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Chapter 15 Treatment of Mycotic Abdominal Aortic Aneurysms and Infected Aortic Grafts 231
antibiotic impregnated grafts or omental flap coverage (or both adjuncts),
compared with traditional aortic ligation with extra-anatomic bypass.
65
In situ
repair provided superior 5-year primary patency (89%) versus axillofemoral
bypass (48%).
65
Moreover, major morbidity or procedure-related mortality
were twofold higher after graft excision with axillofemoral bypass compared
with in situ reconstruction.
65
Operative mortality, limb salvage, and reinfec-
tion rates were not statistically different between groups, although all trends
favored in situ repair.
65
These data argue strongly that in situ repair with
omental flap coverage or antibiotic impregnated grafts is superior to extra-
anatomic reconstructions.
In situ graft replacement with human allograft has yielded mixed results.
Leseche reported a series of 28 patients in whom there were no recurrent infec-
tions over a mean follow-up of 35 months.
66
Kieffer et al. reported a series of 179
patients operated for aortic graft infections or secondary aortoenteric fistulas.
67
In that series, the operative mortality was 20.1%. Early and late allograft ruptures
occurred in 2.8% and 2.1% cases, respectively. Vogt et al. described a series of
mycotic aneurysms and aortic graft infections in which there was a 16% inci-
dence of allograft-related technical complications.
13
The US cryopreserved aortic
allograft registry reported a 20% incidence of allograft-related complications,
including 9% rate of reinfection.
68
Based on these reports, there appears to be
a propensity for reinfection or rupture of allografts. The role of allograft in the
management of infected aortic grafts remains undefined.
In the original series reported by Clagett on the use of SFV for in situ
aortic reconstruction, the operative mortality was 10%.
20
No grafts became
infected, and there was 100% patency at a mean follow-up of 22 months.
In that series, a separate cohort of patients underwent reconstruction using
saphenous vein, but those grafts universally failed. In a follow-up study
of 41 patients by the same group, the mortality for SFV reconstruction
after infected graft excision was 7.3% and the primary patency was 83%.
21
Similar results have been reported by other groups. A report from Belgium
described an 8% operative mortality and a 5-year primary patency of
91%.
69
With expanded indications for the use of SFV, potential pitfalls have
emerged. Graft-related hemorrhage has been observed in 11 of 364 patients
(3%).
70
Although 3 of the 11 episodes of bleeding were caused by techni-
cal errors, 8 of the 11 patients experienced hemorrhage as a consequence of
infection of the vein graft. Despite this report, it is apparent that reinfection
is relatively infrequent event compared to the alternative approaches to in situ
aortic reconstruction. Venous morbidity after SFV harvest includes a 17%
incidence of fasciotomy and a 15% incidence of minor venous insufficiency
(CEAP Class C
3
, leg edema, or less). These data indicate that in situ recon-
struction with SFV offers the greatest opportunity for a definitive repair
without mortality, graft occlusion, or graft infection. However, this approach
may not appropriate for all patients.
For grafts in which preoperative imaging suggests that only a portion is
infected, such as a femoral limb of aortobifemoral bypass, partial excision is
a viable option. A critical prerequisite for this approach is meticulous care to
avoid cross-contaminating uninfected portions of the graft. Separate studies by
Towne and Calligaro found that 86–92% of grafts will remain free of infec-
tion during follow-up using this approach.
71,
72
If partial excision is attempted,
https://t.me/med1917
232 J.G. Modrall
careful long-term surveillance with CT is an important component of the
follow-up of these patients.
Summary
Mycotic aneurysms of the aorta and aortic graft infections are dreaded com-
plications of aortic disease. A thoughtful plan for treatment that is tailored to
each case will minimize the risk of major morbidity or mortality. For mycotic
aneurysms in situ and extra-anatomic approaches are both viable options,
while endovascular repair should be reserved for patients unable to toler-
ate more definitive procedures. For infected aortic grafts, evidence suggests
that in situ repair offer significant advantages over traditional extra-anatomic
approaches. Clearly, however, no single approach is appropriate for all
patients, so a thorough understanding of the various options and their utility
will permit the clinician to optimize outcomes.
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Chapter 15 Treatment of Mycotic Abdominal Aortic Aneurysms and Infected Aortic Grafts 233
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https://t.me/med1917
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Chapter 15 Treatment of Mycotic Abdominal Aortic Aneurysms and Infected Aortic Grafts 235
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Abstract Aortoenteric fistula is a life-threatening problem presenting either
as a primary disease process of the aorta and alimentary tract or as a secondary
aortic graft-related complication. A high index of suspicion and diagnostic
testing are essential for prompt identification. Nonoperative management car-
ries 100% mortality. Once diagnosis of an aortoenteric fistula has been made,
there is no role for conservative medical management, and prompt surgical
treatment is mandatory. Even with the most appropriate treatment, the out-
come for operative treatment of aortoenteric fistula carries high morbidity and
mortality rates.
Keywords Aortoenteric fistula , Aortic graft infection
Definition
An aortoenteric fistula is an uncommon, but potentially serious and life-
threatening communication between the aorta and the gastrointestinal tract.
A primary aortoenteric fistula , first described by Sir Astley Cooper in 1829,
is a consequence of either aortic or gastrointestinal pathology which causes
an inflammatory or erosive reaction leading to a communication between
these two adjacent structures.
1
Because of the anatomic relationship between
the infrarenal aorta and the duodenal–jejunal junction, a primary aortoenteric
fistula usually occurs between an infrarenal abdominal aortic aneurysm and
the third or fourth portion of the duodenum, but can occur less frequently with
other aortic diseases and other bowel segments. Primary aortoenteric fistulae
are rare with a reported incidence in the general population of approximately
0.04–0.07% based on autopsy studies, and 0.1–0.8% in patients with aortic
aneurysm, although it is likely that many of these cases go underreported.
2
A secondary aortoenteric fistula , as described by Brock in 1953, is a com-
munication between a previously reconstructed aorta and the gastrointestinal
tract.
3
These can occur after prior endarterectomy, prosthetic graft or hom-
ograft, or more recently endovascular stent graft.
4
Secondary aortoenteric
Chapter 16
Evaluation and Management
of Aortoenteric Fistula
Martin J. Carignan and Marc A. Passman
G. Upchurch and E. Criado (eds.) Aortic Aneurysms, Contemporary Cardiology
DOI: 10.1007/978-1-60327-204-9_16, © Humana Press, a part of
Springer Science + Business Media, LLC 2009
237
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238 M.J. Carignan and M.A Passman
fistula is more common than primary, with a previously reported incidence
of 10% after aortic repairs, which has decreased to 1% with improvements in
surgical technique, suture, and graft material over the last few decades.
5,
6
Although aortoenteric fistula is uncommon, when present, potential for
morbidity and mortality is significant. A high index of suspicion along with
rapid diagnosis is critical for patient survival. The surgical correction of this
life-threatening and complex problem requires an operative team well-versed
in the management of these difficult patients with multiple medical problems
often presenting in hemorrhagic or septic shock. In the acute setting, the gas-
trointestinal tract and the aorta require reconstruction while controlling sepsis
and ongoing hemorrhage. The following text will review the pathophysiology,
clinical presentation, diagnostic algorithm, treatment options, and outcomes
for both primary and secondary aortoenteric fistulae.
Pathophysiology
For aortoenteric fistula formation, there is usually an underlying inflammatory
process in either the aorta or the gastrointestinal tract that causes the formation
of the fistula. Mechanical forces related to aortic pulsation may also lead to ero-
sion of the aorta into adjacent structures. The anatomic proximity of the anterior
surface of the infrarenal aorta and relatively fixed third and fourth portions of
the duodenum within the retroperitonum explains this most common location.
Eighty-three percent of aortoenteric fistulae are between the infrarenal aorta
and the duodenum, while a smaller percentage will occur elsewhere including
the esophagus, stomach, jejunum, ileum, appendix, and colon.
7–
10
An associa-
tion with infection also exists, including mycotic aneurysms, tuberculosis, and
syphilis for primary aortoenteric fistula and graft infection for secondary fistula,
although it is unclear whether the infection is the initial cause or a consequence
of the process. For primary aortoenteric fistula, aortic pathology that may cause
fistulization with the intestinal tract may include aneurysmal degeneration of the
aorta, ruptured abdominal aorta, mycotic aortic aneurysm, inflammatory aneu-
rysm, and primary aortitis. For secondary aortoenteric fistula, additional factors
may include aortic graft suture line failure with proximal anastomotic disruption,
and pseudoaneuysm formation with subsequent erosion into adjacent bowel.
The pathogenesis of secondary aortoenteric fistula is unknown, but technical
problems at initial aortic operation, repetitive mechanical trauma from aortic
pulsation leading to erosion of the graft into the intestine, suture or graft material
fatigue over time, inadvertent bowel injury and delayed indolent graft infection
have been implicated. While the indication for initial aortic repair, aneurysm
versus occlusive disease does not seem to predispose to aortic graft enteric
fistula formation, repair of ruptured aortic aneurysm is associated with a higher
potential for aortoenteric fistula than elective aneurysm repair, with an incidence
of 1.7% and 0.7%, respectively. Prevention of secondary aortoenteric fistula is
best at the time of initial aortic graft placement with measures consisting of
strict aseptic technique, perioperative antibiotics, hemostasis at the suture line,
complete covering of prosthetic material with retroperitonum, graft bolsters over
the suture line, and a retroperitoneal approach having been suggested to reduce
fistula formation.
11
Less commonly, pathological processes in the gastrointes-
tinal tract such as esophagitis, peptic ulcer disease, ingested foreign body,
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Chapter 16 Evaluation and Management of Aortoenteric Fistula 239
cholecystitis, pancreatitis, appendicitis, diverticulitis, pancreatic pseudocyst,
radiation injury, and malignancy have also been implicated.
12
Clinical Presentation
Symptoms and signs of an aortoenteric fistula are varied, but include gastroin-
testinal bleeding (84%), fever (30%), abdominal pain (33%), back pain (20%),
and abdominal pulsatile mass (7%). For patients presenting with gastrointesti-
nal bleeding, melena (41%) and hematemesis (47%) are seen most often. The
diagnosis of secondary aortoenteric fistula should be suspected in any patient
with symptoms of gastrointestinal bleeding and prior aortic bypass graft until
proven otherwise. Most commonly, secondary aortoenteric fistula will present
between 2 and 6 years after the implantation of the graft. Patients usually
present with a “herald bleed,” which is a brief and brisk episode of bleeding
that stops. The normal clotting mechanism temporarily thromboses the fistula
tract causing melena, hematochezia, hematemesis, and chronic anemia at the
time of initial presentation. Although a mean duration of bleeding episode
prior to diagnosis has been reported as long as 25 days, potential recurrent
delayed life-threatening hemorrhage is possible, and when aortoenteric fistula
is suspected, prompt diagnosis and treatment is important.
13
Once aortoenteric
fistula has been excluded, other more common causes of upper gastrointes-
tinal hemorrhage should be considered. The differential diagnosis of upper
gastrointestinal hemorrhage includes peptic ulcer disease, erosive gastritis,
esophageal varices, Mallory-Weiss tear, malignancy, and esophagitis.
Aortoenteric fistula can also present with low-grade sepsis and no evidence
of bleeding. Symptoms can be nonspecific and include fever, generalized
malaise, and leukocytosis of unknown etiology. For primary aortoenteric fis-
tula, infection is less likely unless there is an underlying mycotic aneurysm
or other infective aortic process, while secondary aortoenteric fistula findings
will more often be associated with infection from a sinus or erosion between
the aortic graft and gastrointestinal tract representing infected or colonized
graft material, but not necessarily a direct hemorrhagic communication.
Diagnostic Evaluation
The urgency of evaluation is dependent on the acuity of the patient’s hemo-
dynamic status. In those patients who are unstable, emergent laparotomy
may be required with intraoperative identification of the aortoenteric fistula.
However, most clinical presentations will be more subacute thereby allowing
further evaluation and diagnosis. Although only 50% of aortoenteric fistulae
can be definitively diagnosed preoperatively, knowing this preoperatively is
important for appropriate operative planning.
14,
15
Undertaking a full evalua-
tion of a patient with suspected gastrointestinal hemorrhage needs to also take
into consideration the possibility of an aortoenteric fistula, when an abdominal
aortic aneurysm is present or there has been any prior operative intervention
on the aorta or its branches.
Physical findings which may prompt a heightened concern for aortoenteric
fistula may include a pulsatile abdominal mass suggesting an abdominal aor-
tic aneurysm or pseudoaneurysm, abdominal incisions from previous aortic
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240 M.J. Carignan and M.A Passman
surgery, groin incisions from endovascular repair, or generalized sepsis for
unknown reasons. Blood work including complete blood count, erythrocyte
sedimentation rate, and blood culture with Gram stain are often nonspe-
cific, but in conjunction with the clinical history may be suggestive of an
aortoenteric fistula. Lack of diagnostic yield with blood cultures may reflect
a noninfectious etiology with only 54% of eventual operative Gram stains
performed being positive. Operative cultures usually contain mixed organ-
isms (43%), most commonly including Gram-positive cocci ( Streptococcus
and Staphylococcus species) (36%), Escherichia coli (11%), Klebsiella (2%),
Enterbacter (2%), and Candida species (2%).
16
Although nonspecific, these
findings should increase suspicion for aortoenteric fistula leading to more
extensive diagnostic evaluation.
Given consideration for other more common causes of upper gastrointestinal
bleeding, the preferred initial diagnostic test should be esophagogastroduode-
noscopy (EGD). When aortoenteric fistula is suspected, complete EGD should
include a thorough examination of the duodenum extending into the third and
fourth portions, since most will be identified in this location. EGD should be
performed by an experienced endoscopist and if an active bleeding source is
seen in the third or fourth portion of the duodenum, direct and emergent opera-
tive treatment should be undertaken. If clot is visualized in the third or fourth
portion of the duodenum, it should be left intact as any attempt to remove
the clot can lead to uncontrollable hemorrhage. EGD only has a sensitivity
of 24%, and failure to find a bleeding source does not eliminate aortoenteric
fistula from the differential. Although most common in the third and fourth
portion of the duodenum, aortoenteric fistula can occur in other locations of
the gastrointestinal tract below the ligament of Treitz [duodenum (60%), jeju-
num (12%), ileum (18%), and cecum (8%)], and additional endoscopy may be
required. There have also been reports of coincidental aortoenteric fistulas and
other causes of upper gastrointestinal bleeding.
Contrast-enhanced computed tomography (CT) of the abdomen and pelvis
should follow if EGD is nondiagnostic. The CT scan is most useful when
performed with intravenous contrast. Oral contrast should not be given, but
water as an alternative to oral contrast may improve visualization of the fistula.
The presence of an abdominal aortic aneurysm or pseudoaneurysm may be
suggestive of primary aortoenteric fistula, while the presence and location of
prior aortic bypass graft may be suggestive of secondary aortoenteric fistula.
Findings suspicious for aortoenteric fistula are associated retroperitoneal
inflammation, periaortic gas or fluid, and bowel wall thickening (Fig. 1 ).
Contrast entering the gastrointestinal tract through the fistulas tract is diag-
nostic, but rarely seen. CT scans have a sensitivity and specificity of 94% and
85%, respectively, for findings suggesting aortoenteric fistula, and has the
advantage of providing additional diagnostic information for other potential
causes of bleeding. Furthermore, additional information obtained from the
CT scan can help with operative planning. This valuable diagnostic tool has
continued to improve over time in data acquisition, image processing, and 3-D
reformatting, which have helped improve image quality and timing of diagno-
sis, and has led to a shift in diagnostic decision making with CT scanning now
the primary diagnostic test needed for surgical disposition.
In the current age of CT, there is no longer a role for contrast fluoroscopic
imaging of the upper gastrointestinal tract (barium or water-soluble contrast)
for diagnosis of aortoenteric fistula, and use of contrast will curtail the diagnostic
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Chapter 16 Evaluation and Management of Aortoenteric Fistula 241
ability of CT scan or angiography. Findings described include a sinus tract
from the bowel wall, contrast material around the graft, a defect in the bowel
wall, partial intestinal obstruction, and bowel displacement. Upper gastrointes-
tinal contrast imaging will rarely diagnosis aortoenteric fistula. Its diagnostic
yield is better for other problems.
Angiography is usually not useful as a diagnostic test (sensitivity of 18%),
but may be helpful for operative planning. Although aortographic documenta-
tion of extravasation of intravenous contrast into the bowel is diagnostic and
may define the fistula site, this is rarely seen. There are other advantages
beyond diagnosis including characterizing the abdominal aorta and additional
lower extremity angiography, which helps plan any needed revascularization.
As magnetic resonance angiography and CT angiography technology improve,
these modalities have essentially replaced angiography.
Nuclear imaging such as Gallium 67 or Indium 111-labeled white blood
cell scanning are sensitive for aortic and graft infections. Indium 111-labeled
leukocyte scans have less nonspecific bowel uptake and a greater target-to-
background ratio than Gallium 67 scans. The utility of these scans is in the
stable patient with questionable aorta or graft infection. A positive scan sug-
gests infection but is not diagnostic of aortoenteric fistula.
Treatment
Once diagnosis of an aortoenteric fistula has been made, there is no role for conserv-
ative medical management and prompt surgical treatment is mandatory. Important
tenants included early diagnosis, appropriate antibiotic coverage, consideration of
timing of operative repair, rapid control of bleeding with control of the aorta above
and below the fistula, complete removal of all affected aortic tissue or prosthetic
graft material, consideration of aortic reconstruction and/or lower extremity revas-
cularization options, and prevention of future secondary aortic problems.
Fig. 1 CT angiogram revealing an abdominal aortic pseudoaneurysm at the proximal anas-
tomosis of a prior aortofemoral graft with abutment of the fourth portion of the duodenum
with associated periaortic fat stranding in a patient presenting with aortoenteric fistula
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