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Present 18.6 aef


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Present 18.6 aef

  1. 1. AORTOENTERIC FISTULA (AEF) F1 : Parach Sirisriro 18 June 2018
  2. 2. REFERENCE Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 49, 615-623.e Textbook Journal 1. Low RN, Wall SD, Jeffrey RB, et. al.: Aortoenteric fistula and perigraft infection: evaluation with CT. Radiology 1990; 175: pp. 157-162. 2. Chung, J. (2018). "Management of Aortoenteric Fistula." Advances in Surgery. 3. Spanos, K., et al. (2017). Current status of endovascular treatment of aortoenteric fistula. Seminars in vascular surgery, Elsevier.
  4. 4. INTRODUCTION Aortoenteric fistula (AEF) is defined as a communication between the aorta and gastrointestinal (GI) tract.
  5. 5. DEFINITION • Primary AEF is a communication between the native aorta and GI tract • Secondary AEF is a communication between a reconstructed aorta (for either aneurysmal or occlusive disease) and the GI tract.
  6. 6. PATHOPHYSIOLOGY Chung, J. (2018). "Management of Aortoenteric Fistula." Advances in Surgery. Primary and secondary AEF occur via similar mechanisms Infection seems to be the main underlying cause of AEF.
  8. 8. PRIMARY AORTOENTERIC FISTULA The incidence of primary AEF varies depending on the study base  0.04% to 0.07% among patients who died of massive GI hemorrhage : in large autopsy series  0.69% to 2.36% among patients with abdominal aortic aneurysms (AAAs) In the majority of cases (83%), an aneurysmal aorta is associated with primary AEF , foreign bodies, tumors , radiotherapy , infection , And GI tract disease
  9. 9. PRIMARY AORTOENTERIC FISTULA • The mean diameter of the aorta with primary AEF is 6.2 cm; • the mean age of patients is 64 years, with a male-to-female ratio of 3 : 1. • Location for primary AEF • Third and fourth portion of the duodenum (54%). esophagus (28%), small and large bowel (15%), and stomach (2%)
  10. 10. • This leads to local compression and ischemia, with weakening of the wall and eventual erosion with fistula formation. PATHOPHYSIOLOGY 1O AORTOENTERIC FISTULA
  12. 12. SECONDARY AORTOENTERIC FISTULA • Secondary AEF is more common than primary AEF and is related to prior vascular surgery, with an incidence of 0.36% to 1.6% • Onset of symptoms is on average 2 to 6 years after graft placement.
  13. 13. SECONDARY AORTOENTERIC FISTULA • The most common location described is the distal duodenum and proximal jejunum. • Secondary AEF has been described at multiple GI sites, depending on the location of the prosthetic graft.
  15. 15. GRAFT ENTERIC FISTULA The graft enteric fistula’s involvement of the suture line will disrupt the arterial anastomosis and cause dramatic hemorrhage. • May be manifested first with infectious symptoms —>direct contact of the graft material with the GI tract—>bacterial translocation between the interstices of the graft GRAFT ENTERIC EROSION PRESENTATION
  16. 16. SECONDARY AORTOENTERIC FISTULA • Pathogenesis • Infection : main cause By initial surgery or through bacteremia • Pulsatile pressure Pressure from a noncompliant prosthesis Suture line disruption • Technical error
  17. 17. PATHOGENESIS Technical Error • The bowel can be injured during the initial dissection and exposure • Directly with sharp injury • Heat transfer from cautery • Indirectly by overretraction and tension.
  18. 18. AEF AFTER ENDOVASCULAR REPAIR • Persistent endoleak with growth of the residual sac, • Multiple coiling efforts to repair an endoleak, • Erosion of the stent- graft through the aorta, • Endotension • Infection at the time of graft placement.
  20. 20. CLINICAL PRESENTATION • The classic clinical triad for primary AEF described by Sir Astley Cooper in 1829 • 64% to 94% for GI bleeding. • 32% to 48% for abdominal pain. • 17% to 25% for a pulsatile abdominal mass. All three of these symptoms occurring concurrently in only 11%of cases
  21. 21. CLINICAL PRESENTATION • Other symptoms reported include back pain, fever, and sepsis. • Herald bleed —> A minor bleed that is self-limited because of vasospasm and thrombus formation. The risk of fatal rebleeding is high 30% of patients rebleed within 6 hours 50% of patients rebleed within 24 hours.
  22. 22. DIAGNOSIS
  23. 23. Diagnosis Hemodynamic unstable Hemodynamic stable Exploratory laparotomy 1. Computed tomography (CT) 2. Esophagogastroduodenoscopy 3. Angiography CT scan —> a preferred initial diagnostic test; CT scans are less invasive than EGD or angiography, are easy to obtain, and do not risk thrombus dislodgement.16
  24. 24. INVESTIGATION • CT scan : The detection rate of CT for AEF is the highest of all modalities (61%) • EGD : The detection rate of AEF by EGD is 25% • Angiography : The angiography detection rate for AEF is 26% • Other tests, leukocyte and erythrocyte tagged nuclear scanning, magnetic resonance imaging, ultrasound, and contrast enhanced GI studies, are potentially useful but usually less accurate and more time intensive.
  25. 25. CT scanEGD
  26. 26. Angiography
  27. 27. TREATMENT
  28. 28. TREATMENT • Conservative nonoperative therapy for AEF is fatal • Surgery is the only treatment option with the potential for success.
  29. 29. TREATMENT • The factors to effective surgical management • Active hemorrhage • The classification of the AEF (primary or secondary) • The presence of sepsis, • The anatomic distribution of the patient’s aneurysmal or occlusive disease.
  30. 30. TREATMENT 1. Urgent Surgical Treatment of Hemorrhage. 2. Surgical Treatment in Stable Patients.
  31. 31. URGENT SURGICAL TREATMENT OF HEMORRHAGE • A midline incision, • Rapid proximal aortic control. Infrarenal aorta control is preferable • Distal control may be obtained with iliac clamping or occlusion balloons. • The bowel should be sharply dissected off of the aneurysm/prosthesis.
  32. 32. URGENT SURGICAL TREATMENT OF HEMORRHAGE • Evaluation of the bowel defect • Small defect —> simple closure • Large defect —> resection and anastomosis should be performed after the aorta has been managed. • The aorta may be resected and reconstruction options —> evidence of infection??
  33. 33. URGENT SURGICAL TREATMENT OF HEMORRHAGE • No evidence of infection : in-situ repair may be performed with prosthetic graft, cadaveric artery, or femoral vein. • Care should be taken to separate the graft from the GI tract with the posterior peritoneum or omentum.
  34. 34. • stump should be oversewn and covered with omentum • followed by retroperitoneal débridement, drain placement • extra- anatomic bypass. URGENT SURGICAL TREATMENT OF HEMORRHAGE Evidence of local infection
  35. 35. SURGICAL TREATMENT IN STABLE PATIENTS • Primary Aortoenteric Fistula. • Secondary Aortoenteric Fistula.
  36. 36. PRIMARY AORTOENTERIC FISTULA. • Depends on whether infection is present in the aortic bed • Mild contamination —>in-situ replacement of the aorta with local débridement and long-term antibiotic therapy • Gross retroperitoneal contamination and sepsis—> aneurysm resection, omentoplasty, retroperitoneal débridement, and extraanatomic bypass should be performed.
  37. 37. PRIMARY AORTOENTERIC FISTULA. • In the postoperative period. Broad-spectrum antibiotics should be used until culture results are available. • In the case of • a negative culture—> antibiotic therapy can be discontinued after 1 week • positive cultures —> a 4 to 6 week course.
  38. 38. SECONDARY AORTOENTERIC FISTULA. • All infected synthetic material must be resected. • The defect in the GI tract should be repaired with conventional techniques appropriate for the location of the fistula. • A flap of omentum should be placed to separate the bowel from the aortic stump closure and to fill the dead space resulting from excision of the graft.
  39. 39. SECONDARY AORTOENTERIC FISTULA. • Operative mortality ranges from 13% to 86%, with an average mortality of 30% to 40%. • Amputation rates hover at 10%, and long-term survival approximates 50% at 3 years.
  40. 40. SECONDARY AORTOENTERIC FISTULA. • The available operative choices • Graft excision alone • In-situ aortic graft replacement • Graft excision and reconstruction with autogenous vein (i.e., the neo-aortoiliac system procedure) • Extraanatomic revascularization and graft excision • Endovascular repair with lifelong antibiotics
  41. 41. GRAFT EXCISION ALONE • If the graft has been placed for occlusive disease or has been chronically occluded, it is possible to resect the graft without reconstruction. • The concern in these clinical scenarios is that removal of the graft will lead to profound ischemia and the risk of amputation. • The patient needs to have sufficient collateralization —> CT or angiography may be helpful.
  42. 42. IN-SITU AORTIC GRAFT REPLACEMENT • use of cryopreserved allografts, antibiotic-soaked synthetic graft, or silver- coated Dacron. • This approach remains controversial; however, in recent years it has become an increasingly accepted strategy.
  43. 43. IN-SITU AORTIC GRAFT REPLACEMENT • Benefits: • Improved longterm patency • Decreased risk of stump blowout • Decreased risk of thrombosis ascending to the renal arteries after resection • Maintenance of blood supply to the colon and pelvis.
  44. 44. IN-SITU AORTIC GRAFT REPLACEMENT • Studies have also begun to demonstrate the potential benefit of in-situ reconstruction. • A meta-analysis in 2006 demonstrated a lower operative mortality for in- situ reconstruction with rifampin-bonded prosthesis compared with extra- anatomic reconstruction in patients with aortic graft infections. • A retrospective study of in-situ reconstruction for secondary AEFs published in 2011 demonstrated no difference in operative mortality between in-situ reconstruction and extra-anatomic reconstruction -Batt M, et al: Early and late results of contemporary management of 37 secondary aortoenteric fistulae. Eur J Vasc Endovasc Surg 41:748, 2011. -O’Connor S, et al: A systematic review and meta-analysis of treatments of aortic graft infection. J Vasc Surg 44:38, 2006.
  45. 45. GRAFT EXCISION AND RECONSTRUCTION WITH AUTOGENOUS VEIN • Use the femoropopliteal vein to reconstruct an autogenous neo- aortoiliac system. • Benefit in this technique • Infection-resistant autologous tissue • avoids the pitfalls of the aortic stump. • Relatively inexpensive • It does not require lifelong anticoagulation
  46. 46. GRAFT EXCISION AND RECONSTRUCTION WITH AUTOGENOUS VEIN • The disadvantages of this procedure • The length of time required to harvest the deep vein and that it cannot be staged. • The risk of venous insufficiency in the harvest limb leading to compartment syndrome and fasciotomy.
  47. 47. OUTCOME • Thirty-day operative mortality is <10%, with 5-year mortality rates of 30% to 50%. • Thirty-day major amputation rates range from 2% to 7.4%, with 5-year limb- salvage rates ranging between 89% and 96%. • Early occlusion of the grafts are rare, with <4% undergoing thrombosis within the first 30 days; 5-year primary patency ranges from 75% to 91%, with secondary patency approaching 91% at 5 years. Chung J, et al: Neoaortoiliac system (NAIS) procedure for the treatment of the infected aortic graft. Semin Vasc Surg 24:220, 2011.
  48. 48. OUTCOME • Recurrent infection is very rare, occurring in <2% of patients. • Venous morbidity is similarly low, • fasciotomy rates of 12% • only 15% of patients experiencing chronic venous insufficiency at 5 years. Chung J, et al: Neoaortoiliac system (NAIS) procedure for the treatment of the infected aortic graft. Semin Vasc Surg 24:220, 2011.
  49. 49. EXTRA-ANATOMIC REVASCULARIZATION AND GRAFT EXCISION • Performed with externally supported (ringed) PTFE and may be performed after abdominal closure with a fresh set of clean instruments to restore flow to the extremities. • Performed before the aortic procedure,if the patient is stable and not actively bleeding.
  50. 50. EXTRA-ANATOMIC REVASCULARIZATION AND GRAFT EXCISION • Aortic stump disruption, which may occur late in the patient’s course,occur in up to 12% of patients. • 5-year patency of axillo-bifemoral bypass reported to be 70%,122 but infection of the graft can occur in 6% to 20% of cases.
  51. 51. EMERGENCE OF EVAR • First reported by Burks in 2001 • 2 of 7 patients with primary aortoenteric fistula • 82-year-old, male, hypertension, coronary artery disease, 10cm AAA • Treated with Aortouniiliac stent graft • Immediate cessation of bleeding achieved • Died 13 months due to myocardial infarction • Several case reports with similar success
  52. 52. ENDOVASCULAR REPAIR • Rapid control of bleeding • Minimal physiologic insult to patient • Avoidance of operating in hostile abdomen • Straightforward and speed of procedure • Eliminating complications associated with open surgical repair • Lower perioperative complication incidence • Shorter hospital stay and more likely to discharge home
  53. 53. EVAR IN AORTODUODENAL FISTULA - CANDIDATE SELECTION • Pre-operative CT scan: diagnosis and planning • Significant co-morbidities / High-risk for conventional operation – Medical: cardiopulmonary, renal, etc. – Surgical: hostile abdomen • Expertise for emergency EVAR • Stent graft in immediate availability
  54. 54. EVAR IN AORTODUODENAL FISTULA - COMPLICATIONS • Persistent sepsis • Repeat intervention or image-guided drainage • Fungal infection, e.g. Aspergillus • Long-term (or life-long) antibiotics • Medical: underlying co-morbidities of patient • Persistent bleeding • No reported incidence • Case report: unsuccessful result not reported? • Secondary aortoenteric fistula
  55. 55. • Objectives: To compare aortoenteric fistula (AEF) outcome after endovascular (EV- AEFR) or open repair (O-AEFR). • 25 patients with AEF (24 secondary, 23 males, median age 75 years) after aortic surgery (median four years). Kakkos SK, et al: Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study. Eur J Vasc Endovasc Surg 41:625, 2011.
  56. 56. Kakkos SK, et al: Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study. Eur J Vasc Endovasc Surg 41:625, 2011.
  57. 57. • The literature 32 identified 33 reports that included 41 patients with AEF who had EVAR as initial management. • Persistent/recurrent/new infection or recurrent hemorrhage developed in 44% of the patients, after a mean follow-up period of 13 months (range, 0.13-36). Antoniou GA, et al: Outcome after endovascular stent graft repair of aortoenteric fistula: a systematic review. J Vasc Surg 49:782, 2009.
  58. 58. • Secondary, as compared to primary, AEF had an almost threefold increased risk of persistent/recurrent infection. • Evidence of sepsis preoperatively was found to be a factor indicating unfavorable outcome (P < .05) • Persistent/recurrent/new infection after treatment was associated with worse 30-day Should be considered only a temporizing strategy until definitive repair can be performed. Antoniou GA, et al: Outcome after endovascular stent graft repair of aortoenteric fistula: a systematic review. J Vasc Surg 49:782, 2009.
  59. 59. ENDOVASCULAR REPAIR Conclusion • Reserved as a bridge to open repair once patients have stabilized and local infection control is established • For those patients with a limited life expectancy who would benefit from a short hospital stay and earlier discharge and will not be exposed to the long-term risks.
  61. 61. Explant in case of 2nd AEF ALGORITHM FOR THE SURGICAL MANAGEMENT OF AORTOENTERIC FISTULA (AEF). EVAR, ENDOVASCULAR AORTIC ANEURYSM REPAIR Hemodynamically stable NO YES Candicate for OR YES NO Minimal contamination Extraanatomiacal bypass Insitu bypass Aortic balloon EVAR Explant in case of 2nd AEF after 2-3 days Minimal contamination Extraanatomiacal bypassInsitu bypass ATB therapy 1 yrs to life times Spanos, K., et al. (2017). Current status of endovascular treatment of aortoenteric fistula. Seminars in vascular surgery, Elsevier.
  62. 62. CONCLUSIONS • The key features to successful treatment are • Timely intervention • Appropriate patient selection • Effective bowel repair • Longterm follow-up.
  63. 63. THANK YOU