and 1 secondary aorto-enteric fistula. All candidates were high surgical risk patients (ASA III-IV) suitable for endoprosthesis positioning by endovascular stent-graft implantation presenting with severe worsening conditions in an emergency situation. The patients were treated under local anesthesia and mild sedation. After treatment there was complete resolution of the clinical presentation and an improvement of general conditions in all 3 patients. In the 1(st) patient legs edema disappeared and in the 2(nd) patient mesogastric pain is absent, respectively at 30 and 8 months. The 3(rd) patient, with secondary aorto-enteric fistula, was submitted 2 months later to aortic graft removal and axillo-bifemoral bypass because of infection development. For the treatment of abdominal aortic surgery complications in high risk patients, particularly in emergency situations, endovascular approach is a feasible and safe alternative to conventional open repair. Further evaluation of this technique and longer follow-up will determine its exact role in the management of these life-threatening complications.     

Endograft infection following emergency repair for abdominal aortic aneurysm dissection and the undervalued role of the bowel reservoir

Endograft infection after emergency endovascular aortic repair (EVAR) procedure has received less attention than other complications, and usually occurs soon after endograft positioning. Consequently, clear guidelines for the prevention and treatment of endograft infection have yet to come. We report a case of an 85‐year‐old patient treated with an emergency EVAR procedure for a fissured abdominal aortic aneurysm, whose immediate follow up was complicated by a prolonged upper gastrointestinal occlusion. Six months, later he developed an endograft infection due to intestinal flora. After exclusion of all other possible causes, bacterial translocation from the bowel appeared the only plausible mechanism. This case highlights the importance of the gastrointestinal tract as a potential source of endograft infection, and suggests how a clinical condition representing potential reservoir of infection should be managed properly.     

Surgical management of ascending aortic graft infection. No-sedation-technique for open mediastinal irrigation.

Two patients with ascending aortic graft infection were successfully treated. The first patient underwent ascending aortic replacement using a Dacron graft for aortic dissection, and developed graft infection. After 25 days' open mediastinal irrigation, allograft replacement and rectus muscle flap transfer were performed. The second patient underwent translocation of the aortic valve with a composite graft for calcific aortic stenosis, and developed graft infection. After 29 days' open irrigation, omental and rectus muscle flap transfer were performed. We were able to perform long-term open mediastinal irrigation using our original no-sedation-technique without any severe complication such as bleeding or secondary infection. We believe this technique is helpful in the management of severe ascending aortic graft infection.     

Successful Repair of an Aortoesophageal Fistula Caused by a Thoracic Aortic Aneurysm: Report of a Case

Aortoesophageal fistula occurring as a complication of a thoracic aortic aneurysm is difficult to repair because of the contaminated surgical field. We report the case of a 67-year-old man in whom an aortoesophageal fistula developed secondary to a dissecting thoracic aortic aneurysm. We performed in situ graft repair of the aneurysm, then covered the site with omentum and resected the esophagus to prevent graft infection. About 5 months later, the esophagus was reconstructed subcutaneously using an ascending colon pedicle. The patient recovered well and has resumed leading a normal life.     

Successful treatment of infected ascending aortic prosthesis by omental wrapping without graft removal

A deep wound infection after a midline sternotomy is a very serious complication. The severity of it can be increased by the presence of prosthetic material. We present a case of a 76-year-old man who had an infection of an ascending aortic graft develop after a Bentall procedure. Rather than following the "traditional" surgical therapy of graft explantation and debridement, we chose to preserve the graft and protect it by omental translocation. The relative merits of this therapeutic approach are outlined and discussed. The patient was discharged on the postoperative day 6 after an uneventful postoperative course.     

A multicenter experience with infected abdominal aortic endograft explantation

Objective

Endovascular aneurysm repair (EVAR) is widely used with excellent results, but its infectious complications can be devastating. In this paper, we report a multicenter experience with infected EVAR, symptoms, and options for explantation and their outcome.

Surgery for aortoiliac aneurysm after kidney transplant

OBJECTIVE: Although aortoiliac aneurysm in kidney transplant patients is uncommon, aortic clamping during the surgical repair of an aneurysm could pose a risk to the grafted kidney and might also increase the risk of vascular prosthesis infection due to immunosuppression. Herein, we present our results related to the treatment of the aortoiliac aneurysm subsequent to kidney transplant. MATERIAL AND METHODS: Four male kidney transplant recipients underwent surgery for aortoiliac aneurysm repair. RESULTS: In the first patient, we protected the kidney graft by perfusion with cold physiological saline. No such protective measures were taken in the remaining three patients other than reducing warm ischemia to a minimum. In one patient with occlusive disease and impaired graft function, renal function improved after surgery. In the other three patients renal function was unaffected by surgery. Despite immunosuppression, no infection of the prostheses was observed. CONCLUSIONS: Surgery for aortoiliac aneurysm can be safely performed in kidney transplant patients. No ischemic damage is incurred by the graft and perioperative infection can be easily avoided. The need to protect the graft during the surgical procedure should be evaluated in each individual case according to predicted times of ischemia and vascular reconstruction and preoperative graft function.     

Internal Hernia With Incarceration of the Cecum: A Case Report After Simultaneous Kidney-Pancreas Transplant

Simultaneous pancreas and kidney (SPK) transplant is the most effective form of managing difficult-to-treat diabetes; however, this does not come without risk. The surgical complications after SPK transplant can be seen in up to 30% of recipients but do not always correlate with a decrease in patient or graft survival. One of the known complications is an internal hernia. Herein, we describe the first case of cecal incarceration in an internal hernia through the defect created by the transplanted ureter and the retroperitoneum in a SPK transplant recipient. Our management entailed the reduction of large bowel and revision of the ureteroneocystostomy to eliminate the potential space that could enable reherniation. Prompt identification of this rare complication with rapid surgical intervention allowed us to avoid serious morbidity or mortality.     

Cytomegalovirus-associated hepatitis and duodenal ulcer in kidney allograft recipients

We report here on two patients with kidney allografts who had hepatitis and duodenal ulcer caused by cytomegalovirus. In one case, hepatosplenomegaly and jaundice appeared after high fever lasting for ten days. Laboratory examinations showed liver dysfunction and lymphocytosis with atypical forms. Virological studies revealed cytomegalovirus infection and we successfully treated the patient with human interferon-β. In the other case, duodenal bleeding followed by interstitial pneumonia occurred at the 54th day after transplantation. Bleeding from the small duodenal ulcer did not stop in spite of conservative and endoscopic therapies, and gastrectomy was performed. Histologically many epithelial cells with intranuclear inclusions were found around the ulcer. Virological studies showed elevation of antibody titres to cytomegalovirus which was isolated from the urine and oropharyngeal secrete. After gastrectomy and treatment with ganciclovir, the general condition improved and graft function was maintained. Our experience with these cases suggests that aggressive diagnostic investigations for cytomegalovirus infection are essential in patients with organ allografts who present liver and gastrointestinal lesions.