Search

Background: Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition., Methods: We performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections., Results: Between 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent in situ revascularization and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6-62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum's second part-jejunum anastomosis was performed in 43% of patients (n = 6), and 19% of the patients (n = 3) died perioperatively. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1-year and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death., Conclusions: Surgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Aorto-enteric fistula (AEF) is a complication with devastating sequelae and significant morbidity. Although open surgery remains primary treatment endovascular approach may be used as a temporary bridge but rarely as a definitive therapy. We present a case of a patient who presented with a secondary AEF, due to hemodynamic instability we chose to treat the fistula with an aortic endograft. The patient underwent bowel resection due to bowel obstruction with omental patch over the aortic rent, 6 weeks of antibiotics. Patient is now at 8-year follow-up without evidence of infection. Although there is scarce literature on this topic, endovascular treatment of bleeding AEF may be feasible as a definitive option. Due to high risk of graft infection we recommend close observation and suppressive antibiotics., (Copyright © 2022. Published by Elsevier Inc.)

A 67-year-old man with massive hematemesis was transferred to the emergency unit of our hospital. The patient was diagnosed with primary aortoduodenal fistula (PADF) based on the CT findings. Upon emergent exploration, multiple duodenal diverticula were found and in situ abdominal aortic aneurysm (AAA) repair using polytetrafluoroethylene (PTFE) graft was performed. The third and fourth parts of the duodenum with multiple duodenal diverticula and the origin of jejunum were excised, and end-to-side duodenojejunostomy was performed. The patient was discharged on the 38th postoperative day with another 6 month oral antibiotic treatment. The duodenal diverticula may be the cause for PADF., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: While endovascular repair of aortic aneurysm (EVAR) has become the mainstay treatment for abdominal aortic aneurysm (AAA), it is not without its disadvantages. Feared complications include graft infections, fistulation and endoleak, the outcomes of which may be life limiting., Case Report: We present a case of a 57 year-old patient with human immunodeficiency virus (HIV) previously treated with EVAR for AAA complicated by endoleak post treatment. He developed an aorto-psoas abscess 2 years later which harboured Mycobacterium avium complex, and medical therapy was unsuccessful. He eventually underwent an extra-anatomical bypass and graft explant, for which an aortoenteric fistula was also discovered and repaired., Conclusion: Infection of endografts post EVAR is relatively rare, and there are presently no guidelines concerning its management. The concomittance of aorto-psoas abscess and aortoenteric fistula is even more uncommon, and necessitated surgical explant for source control purposes in our patient. Lifelong surveillance is required for complications of the aortic stump and bypass patency., (Copyright © 2021. Published by Elsevier Inc.)

Coil migration into the colon is an extremely rare complication of aneurysm embolization and only three cases have been reported. Two of these cases were managed with resection of the involved colon and the remaining case was managed with serial imaging. We present a 70-year-old man who developed hematochezia 2 years after coil embolization of a ruptured left hypogastric artery aneurysm. The patient was successfully treated with diverting colostomy and endoscopic closure of the sigmoid colon defect. We present the only case report of the use of advanced endoscopy to treat endovascular coil migration., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Ascending aortic pseudoaneurysm is a known complication of previous cardiac surgery that needs surgical or endovascular intervention. The presence of arch branches complicates the later approach necessitating additional procedures, either hybrid surgical or endovascular modification of the grafts. We describe a patient who developed an ascending aortic pseudoaneurysm after mitral valve replacement, which recurred after surgical patch closure with the formation of a cutaneous fistula. This high-risk patient was managed by an endovascular approach with in-situ fenestration for the innominate artery by a simple technique., (Copyright © 2021. Published by Elsevier Inc.)

A 63-year-old male presented to the Emergency Department with weakness and hematochezia. He was found to have a massive gastroepiploic artery pseudoaneurysm that had eroded into the transverse colon. He underwent open en bloc resection of the aneurysm, a portion of the stomach, and a portion of the transverse colon. The case and a brief review of gastroepiploic aneurysms is presented., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aortic aneurysm rupture into the retroaortic left renal vein (RALRV) is an uncommon phenomenon. We herein present the case of a 66-year-old man with left flank pain, hematuria, fever, and symptoms of acute right-sided heart failure. Computed tomography angiography (CTA) demonstrated an 83-mm infrarenal aortic aneurysm with a fistula in between the aorta and the RALRV. The patient underwent an urgent endovascular aneurysm repair and a proximal cuff extension due to type Ia endoleak. In the early postoperative period, transcaval coil embolization was performed, 3 months later repeated CTA revealed recanalized fistula, after fluid embolization and vascular plug implantation control CTA showed no sign of endoleak. The patient recovered uneventfully, 1-year follow-up CTA demonstrated aneurysm shrinkage and no sign of endoleak., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: This study aims to review and compare the clinical presentation, management, and outcome in patients with tumor-related (TR) and nontumor-related (NTR) aorto-esophageal fistula (AEF) and aorto-bronchial fistula (ABF) with particular focus on the thoracic endovascular aortic repair., Methods: We retrospectively reviewed a series of 16 consecutive patients with TR (n = 8) and NTR (n = 8), ABF (n = 6), and AEF (n = 10) admitted to our hospital from 2011 to 2019., Results: The median age was 62 years (range 46-81), with 11 men. The most common predisposing factor was esophageal or gastric cardia cancer (n = 6), followed by open repair of the thoracic aorta (n = 5). Endoluminal vacuum therapy (Endo-SPONGE®) accounted for 3 cases of AEFs. Thoracic endovascular aortic repair (TEVAR) was applied in 13 patients (4 with ABFs and 9 with AEFs). The primary technical success of the TEVARs was 100%. One patient (8%) was complicated with postoperative middle cerebral artery syndrome and left-sided hemiparesis. The respective in-hospital, 6-month, and 1-year mortality rates were 0% (n = 0), 25% (n = 2), and 25% (n = 2) for the NTR group and 63% (n = 5), 88% (n = 7), and 100% (n = 8) for the TR group. After a mean period of 13 months, 5 (31%) patients were still alive, and one patient lost to follow-up after 11 months. The survivors (n = 5) had all nontumor-related ABF. Progression of underlying cancer and hemodynamic shock were the most common causes of death., Conclusions: TEVAR represents a reliable option in the treatment of NTR ABFs. In the cases of TR fistulas and NTR AEFs, TEVAR should be applied more selectively. The associated mortality remains very high., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Endovascular approaches to treating a diseased ascending aorta are challenging. We report the use of an endovascular occlusion device for successful closure of a ruptured penetrating atherosclerotic ulcer of an ascending aorta. A 47-year-old female patient with Takayasu arteritis complained of a worsening hemoptysis. She had a history of Bentall procedure for a sinus of Valsalva aneurysm and redo surgery for a ruptured penetrating atherosclerotic ulcer close to the distal anastomosis. She developed methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after the second procedure and required negative pressure wound therapy. Computed tomographic angiography revealed recurrence of a ruptured penetrating aortic ulcer and an aortobronchial fistula. Because of the high risk of redo sternotomy after MRSA mediastinitis, we used an endovascular occlusion device to achieve successful percutaneous closure. The patient was discharged without any complications. Postoperative computed tomography scans showed that the endovascular device was positioned without migration and that complete thrombosis of the penetrating atherosclerotic ulcer was achieved. This is the first report on endovascular repair of a ruptured penetrating atherosclerotic ulcer of the ascending aorta in Takayasu arteritis., (Copyright © 2020. Published by Elsevier Inc.)

Primary aorto-appendicular fistulas are extremely rare in clinical practice, and there are only 3 such cases reported in the available literature. The aim of this study is to present the case of a 68-year-old female patient with primary aorto-appendicular fistula accompanied by infected penetrating aortic ulcer (PAU). At the time of her hospital admission, the patient did not demonstrate any typical symptoms. Multidetector computed tomography imaging of aorta was performed during an additional preoperative examination and the PAU of the infrarenal aortic segment was detected. Other pathological changes were not found. The intraoperative findings confirmed the presence of the PAU firmly attached to the appendix and surrounding signs of inflammation. Appendectomy and partial resection of the PAU were performed, along with aortic reconstruction, using a Dacron tube graft and right renal artery reattachment. During the postoperative period, there were no complications, and the patient was discharged on the 10th postoperative day. Control medical examination and color duplex ultrasonography were performed 18 months after the surgery and they provided satisfactory results., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Innominate artery pathology is traditionally treated with open surgical repair and is associated with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of 3 cases of successful management of innominate artery injuries using an off-label, modified Zenith ESLE stent graft (Cook Medical, Bloomington, IN). Two patients presented with pseudoaneurysms after attempted central venous catheterization, and 1 patient developed a tracheo-innominate fistula. Access was obtained in a retrograde fashion via the right common carotid artery in 2 cases, and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in 2 cases and a bovine arch in 2 cases. Due to the emergent nature of the cases, no cerebral protection maneuvers were taken. The ESLE limbs are of uniform diameter with 3 Z-stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Fourteen- to 18-mm diameter grafts were used. All 3 cases resulted in technical success with complete exclusion of the defect. There were no new neurologic deficits and all patients recovered uneventfully. This approach represents an effective off-label solution for what frequently presents as an emergent problem. In 2 cases, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf conduit. Modification of existing devices successfully addressed the need for a nontapered graft of short length and moderate vessel diameter and allowed for minimally invasive treatment of anatomically complex pathology., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Secondary aortobronchial fistula (ABF) is an uncommon clinical entity associated with increased mortality. Most common presentation is hemoptysis, ranging from repetitive self-limiting episodes to massive hematemesis. Mediastinitis (if present) and excessive blood loss burden the unfavorable case of ABF, whereas stent-graft contamination and sepsis are the main concerns regarding endovascular therapy. We are presenting two patients with secondary ABF treated with thoracic endovascular repair who completed long-term follow-up without complications or evidence of infection., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Primary aortoesophageal fistula (AEF) in the absence of prosthetic graft replacement or aortic endovascular therapy can develop as a rare but life-threatening complication of acute aortic dissection. This case demonstrates that primary AEF should be maintained on the clinical differential of a patient presenting with massive gastrointestinal bleed in the context of an aortic dissection., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Pseudoaneurysm after pancreas transplantation has a reported incidence of 1.4 to 8.0% and may be caused by perioperative infection. Subsequent pseudoaneurysm rupture is a rare cause of arterioenteric fistula. Only 28 cases of arterioenteric fistula after pancreas transplantation have been reported in the past 20 years. We experienced a rare case of arterioenteric fistula resulting from pseudoaneurysm rupture after pancreas transplantation. We successfully treated the arterioenteric fistula with multistaged bridge therapy composed of initial endovascular aneurysm repair, secondary isolation of the fistula, and definitive open repair with extraanatomic bypass. No complications occurred in 1 year of follow-up; this staged therapy seems feasible for patients with arterioenteric fistula., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Only 3 cases of aorto-cisterna chyli fistula have been described in the literature but none with a resulting pseudoaneurysm (PSA)., Methods: A 68-year-old man presented following a motor vehicle collision. Imaging revealed a retroperitoneal hematoma with enhancement of the cisterna chyli, representing an aortic to cisterna chyli fistula. Three days later, computed tomography angiography showed resolution of the fistula, but revealed a PSA. The patient underwent arteriography that confirmed the PSA, and then a computed tomography-guided thrombin injection was performed. Follow-up imaging showed resolution of the PSA., Results: Only 3 cases of aorto-cisterna chyli fistula have been described. We hypothesize that this fistula was caused from his L2 vertebral body fracture, which avulsed the lumbar artery and injured the cisterna chyli. The cisterna chyli provided an outflow tract for the aortic injury. We believe this type of fistula follows a benign clinical course. Aorto-cisterna chyli fistula is rare, and reports point to spontaneous resolution. Our case is unique in that the patient progressed from a fistula to a PSA. Options for treatment of this PSA include covered stent graft, open repair, coil embolization, or thrombin injection., Conclusions: This case report describes an extremely rare diagnosis and the natural history of this aorto-cisterna chyli fistula. Furthermore, the resulting aortic PSA was successfully treated with computed tomography-guided thrombin injection, which in the appropriate setting, should be considered an acceptable option., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aortoenteric fistula (AEF) and aortoenteric erosion (AEE) are deadly and difficult to diagnose. We present here a case report of a patient with a delayed diagnosis of AEF whose preoperative imaging revealed a large vertebral osteophyte which likely directed the aortic impulse into the duodenum. We believe this is the first report documenting an anatomical explanation for AEF/AEE and conclude that the presence of vertebral osteophytes should be considered a risk factor when assessing preoperative likelihood of AEF/AEE., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Ureteroarterial fistulas (UAFs) have a low incidence but are a potentially fatal cause of hematuria. Initially treated by open surgery, endovascular techniques have decreased potential complications., Material and Methods: We present a short series of UAFs (n = 5) treated in our institution in the last 10 years: 1 case showed up after aorta-iliac bypass surgery, 1 case after endovascular aortic repair and embolization of right hypogastric artery, and 3 cases after oncological surgeries. We review the published literature via PubMed., Results: The different approaches (2 open and 3 endovascular procedures) were based on the clinical situation of the patients and on technical limitations. Three patients died after the procedure (2 after open surgery and 1 after endovascular treatment). In our institution, endovascular treatment showed good results in terms of early complications and associated mortality compared with open surgery., Conclusions: UAF is a rare but a potentially fatal complication in patients with predisposing factors. No long-term follow-up has been published to assess the possible complications arising from the technique, such as prosthetic infection. No antibiotic treatment protocols have been established, so long-term follow-up is necessary to determine late complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aortoesophageal (AEF) and aortobronchial fistula (ABF) after thoracic endovascular aortic repair (TEVAR) are rare complications with catastrophic consequences without treatment. In this case report, we presented a patient with AEF and ABF after TEVAR successfully treated with endograft explantation and replaced by Dacron graft followed by esophagectomy and left principal bronchus repairing. We report a patient with AEF and ABF after TEVAR who was evaluated due to dysphagia and chest pain followed by hematemesis and hemoptysis. Endoscopic examination revealed lesion of the esophageal wall with chronic abscess formation and stent-graft protrusion into the cavity. Patient was operated on with extracorporeal circulation. AEF and ABF were confirmed intraoperatively. Endograft was explanted and in situ reconstruction of thoracic aorta was carried out with tubular Dacron 22-mm prosthesis wrapped with omental flap. After aortic reconstruction, esophageal mucosal stripping was performed with cervical esophagostomy, pyloromyotomy, and Stamm-Kader gastrostomy for nutrition. In addition, omentoplasty of the defect in the left principal bronchus was performed. To re-establish peroral food intake esophagocoloplasty was carried out 8 months after previous surgery utilizing transversosplenic segment of the colon and retrosternal route. In very selective cases, stent-graft explantation and in situ reconstruction with Dacron graft covered by omental flap followed by esophagectomy and bronchus repairing permit adequate debridement reducing the risk of mediastinitis and graft infection and allow a safe esophageal reconstruction in a second procedure., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A secondary aortoenteric fistula (SAEF) is a relatively rare complication of aortoiliac reconstructive surgery, often involving relatively fixed duodenal third portion and a vascular anastomosis. We observed a 52-year-old man with a recurrent right lower leg abscess following the erosion between ipsilateral bifurcated prosthetic graft limb and nonfixed jejunum. In situ graft-sparing surgical treatment with aggressive debridement was successfully performed. A SAEF may occur even at a nonvascular anastomosis site, or in nonfixed small bowel, and may become a source of a septic embolus. A high index of suspicion for SAEF is required for early diagnosis and treatment of this life-threatening complication., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Continued enlargement of the aneurysm sac after thoracic endovascular aortic repair (TEVAR) is a known risk after endovascular treatment of thoracic aortic aneurysms. For this reason, periodic outpatient follow-up is required to identify situations that require repair. Here, we describe an aortobronchial fistula (ABF) in a patient lost to follow-up, that presented 3 years after an elective TEVAR done for a primary, descending thoracic aortic aneurysm. Our patient arrived in extremis and suffered massive hemoptysis leading to her demise. Computed tomography (CT) angiogram near the time of her death demonstrated a bleeding ABF immediately distal to her previous TEVAR repair. Aortic aneurysmal disease remains life threatening even after repair. Improved endovascular techniques and devices have resulted in decreased need for reintervention. However, this case demonstrates the risk of thoracic aortic disease progression and highlights the importance of establishing consistent, long-term follow-up after TEVAR., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aortoesophageal fistulas (AEFs) are rare and life-threatening conditions. Till date, an association between an AEF and sarcoidosis has not been reported yet. The aim of this report is to demonstrate a case of AEF secondary to sarcoidosis and its multistage interdisciplinary surgical therapy. A 66-year-old male was diagnosed with sarcoidosis in 2014. He has been treated with glucocorticoids since then and no severe health restrictions due to the disease have occurred. In December 2015, the patient presented with acute thoracic pain and hematemesis: an esophagogastroscopy revealed an AEF. First, stent-graft implantation in the thoracic aorta was urgently performed as a "bridging" procedure. Second, esophagectomy and local debridement were performed, followed by explantation of the stent graft and reconstruction by means of xenograft replacement of the stented aorta in a third operation. Finally, retrosternal gastric pull-up was performed in a fourth operative procedure. Sixteen days after the last operation the patient could be discharged to a rehabilitation clinic. Follow-up is uneventful so far; the antibiotic therapy was stopped at the time of hospital discharge. The pathogenesis of sarcoidosis, a rare autoimmunological disease, has not been completely clarified yet. The diagnosis relies on clinical symptoms and radiological as well as histopathological findings. Many cases of sarcoidosis show spontaneous regression, but severe complications may occur. While tracheoesophageal fistulas have been described in the literature, AEFs related to sarcoidosis have not been mentioned yet. Despite surgical and antibiotic treatment, the morbidity and mortality rates of AEF are high. Because the endovascular treatment has been established for emergency procedures of the aorta, it is considered as an appropriate first-line "bridging" treatment option. To achieve good long-term results, surgical treatment has to involve esophagectomy with secondary reconstruction of the upper gastrointestinal tract, as well as open aortic replacement using xenograft or homograft material. Sarcoidosis may lead to AEF as demonstrated in this case. Successful treatment can be realized by a multistage interdisciplinary surgical approach., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Complex aortic aneurysms such as paravisceral aneurysm represent a challenging condition especially in the case of rupture. The presence of an aortoenteric fistula in this setting is associated with a very high mortality and morbidity. We report the case of a 72-year-old patient with contained ruptured paravisceral aortic aneurysm who underwent surgeon-modified fenestrated endovascular aneurysm repair (sm-fEVAR) with fenestrations for multiple renal arteries and the superior mesenteric artery. The patient successfully recovered from the repair but developed an aortogastric fistula on the basis of a preexisting gastric ulceration so that second-stage atypical gastrectomy was conducted. The further postoperative course was complicated by severe pancreatitis and sepsis resulting in multiorgan failure and in-hospital death 1.5 months later. We were able to demonstrate the technical feasibility of an sm-fEVAR for a contained ruptured paravisceral aneurysm. Coverage of the celiac artery is required in some complex cases but may lead to severe ischemic complication despite from angiographic sufficient collateralization., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Backgrounds: Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity., Case Report: A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding., Conclusions: Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aortoenteric fistula (AEF) is a dreadful complication of abdominal aortic surgery. Surgical treatment is associated to high mortality and requires urgent graft removal with extra-anatomic or in situ reconstruction. Other authors suggest the use of stent grafts, both as a stand-alone procedure or as a bridge solution before open repair. We reviewed the results of a cohort of patients that presented at our institution with an AEF and were treated with a novel 2-step endovascular-open surgical procedure. The first step consisted in immediate endovascular occlusion of the infrarenal graft with deployment, below the renal arteries, of an aortic occluder and/or endovascular plugs. After occlusion of the infrarenal graft, extra-anatomic reconstruction (axillofemoral bypass) was performed. The second step consisted in the removal of the infrarenal graft with aortic stump ligation and took place after a few days recovery to allow improvement of patients' condition. A total of 5 selected patients were treated. Endovascular aortic occlusion was achieved in all cases with the deployment of 1 (3 patients) or 2 (2 patients) devices. The mean interval between the first and the second step was 7 days (min 4-max 13). Complete removal of the aortic graft was possible in all patients. One patient died on the first postoperative day due to multiorgan failure (1 of 5, 20%). Mean survival after discharge was 24 months (min 6-max 36). One patient died at 6 months because of aortic stump blowout. In our initial experience, endovascular aortic occlusion seems an effective option to prevent fatal enteric bleeding and a valuable first-step treatment for selected cases of AEF., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Secondary aortoduodenal fistula (SADF) is a rare, life-threatening complication of abdominal aortic reconstruction. Clinical presentation varies and treatment requires complex surgical repair associated with considerable morbidity and mortality. This retrospective study examines the contemporary management of SADF at a tertiary vascular surgical practice., Methods: Thirteen patients were managed for SADF between 2004 and 2014. Vascular and duodenal reconstructions were considered. Primary end points included bile leak, major complications, and mortality., Results: Of the 13 patients presenting with SADF, 6 presented with luminal blood loss. During mean follow-up (632 days), the rate of major complication was 77%. Overall, 38% developed duodenal leak. All leaks occurred after graft explantation with extra-anatomic bypass, and the majority of these patients (80%) had no preceding history of acute gastrointestinal (GI) bleed. There were no leaks identified after duodenal exclusion with gastrojejunostomy. Patients that developed duodenal leak had longer mean intensive care unit length of stay (LOS; 7.0 vs. 2.3 days, P = 0.004), longer mean overall hospital LOS (36.6 vs. 18.5 days, P = 0.012), and greater late mortality (40% vs. 13%). There were 2 SADF-related deaths. Overall mortality trended higher in females (67% vs. 20%, P = 0.125) and those that presented without acute GI bleed (43% vs. 17%, P = 0.308)., Conclusions: Surgical reconstruction for SADF results in major morbidity. Those presenting with acute GI bleed trended toward better outcomes than those without. Duodenal leak remains a serious complication. Duodenal exclusion may represent a more appropriate and conservative approach for management of the duodenal defect in select patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Penetrating aortic ulcer (PAU) is an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina of the aortic wall. PAUs are classified as a category of acute aortic syndrome and have a reported rupture rate of up to 38%. To our knowledge, there is no prior published report of a PAU causing an aortogastric fistula. With the goal of raising awareness of this potentially catastrophic complication, we present herein a case of a PAU that ruptured into the gastric fundus, resulting in massive bleeding. The diagnosis was confirmed by computed tomography angiography, and thoracic endovascular aortic repair was used to control bleeding. Unfortunately, the patient did not survive the severe hypovolemic shock., (Copyright © 2015 Elsevier Inc. All rights reserved.)

When an aortoenteric fistula (AEF) arises secondary to suprarenal or more proximal aortic repair, mortality and the complexity of the surgery increases. We present the first reported case to our knowledge of a secondary AEF arising 13 years after surgical repair of middle aortic syndrome. We performed the original surgery on a 22-year-old male who presented with hypertension and claudication by placing a Dacron prosthetic patch on the juxtarenal and infrarenal aorta, bilateral vein bypasses to the left and right renal artery, and a Dacron bypass to the proximal superior mesenteric artery. Thirteen years later, he presented with massive gastrointestinal bleeding and syncope. We performed a distal descending thoracic aortic rifampin-soaked bifurcated Dacron graft to the left renal artery and to a large meandering mesenteric artery followed by excision of all previous prosthetic graft and insertion of a rifampin-soaked tube graft from the distal descending thoracic aorta to the distal abdominal aorta with omental flap coverage. After a complicated postoperative course, he was discharged 2 months later and remains on dialysis at his 6-month postoperative follow-up without evidence of recurrent infection., (Copyright © 2015 Elsevier Inc. All rights reserved.)

A 68-year-old woman with ventilator-dependent respiratory failure and multiple comorbidities developed acute massive hemoptysis. Computed tomographic angiogram revealed a 3.9-cm pseudoaneurysm arising from the innominate artery abutting the trachea. The patient was successfully treated with stent graft insertion via the right common carotid artery, with exclusion of the aneurysm from the proximal innominate to the right common carotid artery, with ligation of the proximal right subclavian artery and right common carotid to subclavian artery bypass. The patient remained medically stable for 3 months after the procedure with no evidence of endoleak or infection. She then developed recurrent hemoptysis with fatal cardiac arrest. Open surgical repair has been the treatment of choice for tracheoinnominate artery fistula. However, direct repair confers a high mortality risk. Endovascular exclusion offers a less invasive treatment option for tracheoinnominate artery fistula and can serve as a bridge for patients with potential for becoming better surgical candidates., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: An aortoenteric fistula is an abnormal communication between the aorta and the bowel lumen. It is usually caused by previous aortic surgery and involves the duodenum (ADF) in most cases. The treatment of this high-mortality condition is based on the correction of enteric and vascular defects. However, enteric repair indications and impact are unknown., Objective: We sought to characterize the surgical procedures available for duodenal repair in ADF and estimate their impact in mortality., Methods: A literature search was conducted, between the years 1951-2010. Cases (791 from 614 references) were individually registered and analyzed to demography, enteric location, type and cause of fistula, type of surgical procedure, mortality, and cause of death. Risk factors to outcome were estimated by univariate and multivariate analysis., Results: The enteric procedure was described in 331 cases: duodenorrhaphy (with or without omentum interposition; with or without enterostomy) in 266 cases, duodenal resection/reconstruction in 54 cases, antibiotic or abdominal drainage alone in 4 cases, and nothing was done in 7 cases. Vascular treatment was described in 515 cases: extra-anatomic bypass in 207 cases, in situ graft in 197 cases, direct closure of the aortic defect in 52 cases, endovascular procedures in 32 cases, and others arterial reconstructions in 27 cases. Univariate analysis revealed that mortality caused by ADF is directly associated with primary ADF type, direct closure of the aortic defect, and is inversely associated with recent publications, omentum interposition, use of an in situ graft, and endovascular prosthesis. Multivariate analysis revealed that omentum interposition and the use of an in situ graft were independent factors to the outcome, and that omentum use was the strongest factor related to survival. The most common cause of death was ADF recurrence (41.8%), which was significantly high (P = 0.036) in the patients who underwent simple duodenorrhaphy., Conclusions: The literature supports the use of omentum interposition and suggests that duodenal derivation is preferable to the simple closure of fistula. Delayed or avoided enteric repair after endovascular treatment emerged as an option, but needs additional supporting research., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: We present a case of successful endovascular exclusion of an aortoduodenal fistula using an endovascular graft iliac plug. This treatment modality of aortoduodenal fistula arising from a recurrent mycotic aortic aneurysm stump has not yet been described in the literature., Case Report: An 80-year-old man underwent emergency repair of a ruptured infrarenal mycotic aortic aneurysm with an axillobifemoral vascular bypass. Four months after the operation, a pseudoaneurysm arising from the aortic stump invaded the third part of the duodenum, forming an aortoduodenal fistula. An endovascular graft iliac plug and a chimney stent were used to achieve endovascular exclusion of the aortoduodenal fistula., Conclusion: The management of aortoduodenal fistula arising from recurrent mycotic aortic aneurysm stump with an endovascular graft iliac plug is successful, especially in patients with a previous history of abdominal aortic surgeries. This procedure reduces the mortality and morbidity associated with open surgery. Further validation with a greater number of cases and longer follow-up times would be required to prove that this is a viable definitive treatment modality., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Subclavian artery-esophageal fistula is a life-threatening entity. It usually occurs in cases of an aberrant right subclavian artery. A fistula between a non-aberrant subclavian artery and esophagus is extremely rare and difficult to diagnose. It is generally due to ingestion of a foreign body and it is often lethal. We present a case of subclavian artery-esophageal fistula complicated by mediastinitis in a 45-year-old man. The fistula, induced by ingestion of a fish bone, was successfully treated by endovascular stent grafting and left thoracotomy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Vascular involvement in Behcet's disease is rare, but may be at the forefront of the clinical picture with possible life-threatening scenarios. We reviewed our preliminary results with endovascular treatment of abdominal aortic pathologies in Behçet's disease., Methods: Data regarding seven patients with abdominal aortic pathologies (aneurysm, pseudoaneurysm, and aortoenteric fistula) and Behçet's disease were treated with endovascular stent-grafting between 2002 and 2006., Results: Seven patients (aged, 39.1 ± 9; range, 27-52 years) with a mean aortic diameter of 58.4 ± 6.3 mm received endovascular stent-grafts, two patients being in emergency settings. Two patients were in active disease state. Four tube-shaped, two aorto-bi-iliac, and one aorto-uni-iliac stents were implanted. One patient expired on day 28 with multiorgan failure after emergency stent-grafting owing to enlarging periprosthetic hematoma following open surgery for ruptured aneurysm. Another patient was declined for endovascular therapy owing to hypoplastic aortoiliac vasculature., Conclusion: Endovascular approach provides a reasonable alternative to open repair for the treatment of abdominal aortic aneurysms in select cases; however, in emergency settings, endovascular repair may well have an important, but limited, role in select patients with aortoenteric fistulae, it may yet require a surgical intervention., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Aortoesophageal fistula is rare but fatal if untreated. Open thoracic surgery is associated with high operative mortality and morbidity. We report a case of a 77-year-old man who, treated with thoracic endovascular aortic repair (TEVAR) for descending thoracic aneurysm in another center, after an acute episode of hematemesis and melena was referred to our center. The total body computed tomography scan showed the presence of reperfusion of the descending thoracic aneurysm sac (8.8 cm in diameter) in the proximal and distal TEVAR landing zone (endoleak type I) without clear signs of fistulous tract with the esophageal lumen. The patient underwent new TEVAR inside previous implantation with proximal landing very close to left subclavian artery and distal landing just above celiac trunk. For the presence of a tracheoesophageal fistula, an esophageal endoprosthesis was implanted few days later, and a jejunostomy was performed. At 30 days, patient was in good general condition, but he died at 3 months' follow-up. Aortoesophageal fistula is a rare and usually fatal condition; early recognition and TEVAR treatment prevent immediate exsanguination in patients, but after deployment of the endograft, most patients are at risk for infectious complications. Cessation of bleeding and restoration of circulation is of paramount urgency, but infectious diseases and esophageal repair remain open problems., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Asymptomatic penetration of the inferior vena cava (IVC) wall with retrievable filters is not uncommon. Occasionally, this can be a cause for morbidity, and rarely for mortality. We present a case of duodenocaval fistula, secondary to penetration from a strut of retrievable IVC filter that presented as lower gastrointestinal bleeding and discuss the subsequent management. Although newer generation retrievable filters provide a longer time for retrieval, they are associated with an increased incidence of IVC wall penetration, caudal migration, and occasionally symptomatic presentation, thereby necessitating surgical intervention. Close follow-up is warranted, and prompt retrieval of such devices should be done when their use is no longer indicated., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

The case reported is of a 30-year-old patient with a left internal carotid-jugular fistula secondary to the explosion of an improvised explosive device during the Afghan war. Carotid resection with arterial bypass using a venous allograft and internal jugular ligation were performed by left cervicotomy associated with sternotomy at a specialized center. The management of cervical arteriovenous fistulas that occur as a result of penetrating trauma faced during the war must be considered and it should be noted that, on battlefields, treatment is not always performed in specialized units., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

A 62-year-old man was presented to our facility with recurrent right lower limb abscesses. He had an aortobifemoral graft for an aortoiliac occlusive disease. The diagnosis of paraprosthetic fistula was confirmed by performing a high-resolution contrast-enhanced computed tomography, whereas labeled leukocyte imaging provided a negative result. The graft present in the right limb was removed and extra-anatomical femoro-femoral bypass was performed along with segmental ileal resection of the affected loop and a side-to-side anastomosis. Recovery was unremarkable, with no recurrence of abscess 18 months after surgery. To our knowledge, this is the first report in published data on a paraprosthetic fistula presenting as recurrent lower limb abscesses. In this article, we have discussed the clinical features, principal diagnostic findings, and therapeutic options., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding, and carries high morbidity and mortality even in modern practice. Cervical carcinoma is a major health threat among adult women, and its recurrence is not uncommon. We herein present a case of primary aortoduodenal fistula because of recurrent cervical carcinoma. Our case demonstrated that diagnosis of primary aortoenteric fistula requires a high index of suspicion and a combination of diagnostic modalities to establish the diagnosis. Prompt diagnosis and rapid treatment are critical in reducing mortality and morbidity. Although rare, metastatic carcinoma can lead to aortoenteric fistula., (Copyright © 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

A child had a percutaneous endoscopic gastrostomy tube removed by transecting it at skin level. The internal portion ("the bolster") was allowed to pass in the GI tract. She subsequently had odynophagia. Magnetic resonance imaging identified a foreign body within the lower thoracic esophagus. During esophagoscopy, the bolster was removed. The following morning, she had massive hematemesis with cardiovascular collapse. As an emergent maneuver, an intra-aortic balloon was percutaneously deployed at the bedside without fluoroscopic guidance. This temporized the exsanguination. Subsequent intraoperative aortography confirmed an aortoesophageal fistula. A stent-graft was deployed with immediate hemodynamic stabilization. She later underwent esophageal resection and recovered well., (Published by Elsevier Inc.)

A 78-year-old woman was admitted to our hospital with intermittent hemoptysis. She had undergone descending aortic replacement through a left thoracotomy 7 years previously. Enhanced computed tomography revealed a pseudoaneurysm at the proximal suture line in the descending aorta and an ascending aortic aneurysm. Bronchoscope revealed bleeding from the left lower bronchus. Ascending and total aortic arch replacement and simultaneous open stent-graft placement into the descending aorta were performed through a median sternotomy. Selective antegrade cerebral perfusion and moderate hypothermia were used during these procedures. The postoperative course was favorable. Open stent-graft placement is a good alternative for treating aortobronchial fistula caused by suture line pseudoaneurysm in the descending aorta., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

We report on N-butyl 2-cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of an aortoesophageal fistula secondary to placement of an esophageal stent. A 53-year-old man with lung cancer was admitted with massive hematemesis due to the formation of an aortoesophageal fistula 20 days after esophageal stent placement. Injection of N-butyl 2-cyanoacrylate into the aortoesophageal fistula was performed as emergent treatment for this hemodynamically unstable condition, and an endovascular stent graft was subsequently placed via the right femoral artery. The patient was well without hematemesis until he died of pneumonia 45 days later. Cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of massive hemorrhage caused by an aortoesophageal fistula is a prompt, effective method and can be an alternative to surgical repair., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

A secondary aortoenteric fistula (SAEF) is relatively rare after abdominal aortoiliac reconstructive surgery. Most SAEFs are associated with a graft prosthesis, and rectum involvement is rarely reported. We report a rectal SAEF after aortoiliac aneurysmorrhaphy, i.e., oversewing the artery without a graft. A 62-year-old man had an appendicitis-related infected right common iliac artery aneurysm and sterile left aortoiliac arterial aneurysm. Six weeks after an appendectomy with a right iliac aneurysmectomy, left aortoiliac reduction aneurysmorrhaphy, and femorofemoral bypass grafting, he developed repeated bloody stool. Abdominal computed tomography and colonoscopy findings strongly indicated communication between the native aortic or iliac arteries and the rectal lumen. Emergency surgery-left infected aortoiliac artery excision, oversewing the aortic stump, right axillofemoral bypass, and sigmoid protectomy with an end-colostomy-was performed. Unfortunately, the aortic stump developed a pseudoaneurysm 6 weeks after the second laparotomy. During the third emergency laparotomy, more of the stump was amputated and wrapped in the omentum. At 45-month follow-up, the patient was well and without infection recurrence or leg ischemia. This case is a reminder that even patients without a graft prosthesis are at risk for SAEF after any aortoiliac surgery. We also comprehensively reviewed the English literature from 1960 to 2008 on prosthesis-free SAEF patients., (Copyright 2009 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Estimates of the incidence of aortoenteric fistula as a sequela of surgery of the aorta range 1-2%. This complication is less common in patients who have had an aortic endograft implanted for aortoiliac aneurysm. We present three cases of aortoenteric fistula complicating endovascular treatment of abdominal aortic aneurysm (3/423 patients, 0.7% in our series).

Penetrating abdominal trauma with injury to the aorta and vena cava usually requires emergent intervention and is frequently lethal. Formation of a chronic aortocaval fistula (ACF) is an uncommon late complication of these injuries. We report a case of an ACF presenting 17 years after a gunshot wound to the abdomen, with progressive congestive heart failure as the presenting symptom. The ACF was successfully treated with an endoprosthesis designed for the thoracic aorta.

Aortoenteric fistula (AEF) is an infrequent but disastrous complication of open abdominal aortic repair. Left untreated, it has a 100% fatality rate. The traditional approaches to the repair of secondary AEF (SAEF) are associated with average mortality rates of 21-59% and numerous major complications. Here, we report a case of acute gastrointestinal bleeding due to SAEF, successfully treated with endovascular stent graft repair. At 1-year follow-up, the patient was doing well without any signs of recurrent fistula. Endovascular treatment of AEF provides another treatment option that may be particularly valuable in patients whose comorbidities would preclude open repair.

Gastrointestinal bleeding can be caused by a variety of pathologies. Primary aortoappendicular fistula is rare and, in our case, arose in addition to a chronic contained rupture sac of an abdominal aortic aneurysm. Clinical diagnosis is difficult. Aortic aneurysmorrhaphy along with extensive debridement and emphasis on antibiotic therapy is curative.

Tracheoinnominate artery fistula is an uncommon but life-threatening complication usually requiring emergency ligation of the artery. The recent introduction of stent-grafts offers a new therapeutic option for emergency management of hemorrhage. Stent-grafts can be used for definitive treatment or as a bridge to surgery. The purpose of this report is to describe a case of hemoptysis due to a tracheoinnominate artery fistula that occurred after a single orotracheal intubation for general anesthesia and was treated by placement of a covered stent followed 12 hours later by surgical revascularization of the innominate artery using a cryopreserved arterial allograft.

We report an unusual case of a ureteroiliac fistula due to prolonged ureteral stenting for hydronephrosis combined with an aortic-bifemoral stent graft in an inflammatory abdominal aortic aneurysm (AAA), treated with an endovascular stent graft. In a 77-year-old man ureteral J-stents were placed for bilateral hydronephrosis due to retroperitoneal fibrosis caused by an inflammatory AAA. The aneurysm was treated with an endovascular aortic-bifemoral stent graft. Three months later, the patient suffered from severe hypovolemic shock. Emergency angiography showed a fistula between the right ureter and the right common iliac artery just distal to the right leg of the stent graft. The ureteroiliac fistula was treated with a wall graft (10F). The patient recovered well and remained asymptomatic. Ureteroiliac fistula remains a rare complication of ureteral stenting. Several risk factors have been described before. This case emphazes the increased risk of an arterial-ureteral fistula due to an indwelling ureteral stent and an inflammatory AAA, especially in combination with an additional stent graft for this inflammatory AAA.