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Secondary Aortoenteric Fistula after Endovascular Aortic Interventions: A Systematic Literature Review
Review Article
Secondary Aortoenteric Fistula after Endovascular Aortic Interventions: A Systematic Literature Review David Bergqvist, MD, PhD, FRCS, Martin Bjo¨rck, MD, PhD, and Rickard Nyman, MD, PhD
PURPOSE: To evaluate the collective incidence of, and experience with, aortoenteric fistula after endovascular aortoiliac therapy. MATERIALS AND METHODS: A systematic literature research was performed to identify cases of aortoenteric fistulation after aortic stent-graft procedures or stent implantation. RESULTS: The review revealed 16 cases of aortoenteric fistulation after aortic stent-grafting (n ⴝ 15) or stent placement (n ⴝ 1), in 14 patients with abdominal aortic aneurysm. Six had undergone endovascular aneurysm repair because of what was considered a “hostile abdomen.” The symptoms did not differ from those in patients with arterioenteric fistulation after open aortic repair. A defect in the stent-graft or its function was the predominant cause of fistulation. One fistula was diagnosed at autopsy, two patients died perioperatively, and 13 survived with in situ repair or an axillobifemoral graft, all after removal of the stent-graft or stent. However, the follow-up time was short, longer than 1 year in only five of the 13 survivors. CONCLUSIONS: Aortoenteric fistulation does occur after endovascular implantation of stents and stent-grafts. The incidence is unknown but is probably low. Follow-up time in most publications was less than 1 year, which is considered short to assess potential graft infection. J Vasc Interv Radiol 2008; 19:163–165
SECONDARY aortoenteric fistulation is a well known, infrequent but serious complication after open aortoiliac reconstructive surgery. The prerequisite is close contact between the reconstruction and a part of the bowel, the cause being pressure and bowel erosion from an anastomotic aneurysm, the anastomotic suture line, or the graft itself. Intuitively, this risk should
From the Department of Surgical Sciences, Section of Vascular Surgery (D.B., M.B.), and Department of Radiology (R.N.), Uppsala University Hospital, Uppsala SE 751 85, Sweden. Received April 10, 2007; final revision received October 5, 2007; accepted October 8, 2007. Address correspondence to D.B.; E-mail: [email protected] Support for this study was received from the Swedish Research Council. None of the authors have identified a conflict of interest. © SIR, 2008 DOI: 10.1016/j.jvir.2007.10.013
be minimal after endovascular reconstruction because the graft is hidden in the aneurysmal sac. However, in 1998, Norgren et al (1) reported one patient with an aortoduodenal fistula after stent-grafting of an aortic aneurysm resulting in a life-threatening bleeding complication. The possibility of a stent causing an aortoenteric fistula is also known in the opposite direction: a stent placed in the bowel to treat a stricture with perforation of the bowel, and then of the aorta, has been reported to cause a massive gastrointestinal hemorrhage (2). Aortoesophageal fistula has been described as a complication of stent-graft repair of the thoracic aorta (3,4), but the present review is focused on enteric fistulation. This review was undertaken to evaluate aortoenteric fistulation after endovascular aortoiliac reconstruction by way of a systematic literature review to identify published cases.
MATERIALS AND METHODS A literature search was performed in PubMed and Medline for the terms “aortoiliac reconstruction,” “stent-graft,” “endovascular,” “endograft,” and “enteric fistula.” Abstracts were read and all articles of potential relevance were read in full. The reference lists of identified articles were also scrutinized to identify further cases. Articles published in English, German, or Scandinavian languages were selected. As this is a literature review, no institutional review board approval was required.
RESULTS Primary Aortic Procedure Nineteen articles were identified that described a total of 20 cases (1,522). The four cases reported by Ohki et al (19), Lipsitz et al (5), and Baril et al (22) are included in analyses of late
163
164
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complications and conversions to open surgery, but very few details can be extracted, which is why they are not discussed further. There were 14 male patients and two female patients with a median age of 67 years (range, 47–76 y). The indication for endovascular treatment was aneurysm in 14 cases and occlusive disease in two. The median size of the aneurysm was 60 mm (range, 50 – 80 mm). In six patients, the indication for endovascular as opposed to open treatment was strengthened by the presence of a “hostile abdomen.” Six different commercial devices were used in 14 patients: AneuRx (Medtronic, Minneapolis, Minn), n ⫽ 5; Ancure (Guidant, Indianapolis, Ind), n ⫽ 3; Stentor (MinTec, La Ciotat, France), n ⫽ 2, Zenith (Cook, Bloomington, Ind), n ⫽ 2; Vanguard (Boston Scientific, Natick, Mass), n ⫽ 1; and AVE Medtronic (Medtronic), n ⫽ 1. One device was homemade (18). One patient with occlusive disease underwent aortic endarterectomy and received an aortobifemoral polytetrafluoroethylene graft. After 18 hours, the graft occluded and was treated with thrombolysis, and because of an intimal flap with a pressure gradient, the upper anastomosis was expanded with a Palmaz stent (17). Postoperatively, there was endoleak in six cases, sepsis in four, and signs of inflammation on computed tomography (CT) in one, and another patient underwent an exploratory laparotomy because of suspected but unverified bowel strangulation. Aortoenteric Fistula After a median interval of 16 months (range, 4 –72 months), the symptoms of aortoenteric fistulation started. Gastrointestinal bleeding was seen in 12 patients, abdominal pain in nine, sepsis in four, and anemia in four. One patient developed a thigh abscess, and in two patients, the graft occluded, resulting in claudication. Nine of the patients also had diffuse symptoms such as malaise, fever, dizziness, and nausea. CT led to diagnosis or strong suspicion of a fistula in 13 patients, and the diagnosis was obtained at endoscopy in two patients. One each was diagnosed at angiography and autopsy. The delay between symptom
presentation and diagnosis was from a few hours with emergency laparotomy to 8 months. The bowel segment involved in the fistula was the duodenum in 11 patients, jejunum and ileum in two each, and not reported in one. The Table lists the arterial causes or mechanisms considered responsible for the fistulas. In five cases, there was a clear mechanism related to the stentgraft; in six other cases, no clear mechanism was found, but there was a communication with the aneurysmal sac, which can be explained by an endoleak and expansion of the aneurysm. In two patients, an infectious complication was considered important in the pathogenesis, and in another case an inflammatory bowel segment related to Crohn disease was eroded by the aneurysm. In one patient, the diagnosis was made postmortem, with the patient having died of bleeding. Another patient died perioperatively because of bleeding. Therefore, the overall operative mortality rate was 7%. In the remaining 14 patients, the stent-graft was removed and reconstruction was performed with an axillobifemoral bypass in seven patients and an in situ reconstruction in the other seven. One patient died on the sixth postoperative day of multiple-organ failure. Of the 13 who survived, the median follow-up time was 8 months (range, 27 days to 40 months). In five patients, follow-up was 1 year or longer. During follow-up, two patients had sepsis and one each developed reversible renal failure and endocarditis. One patient underwent a repeat operation because of iliac anastomotic bleeding, with insertion of a new polyester graft.
DISCUSSION It is obvious from the patients discussed in this article that endovascular aortic stent-grafting is not a guarantee against the development of aortoenteric fistula. However, the incidence is not known, and because this is also the case after open surgery, no comparison of relative risks can be made. Without giving any details, Ohki et al (19) reported two cases of aortoduodenal fistula after 239 endovascular graft repairs for nonruptured abdominal aortic aneurysm and Lipsitz et al (5) reported one case after 386 endograft
February 2008
JVIR
Causes of Aortoenteric Fistulation in Patients with an Aortic Stent or Stent-Graft Cause
Cases
Endoleak/aneurysm expansion/ rupture Stent-related* Infection/inflammation Unknown
6 5 2 1
* Defect or fracture of stents, erosion from stent, coils or angulation.
procedures. In 11 secondary aortoenteric fistulae reported from one center in the United States from 1997 through 2006 (22), one aortoduodenal fistula was seen after endovascular aortic aneurysm repair. The mechanism was unclear, but the device had transrenal bare stents without hooks. After open repair, the follow-up time was 47 months, and the patient was still alive. These cases were not sufficiently described to be included in this review. There seem to be two main mechanisms for aortoenteric fistula to occur after endovascular aortic grafting. One is caused by the stent-graft device, directly or by a mechanical failure such as fracture of the stent with injury to the bowel. The other is a rupture of an expanding aortic aneurysm into the bowel. In these cases, there has been an endoleak, which means defective function of the stent-graft in excluding the aneurysm from the circulation with expansion as a consequence. This can be looked at as failed therapy. Whether it was a case of a large aneurysm that,did not shrink after stentgrafting or endotension that led to enteric fistulation is not known at present. Another theoretical possibility is bowel erosion by inflammatory adventitial tissue with bleeding from inflammatory vessels. Endovascular aneurysm repair prompted by a case of hostile abdomen seems to be a risk factor for this complication, as six of 16 cases had been treated with an endovascular technique in this clinical situation. In the presence of a hostile abdomen, the endovascular solution may also be appealing in cases with difficult vascular anatomy, when open repair would normally be selected. The delay between reconstruction and development of fistula symptoms
Volume 19
Number 2
does not seem to differ from aortoenteric fistula after open reconstruction. Although small, the present series indicates a somewhat less dramatic course after the symptoms start; the bleeding in particular seems to be less intense. Just as after open surgery, the awareness of the possibility must be high, leading to a diagnosis as quickly as possible. Although endoscopy was rarely used, it must be recommended, as it also can exclude other causes of upper gastrointestinal bleeding. Otherwise, a CT scan seems to yield much information and can strengthen the suspicion (ie, inflammatory tissue, signs of infection, dense connection between aneurysm/graft and bowel) if the fistula is not directly seen. It seems reasonable to remove the stent-graft, and in the reports so far, this has not caused any technical problems. The difficult question is how to perform a reconstruction, and in the publications there are two principles: a new graft in situ or closure of the aorta combined with axillobifemoral bypass. Our preference is to use the latter in cases of a gross infection, preferably starting with the bypass if time permits and if there is no infection to perform in situ reconstruction. A problem with the publications reviewed herein is the rather short follow-up time: it was less than 1 month in one study and more than 1 year in only five. In conclusion, aortoenteric fistulation does occur after endovascular stent implantation and stent-grafting. The incidence is unknown but probably low. In patients with gastrointestinal bleeding after endovascular aneurysm repair, an aortoenteric fistula must be strongly suspected. Follow-up of at least 1 year is recommended. References 1. Norgren L, Jernby B, Engellau L. Aortoenteric fistula caused by a ruptured stent-graft: a case report. J Endovasc Surg 1998; 5:269 –272.
Bergqvist et al
2. Verhey P, Best A, Lakin P, Nachiondo J, Petersen B. Successful endovascular treatment of aortoenteric fistula secondary to eroding duodenal stent. J Vasc Interv Radiol 2006; 17:1345–1348. 3. Hance KA, Hsu J, Eskew T, Hermreck AS. Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection. J Vasc Surg 2003; 37:886 – 888. 4. Eggebrecht H, Baumgart D, Radecke K, et al. Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta. J Endovasc Ther 2004; 11:161– 167. 5. Lipsitz EC, Ohki T, Veith FJ, et al. Delayed open conversion following endovascular aortoiliac aneurysm repair: partial (or complete) endograft preservation as a useful adjunct. J Vasc Surg 2003; 38:1191–1198. 6. Kar B, Dougherty K, Reul GJ, Krajcer Z. Aortic stent-graft infection due to a presumed aortoenteric fistula. J Endovasc Ther 2002; 9:901–906. 7. Abou-Zamzam AM Jr, Bianchi C, Mazraany W, et al. Aortoenteric fistula development following endovascular abdominal aortic aneurysm repair: a case report. Ann Vasc Surg 2003; 17:119 –122. 8. Alankar S, Barth MH, Shin DD, Hong JR, Rosenberg WR. Aortoduodenal fistula and associated rupture of abdominal aortic aneurysm after endoluminal stent graft repair. J Vasc Surg 2003; 37:465– 468. 9. Bertges DJ, Villella ER, Makaroun MS. Aortoenteric fistula due to endoleak coil embolization after endovascular AAA repair. J Endovasc Ther 2003; 10: 130 –135. 10. Hausegger KA, Tiesenhausen K, Karaic R, Tauss J, Koch G. Aortoduodenal fistula: a late complication of intraluminal exclusion of an infrarenal aortic aneurysm. J Vasc Interv Radiol 1999; 10:747–750. 11. Kahlke V, Brossmann J, Klomp HJ. Lethal hemorrhage caused by aortoenteric fistula following endovascular stent implantation. Cardiovasc Intervent Radiol 2002; 25:205–207. 12. Lyden SP, Tanquilut EM, Gavin TJ, Adams JE. Aortoduodenal fistula after abdominal aortic stent graft pre-
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
•
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senting with extremity abscesses. Vascular 2005; 13:305–308. Makar R, Reid J, Pherwani AD, et al. Aorto-enteric fistula following endovascular repair of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2000; 20:588 –590. Janne d’Othee B, Soula P, Otal P, et al. Aortoduodenal fistula after endovascular stent-graft of an abdominal aortic aneurysm. J Vasc Surg 2000; 31:190 – 195. Parry DJ, Waterworth A, Kessel D, Robertson I, Berridge DC, Scott DJ. Endovascular repair of an inflammatory abdominal aortic aneurysm complicated by aortoduodenal fistulation with an unusual presentation. J Vasc Surg 2001; 33:874 – 879. Ratchford EV, Morrissey NJ. Aortoenteric fistula: a late complication of endovascular repair of an inflammatory abdominal aortic aneurysm. Vasc Endovascular Surg 2006; 40:487– 491. Tshomba Y, Kahlberg A, Marone EM, Setacci F, Logaldo D, Chiesa R. Aortoenteric fistula as a late complication of thrombolysis and bare metal stenting for perioperative occlusion of aortofemoral bypass. J Vasc Surg 2006; 44:408 – 411. Ueno M, Iguro Y, Nagata T, Sakata R. Aortoenteric fistula after endovascular stent grafting for an abdominal aortic aneurysm: report of a case. Surg Today 2006; 36:546 –548. Ohki T, Veith FJ, Shaw P, et al. Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience. Ann Surg 2001; 234:323–334. French JR, Simring DV, Merrett N, Thursby P. Aorto-enteric fistula following endoluminal abdominal aortic aneurysm repair. Aust N Z J Surg 2004; 74:397–399. Ruby BJ, Cogbill TH. Aortoduodenal fistula 5 years after endovascular abdominal aortic aneurysm repair with the Ancure stent graft. J Vasc Surg 2007; 45:834 – 836. Baril DT, Carroccio A, Ellozy SH, et al. Evolving strategies for the treatment of aortoenteric fistulas. J Vasc Surg 2006; 44:250 –257.
Secondary Aortoenteric Fistula after Endovascular Aortic Interventions: A Systematic Literature Review David Bergqvist, MD, PhD, FRCS, Martin Bjo¨rck, MD, PhD, and Rickard Nyman, MD, PhD
PURPOSE: To evaluate the collective incidence of, and experience with, aortoenteric fistula after endovascular aortoiliac therapy. MATERIALS AND METHODS: A systematic literature research was performed to identify cases of aortoenteric fistulation after aortic stent-graft procedures or stent implantation. RESULTS: The review revealed 16 cases of aortoenteric fistulation after aortic stent-grafting (n ⴝ 15) or stent placement (n ⴝ 1), in 14 patients with abdominal aortic aneurysm. Six had undergone endovascular aneurysm repair because of what was considered a “hostile abdomen.” The symptoms did not differ from those in patients with arterioenteric fistulation after open aortic repair. A defect in the stent-graft or its function was the predominant cause of fistulation. One fistula was diagnosed at autopsy, two patients died perioperatively, and 13 survived with in situ repair or an axillobifemoral graft, all after removal of the stent-graft or stent. However, the follow-up time was short, longer than 1 year in only five of the 13 survivors. CONCLUSIONS: Aortoenteric fistulation does occur after endovascular implantation of stents and stent-grafts. The incidence is unknown but is probably low. Follow-up time in most publications was less than 1 year, which is considered short to assess potential graft infection. J Vasc Interv Radiol 2008; 19:163–165
SECONDARY aortoenteric fistulation is a well known, infrequent but serious complication after open aortoiliac reconstructive surgery. The prerequisite is close contact between the reconstruction and a part of the bowel, the cause being pressure and bowel erosion from an anastomotic aneurysm, the anastomotic suture line, or the graft itself. Intuitively, this risk should
From the Department of Surgical Sciences, Section of Vascular Surgery (D.B., M.B.), and Department of Radiology (R.N.), Uppsala University Hospital, Uppsala SE 751 85, Sweden. Received April 10, 2007; final revision received October 5, 2007; accepted October 8, 2007. Address correspondence to D.B.; E-mail: [email protected] Support for this study was received from the Swedish Research Council. None of the authors have identified a conflict of interest. © SIR, 2008 DOI: 10.1016/j.jvir.2007.10.013
be minimal after endovascular reconstruction because the graft is hidden in the aneurysmal sac. However, in 1998, Norgren et al (1) reported one patient with an aortoduodenal fistula after stent-grafting of an aortic aneurysm resulting in a life-threatening bleeding complication. The possibility of a stent causing an aortoenteric fistula is also known in the opposite direction: a stent placed in the bowel to treat a stricture with perforation of the bowel, and then of the aorta, has been reported to cause a massive gastrointestinal hemorrhage (2). Aortoesophageal fistula has been described as a complication of stent-graft repair of the thoracic aorta (3,4), but the present review is focused on enteric fistulation. This review was undertaken to evaluate aortoenteric fistulation after endovascular aortoiliac reconstruction by way of a systematic literature review to identify published cases.
MATERIALS AND METHODS A literature search was performed in PubMed and Medline for the terms “aortoiliac reconstruction,” “stent-graft,” “endovascular,” “endograft,” and “enteric fistula.” Abstracts were read and all articles of potential relevance were read in full. The reference lists of identified articles were also scrutinized to identify further cases. Articles published in English, German, or Scandinavian languages were selected. As this is a literature review, no institutional review board approval was required.
RESULTS Primary Aortic Procedure Nineteen articles were identified that described a total of 20 cases (1,522). The four cases reported by Ohki et al (19), Lipsitz et al (5), and Baril et al (22) are included in analyses of late
163
164
•
Secondary Aortoenteric Fistula after Endovascular Aortic Interventions
complications and conversions to open surgery, but very few details can be extracted, which is why they are not discussed further. There were 14 male patients and two female patients with a median age of 67 years (range, 47–76 y). The indication for endovascular treatment was aneurysm in 14 cases and occlusive disease in two. The median size of the aneurysm was 60 mm (range, 50 – 80 mm). In six patients, the indication for endovascular as opposed to open treatment was strengthened by the presence of a “hostile abdomen.” Six different commercial devices were used in 14 patients: AneuRx (Medtronic, Minneapolis, Minn), n ⫽ 5; Ancure (Guidant, Indianapolis, Ind), n ⫽ 3; Stentor (MinTec, La Ciotat, France), n ⫽ 2, Zenith (Cook, Bloomington, Ind), n ⫽ 2; Vanguard (Boston Scientific, Natick, Mass), n ⫽ 1; and AVE Medtronic (Medtronic), n ⫽ 1. One device was homemade (18). One patient with occlusive disease underwent aortic endarterectomy and received an aortobifemoral polytetrafluoroethylene graft. After 18 hours, the graft occluded and was treated with thrombolysis, and because of an intimal flap with a pressure gradient, the upper anastomosis was expanded with a Palmaz stent (17). Postoperatively, there was endoleak in six cases, sepsis in four, and signs of inflammation on computed tomography (CT) in one, and another patient underwent an exploratory laparotomy because of suspected but unverified bowel strangulation. Aortoenteric Fistula After a median interval of 16 months (range, 4 –72 months), the symptoms of aortoenteric fistulation started. Gastrointestinal bleeding was seen in 12 patients, abdominal pain in nine, sepsis in four, and anemia in four. One patient developed a thigh abscess, and in two patients, the graft occluded, resulting in claudication. Nine of the patients also had diffuse symptoms such as malaise, fever, dizziness, and nausea. CT led to diagnosis or strong suspicion of a fistula in 13 patients, and the diagnosis was obtained at endoscopy in two patients. One each was diagnosed at angiography and autopsy. The delay between symptom
presentation and diagnosis was from a few hours with emergency laparotomy to 8 months. The bowel segment involved in the fistula was the duodenum in 11 patients, jejunum and ileum in two each, and not reported in one. The Table lists the arterial causes or mechanisms considered responsible for the fistulas. In five cases, there was a clear mechanism related to the stentgraft; in six other cases, no clear mechanism was found, but there was a communication with the aneurysmal sac, which can be explained by an endoleak and expansion of the aneurysm. In two patients, an infectious complication was considered important in the pathogenesis, and in another case an inflammatory bowel segment related to Crohn disease was eroded by the aneurysm. In one patient, the diagnosis was made postmortem, with the patient having died of bleeding. Another patient died perioperatively because of bleeding. Therefore, the overall operative mortality rate was 7%. In the remaining 14 patients, the stent-graft was removed and reconstruction was performed with an axillobifemoral bypass in seven patients and an in situ reconstruction in the other seven. One patient died on the sixth postoperative day of multiple-organ failure. Of the 13 who survived, the median follow-up time was 8 months (range, 27 days to 40 months). In five patients, follow-up was 1 year or longer. During follow-up, two patients had sepsis and one each developed reversible renal failure and endocarditis. One patient underwent a repeat operation because of iliac anastomotic bleeding, with insertion of a new polyester graft.
DISCUSSION It is obvious from the patients discussed in this article that endovascular aortic stent-grafting is not a guarantee against the development of aortoenteric fistula. However, the incidence is not known, and because this is also the case after open surgery, no comparison of relative risks can be made. Without giving any details, Ohki et al (19) reported two cases of aortoduodenal fistula after 239 endovascular graft repairs for nonruptured abdominal aortic aneurysm and Lipsitz et al (5) reported one case after 386 endograft
February 2008
JVIR
Causes of Aortoenteric Fistulation in Patients with an Aortic Stent or Stent-Graft Cause
Cases
Endoleak/aneurysm expansion/ rupture Stent-related* Infection/inflammation Unknown
6 5 2 1
* Defect or fracture of stents, erosion from stent, coils or angulation.
procedures. In 11 secondary aortoenteric fistulae reported from one center in the United States from 1997 through 2006 (22), one aortoduodenal fistula was seen after endovascular aortic aneurysm repair. The mechanism was unclear, but the device had transrenal bare stents without hooks. After open repair, the follow-up time was 47 months, and the patient was still alive. These cases were not sufficiently described to be included in this review. There seem to be two main mechanisms for aortoenteric fistula to occur after endovascular aortic grafting. One is caused by the stent-graft device, directly or by a mechanical failure such as fracture of the stent with injury to the bowel. The other is a rupture of an expanding aortic aneurysm into the bowel. In these cases, there has been an endoleak, which means defective function of the stent-graft in excluding the aneurysm from the circulation with expansion as a consequence. This can be looked at as failed therapy. Whether it was a case of a large aneurysm that,did not shrink after stentgrafting or endotension that led to enteric fistulation is not known at present. Another theoretical possibility is bowel erosion by inflammatory adventitial tissue with bleeding from inflammatory vessels. Endovascular aneurysm repair prompted by a case of hostile abdomen seems to be a risk factor for this complication, as six of 16 cases had been treated with an endovascular technique in this clinical situation. In the presence of a hostile abdomen, the endovascular solution may also be appealing in cases with difficult vascular anatomy, when open repair would normally be selected. The delay between reconstruction and development of fistula symptoms
Volume 19
Number 2
does not seem to differ from aortoenteric fistula after open reconstruction. Although small, the present series indicates a somewhat less dramatic course after the symptoms start; the bleeding in particular seems to be less intense. Just as after open surgery, the awareness of the possibility must be high, leading to a diagnosis as quickly as possible. Although endoscopy was rarely used, it must be recommended, as it also can exclude other causes of upper gastrointestinal bleeding. Otherwise, a CT scan seems to yield much information and can strengthen the suspicion (ie, inflammatory tissue, signs of infection, dense connection between aneurysm/graft and bowel) if the fistula is not directly seen. It seems reasonable to remove the stent-graft, and in the reports so far, this has not caused any technical problems. The difficult question is how to perform a reconstruction, and in the publications there are two principles: a new graft in situ or closure of the aorta combined with axillobifemoral bypass. Our preference is to use the latter in cases of a gross infection, preferably starting with the bypass if time permits and if there is no infection to perform in situ reconstruction. A problem with the publications reviewed herein is the rather short follow-up time: it was less than 1 month in one study and more than 1 year in only five. In conclusion, aortoenteric fistulation does occur after endovascular stent implantation and stent-grafting. The incidence is unknown but probably low. In patients with gastrointestinal bleeding after endovascular aneurysm repair, an aortoenteric fistula must be strongly suspected. Follow-up of at least 1 year is recommended. References 1. Norgren L, Jernby B, Engellau L. Aortoenteric fistula caused by a ruptured stent-graft: a case report. J Endovasc Surg 1998; 5:269 –272.
Bergqvist et al
2. Verhey P, Best A, Lakin P, Nachiondo J, Petersen B. Successful endovascular treatment of aortoenteric fistula secondary to eroding duodenal stent. J Vasc Interv Radiol 2006; 17:1345–1348. 3. Hance KA, Hsu J, Eskew T, Hermreck AS. Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection. J Vasc Surg 2003; 37:886 – 888. 4. Eggebrecht H, Baumgart D, Radecke K, et al. Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta. J Endovasc Ther 2004; 11:161– 167. 5. Lipsitz EC, Ohki T, Veith FJ, et al. Delayed open conversion following endovascular aortoiliac aneurysm repair: partial (or complete) endograft preservation as a useful adjunct. J Vasc Surg 2003; 38:1191–1198. 6. Kar B, Dougherty K, Reul GJ, Krajcer Z. Aortic stent-graft infection due to a presumed aortoenteric fistula. J Endovasc Ther 2002; 9:901–906. 7. Abou-Zamzam AM Jr, Bianchi C, Mazraany W, et al. Aortoenteric fistula development following endovascular abdominal aortic aneurysm repair: a case report. Ann Vasc Surg 2003; 17:119 –122. 8. Alankar S, Barth MH, Shin DD, Hong JR, Rosenberg WR. Aortoduodenal fistula and associated rupture of abdominal aortic aneurysm after endoluminal stent graft repair. J Vasc Surg 2003; 37:465– 468. 9. Bertges DJ, Villella ER, Makaroun MS. Aortoenteric fistula due to endoleak coil embolization after endovascular AAA repair. J Endovasc Ther 2003; 10: 130 –135. 10. Hausegger KA, Tiesenhausen K, Karaic R, Tauss J, Koch G. Aortoduodenal fistula: a late complication of intraluminal exclusion of an infrarenal aortic aneurysm. J Vasc Interv Radiol 1999; 10:747–750. 11. Kahlke V, Brossmann J, Klomp HJ. Lethal hemorrhage caused by aortoenteric fistula following endovascular stent implantation. Cardiovasc Intervent Radiol 2002; 25:205–207. 12. Lyden SP, Tanquilut EM, Gavin TJ, Adams JE. Aortoduodenal fistula after abdominal aortic stent graft pre-
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
•
165
senting with extremity abscesses. Vascular 2005; 13:305–308. Makar R, Reid J, Pherwani AD, et al. Aorto-enteric fistula following endovascular repair of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2000; 20:588 –590. Janne d’Othee B, Soula P, Otal P, et al. Aortoduodenal fistula after endovascular stent-graft of an abdominal aortic aneurysm. J Vasc Surg 2000; 31:190 – 195. Parry DJ, Waterworth A, Kessel D, Robertson I, Berridge DC, Scott DJ. Endovascular repair of an inflammatory abdominal aortic aneurysm complicated by aortoduodenal fistulation with an unusual presentation. J Vasc Surg 2001; 33:874 – 879. Ratchford EV, Morrissey NJ. Aortoenteric fistula: a late complication of endovascular repair of an inflammatory abdominal aortic aneurysm. Vasc Endovascular Surg 2006; 40:487– 491. Tshomba Y, Kahlberg A, Marone EM, Setacci F, Logaldo D, Chiesa R. Aortoenteric fistula as a late complication of thrombolysis and bare metal stenting for perioperative occlusion of aortofemoral bypass. J Vasc Surg 2006; 44:408 – 411. Ueno M, Iguro Y, Nagata T, Sakata R. Aortoenteric fistula after endovascular stent grafting for an abdominal aortic aneurysm: report of a case. Surg Today 2006; 36:546 –548. Ohki T, Veith FJ, Shaw P, et al. Increasing incidence of midterm and long-term complications after endovascular graft repair of abdominal aortic aneurysms: a note of caution based on a 9-year experience. Ann Surg 2001; 234:323–334. French JR, Simring DV, Merrett N, Thursby P. Aorto-enteric fistula following endoluminal abdominal aortic aneurysm repair. Aust N Z J Surg 2004; 74:397–399. Ruby BJ, Cogbill TH. Aortoduodenal fistula 5 years after endovascular abdominal aortic aneurysm repair with the Ancure stent graft. J Vasc Surg 2007; 45:834 – 836. Baril DT, Carroccio A, Ellozy SH, et al. Evolving strategies for the treatment of aortoenteric fistulas. J Vasc Surg 2006; 44:250 –257.