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AortoentericAortoenteric FistulaFistulaAortoentericAortoenteric FistulaFistula
Joyce AuSUNY Downstate Grand Rounds
November 1, 2012November 1, 2012
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CASECASE
• 77M with nonbloody emesis x 2 weeks77M with nonbloody emesis x 2 weeks, dysphagia, anemia, and general malaise
• PMH: HTN DM chronic kidney disease• PMH: HTN, DM, chronic kidney disease, mild dementiaPSH t i f t d• PSH: emergent, open repair of ruptured AAA with aorto-bi-iliac Dacron graft in 20092009
• Meds: HCTZ, losartan, metoprolol, zocor, insulin, donepezil, terazosin
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• T=97 BP=128/98 HR=81 RR=18T 97, BP 128/98, HR 81, RR 18• Lethargic• RRR clear BS• RRR, clear BS• Abd soft, ND, NT• Pulses
2+ radial on L but nonpalpable on R2+ femoral b/l1+ popliteal, DP, PT on L but nonpalpable on RUnable to get blood pressure from cuff from
anywhere but L arm
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• CBC: 9 4 (83% PMN) / 10 7 / 31 1 / 118CBC: 9.4 (83% PMN) / 10.7 / 31.1 / 118WBC increased to 14 (94% PMN)
BMP: 139 / 4 7 / 102 / 25 / 24 / 1 4 / 90• BMP: 139 / 4.7 / 102 / 25 / 24 / 1.4 / 90• Blood and urine cultures – Enterococcus
ffaecalis
• Esophagogram – negative
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• EGDG
Visible prolene; pulsatile mass with extrinsicVisible prolene; pulsatile mass with extrinsic compression onto 3rd-4th portion of duodenum; Dacron material
• CT – periaortic gas
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• In setting of sepsis and relatively stableIn setting of sepsis and relatively stable patient, plan for staged procedure
• 1st surgery extra anatomic bypass with• 1st surgery – extra-anatomic bypass with left axillo-bifemoral PTFE graft
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• ResuscitationResuscitation• Daptomycin, ertapenem, micafungin
NPO PPN• NPO, PPN• Echo – EF>55%• Vein mapping • Palliative Care discussion with family onPalliative Care discussion with family on
poor prognosis
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• 3 days later - 2nd surgery y g y• Exposure - exploratomy laparotomy, lysis of
adhesions, left medial visceral rotationadhesions, left medial visceral rotation
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• OR findings:OR findings: Splenic abscessL k f bil d ti ftLeakage of bile around aortic graftRedundant graft with kinks in aortic and
iliac portions3rd-4th portion of duodenum with 2 holes3 4 portion of duodenum with 2 holes
in back wall against graft
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• ProcedureProcedure– Proximal and distal control of aortic graft
Primary repair of duodenum duodenal– Primary repair of duodenum, duodenal exclusion with stapled closure of antrum, lateral draining duodenostomy,lateral draining duodenostomy, gastrojejunostomy
– Excision of aortic graftg
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• Intraop development of septic shockIntraop development of septic shock requiring levophed and vasopressin
• EBL=1000 ml 4 units pRBC 12L• EBL=1000 ml, 4 units pRBC, 12L crystalloid, UOP=690 ml over 12 hours
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• Postoperative day 0-1Postoperative day 0 1– T=98…95.6, BP=121/35, HR=125– pH 7 41 / 34 / 151 / -2 3pH 7.41 / 34 / 151 / 2.3 …
6.89 / 28 / 96 / -27…bicarbonate drip…7.22 / 32 / 88 / -13.87.22 / 32 / 88 / 13.8
– Renal failure with urine output 5-10 ml/hr– WBC = 21.8 x 1000/mm3
– Multiple hypoglycemic episodes to
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AORTOENTERIC FISTULA (AEF)
Intro Presentation Surgical T t tEtiology Workup Treatment
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HISTORYHISTORY
• First described in 1829 byFirst described in 1829 bySir Astley Paston Cooper
• 1953, Brock reported secondary• 1954, Zenker performed first repair of , p p
primary AEF• 1958 McKenzie performed first repair of1958, McKenzie performed first repair of
secondary AEF
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CLASSIFICATIONCLASSIFICATION
• Primary = between native aorta and bowelPrimary = between native aorta and bowel– 0.04-0.07% general population
Secondary = between aortic graft and• Secondary = between aortic graft and bowel
M– More common– 0.77-1.60% patients with aortic grafts– 20-45% of patients with aortic graft infections
Cronentwett et al. Rutherford’s Vascular Surgery 7th ed.Batt et al. Eur J Vasc Surg 2011
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• Type I – direct t t i
• Type II – graft enteric i kaortoenteric
communication– A=no pseudoaneurysm
erosion; a.k.a. aortoparaprosthetic sinus– Along graftp y
B=pseudoaneurysm– At suture line
g g
Dachs et al. Am Fam Physician 1992
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ETIOLOGYETIOLOGY
Fixed nature of duodenumFixed nature of duodenum Pulsatile force I f tiInfection Other
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• Fixed nature ofFixed nature of duodenum
Ligament of Treitz– Ligament of Treitz, retroperitoneum
– 83% AEF occur in 3rd83% AEF occur in 3and 4th portions of duodenum
Dachs et al. Am Fam Physician 1992
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• Pulsatile forcePulsatile force– Abdominal aortic aneurysm
Aortic graft that is noncompliant bulky– Aortic graft that is noncompliant, bulky, redundant, kinked
– Aortic graft pseudoaneurysm– Aortic graft pseudoaneurysm– EVAR graft with angulated neck or endoleak
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• InfectionInfection – Mycotic aneurysm
Aortic graft infection– Aortic graft infection• Emergency operation, extended OR time,
concomitant GI/GU procedure, reoperativep , pvascular procedure
• Incidence of AEF increases to 40%
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• OtherOther– Inflammation – aortitis from syphilis or TB,
PUDPUD– Injury - operative duodenal devascularization– Cancer– Cancer
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Cronenwett et al. Rutherford’s Vascular Surgery 7th ed.
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AORTOENTERIC FISTULAAORTOENTERIC FISTULA
Intro Presentation Surgical T t tEtiology Workup Treatment
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SIGNS & SYMPTOMSSIGNS & SYMPTOMS
• “Classic” triad of GI bleed sepsis andClassic triad of GI bleed, sepsis, and abdominal pain
Batt et al. Eur J Vasc Surg 2011
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• GI bleedGI bleed– Herald bleed – small, brisk, stops
Recurrent bleed temporary seal by thrombus– Recurrent bleed – temporary seal by thrombus– Massive hemorrhage
I f ti• Infection – Fever, malaise, septic emboli
• Abdominal pain – More common with aortoenteric erosion
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DIAGNOSTIC WORKUPDIAGNOSTIC WORKUP
• High index of suspicionHigh index of suspicion– Only 50% patients with AEF have a definitive
diagnosis of AEF before surgerydiagnosis of AEF before surgery
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• If unstable exploratory laparotomyIf unstable, exploratory laparotomy• If stable, EGD and CT
Oth t t ( t h WBC l• Other tests (aortography, WBC nuclear scan, MRI) – less accurate, take more titime
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• EGDEGD– Reach 3rd and 4th portions of duodenum– Pulsation from extrinsic massPulsation from extrinsic mass– Ulceration– Bleedingg– Graft material
– If dislodge any tamponading thrombus, sudden deterioration and bleed
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Graft sutureRaised pulsating ulcer Clot and GraftRaised pulsating ulcer Clot and Graft
Abernethy et al. NEJM 1997Zachary et al. NEJM 1993
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• CTCT– Periaortic gas or fluid
Bowel wall thickening and adherence to graft– Bowel wall thickening and adherence to graft– Retroperitoneal inflammation
Pseudoaneurysm– Pseudoaneurysm– Contrast extravasation
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Perigraft airDuodenum adhesed to
graftContrast extravasation from
sigmoid to graft limb
Simon et al. Case Report Med 2011Koshy et al. J Gastroentero Hepato 2011Peirce et al. AJR 2005
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Kuestner et al. J Vasc Surg 1995
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AORTOENTERIC FISTULAAORTOENTERIC FISTULA
Intro Presentation Surgical T t tEtiology Workup Treatment
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SURGICAL TREATMENTSURGICAL TREATMENT
• Goals: 1 Save the lifeGoals: 1. Save the life2. Save the legs
• PrinciplesControl the bleedRepair the bowelpControl the infectionMaintain distal perfusionp
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• If unstable emergency surgery with graftIf unstable, emergency surgery with graft excision then extra-anatomic bypass or aortic reconstructionaortic reconstruction
• If stable, extra-anatomic bypass then graft excisionexcision
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EMERGENCY SURGERYEMERGENCY SURGERY• Midline laparotomyp y• Proximal control of aorta• Distal control at iliac arteries• Aortic resection and reconstruction
- If infection, extra-anatomic bypassIf i f ti i it t tiIf no infection, in situ reconstruction
• Bowel repair- Primary transverse closurePrimary transverse closure
Resection & anastomosisRoux-en-Y reconstruction
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• Tradeoff: Stop the bleeding quickly to saveTradeoff: Stop the bleeding quickly to save the life, but aortic clamp time is prolonged with increased risk of limb losswith increased risk of limb loss
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EXTRA-ANATOMIC BYPASSEXTRA ANATOMIC BYPASS
• Axillo-bifemoral bypassAxillo bifemoral bypass
Cronenwett et al. Rutherford’s Vascular Surgery 7th ed.
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• For presence of infectionFor presence of infection• If contamination by femoral vessels
Bil t l i ill f l ft– Bilateral uniaxillo-femoral graft– Composite graft
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• Staged procedure =Staged procedure = Preliminary extra-anatomic bypass1 3 d l t ft i i1-3 days later, graft excision
– Goal: reduce physiological stress upon the ti tpatient
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• Staged procedureStaged procedure– Decreased mortality from 43% to 26%
Decreased aortic stump blowout from 30% to– Decreased aortic stump blowout from 30% to 9%
– Decreased reinfection from 46% to 16%– Decreased reinfection from 46% to 16%– Decreased amputation rate from 43% to 16%
18% bypass failure– 18% bypass failure
Reilly et al. J Vasc Surg 1987Kuestner et al. J Vasc Surg 1995
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IN SITU AORTIC RECONSTRUCTIONRECONSTRUCTION
• Careful patient selectionCareful patient selection– Only for no or minimal infection
Conduits• Conduits– Deep vein of lower extremity
C f– Cryopreserved allograft– Rifampin-soaked prosthetic graft
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• Advantage: no aortic stump blowoutAdvantage: no aortic stump blowout• Disadvantage:
Ti i– Time consuming– Possible re-infection
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OVERALLOVERALL
Cronenwett et al. Rutherford’s Vascular Surgery 7th ed.
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Batt et al. Eur J Vasc Surg 2011
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ENDOVASCULARENDOVASCULAR
• Balloon occlusion catheter or stent graftBalloon occlusion catheter or stent graft for initial control of bleeding from aorta
• Less stress transfusion operative time• Less stress, transfusion, operative time• Despite lifelong antibiotics, reinfection or
t AEF i 60%recurrent AEF occurs in 60%• “Bridge to surgery”
Danneels et al. Eur J Vasc Endovasc Surg 2006
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TECHNIQUES FOR PREVENTIONFOR PREVENTION
• Aseptic technique broad spectrumAseptic technique, broad spectrum antibiotics
• Gentle treatment of bowel• Gentle treatment of bowel• Coverage of graft to separate it from
d dduodenumAneurysm sac, retroperitoneal tissue,
tomentum
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SUMMARYSUMMARY
• Fixed duodenum pulsation and infectionFixed duodenum, pulsation and infection contribute to formation of AEF
• High index of suspicion is necessary for• High index of suspicion is necessary for identification P ti t t bilit d f i f ti• Patient stability and presence of infection influences surgical strategy and outcome
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QUESTIONSQUESTIONS
1 Least important for diagnosing AEF is1. Least important for diagnosing AEF is
CTa. CTb. Aortographyc. Endoscopyd Suspicion of itd. Suspicion of it
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2. Patient with AAA repair 5 years ago has fever and p y g+blood cx. Which are true?
C f f fa. CT is preferred initial imaging for suspected graft infection
b Mortality after surgery for infected aortic graft isb. Mortality after surgery for infected aortic graft is 5-10%
c. Graft infections within 4 months of AAA repair are pmore virulent than later ones
d. Staph. epidermis is the most common infecting pathogenpathogen
e. Upper GI bleed is the most common initial presentation of an infected abdominal aortic graft
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3. 75M with AAA repair 5 years ago has malaise, p y g ,abdominal pain, WBC 19, CT showing fluid collection by psoas, graft, and air by graft. Which is true?is true?
a Treatment will require ostomy formationa. Treatment will require ostomy formationb. Negative upper endoscopy eliminates the need for
operationc. Graft excision and extra-anatomic reconstruction
should be performedd S stemic antibiotics sho ld be started immediateld. Systemic antibiotics should be started immediatelye. Percutaneous drainage is adequate therapy
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That’s all, folks.Thank you!Thank you!
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