Endovascular treatment for aorto-enteric fistula and aorto ... · Aorto-enteric fistula Conventional surgical repair •Primary: Aortic ligation and extra-anatomic bypass •Secondary:

Endovascular treatment for aorto-enteric

fistula and aorto-caval communication

Athanasios D. Giannoukas, MD, MSc, PhD, FEBVS

Professor of Vascular Surgery

University of Thessaly Medical School

Chairman, Department of Vascular Surgery

University Hospital of Larissa, Greece

Aorto-enteric fistula

• Abnormal communication between aortic and bowel

lumen necessitating immediate intervention

• Primary (incidence 0.02 – 0.07%)or secondary (more

often: <1%)

• GI bleeding alone or in combination with sepsis


Conventional surgical repair

• Primary: Aortic ligation and extra-anatomic bypass

• Secondary: extra-anatomic by-pass, graft excision

and aortic ligation or

graft excision and in-situ aortic reconstruction

• High morbidity and mortality rates (>40%)

O’Mara CS et al. Am J Surg 1981;142:203

Bianchi P et al. Surg Today 2007;37:1053

CASE 1

Graft removal, aortic stump closure

with omentum and ABF graft

Pt survived, 2yr-FU no evidence of

infection

Case 2

Case 2

Successful revascularisation and

thoracic & abdominal

endografting

Pt died 4 days later in the ICU due

to MOF

Case 3

ABF graft

Pt alive 3 year-FU without

evidence of infection

Aorto-enteric fistulawhy endovascular treatment?

• Patients with AEFs have limited overall survival.

• Endovascular therapy is an alternative to open repair

associated with decreased perioperative morbidity

and mortality and a shorter in-hospital stay, and

allows for acceptable survival given the presence of

coexisting medical co-morbidities.

• Furthermore, endovascular repair provides a

therapeutic option to control bleeding and allows for

continued intervention in a stabilized setting.

Baril DT et al. J Vasc Surg 2006;44:250

Endovascular repair of


• Systematic review of English literature up to April

2008

• Endovascular repair of primary or secondary A-E

fistulae

• 33 reports with 41 pts

Antoniou GA, Koutsias S, Antoniou SA, Georgiakakis A, Lazarides M,

Giannoukas AD. J Vasc Surg 2009;49:782-9



• Persistent/recurrent/new infection or haemorrhage

developed in 44% after a mean f-up of 13 mths

• Secondary as compared to primary AEF had an

almost three-fold increased risk

• Evidence of co-existing sepsis was factor of

unfavourable outcome (p< .05)

• Persistent/recurrent/new infection after treatment was

associated with worse 30-day and overall outcome

(p< .05)







Aorto-enteric fistulaEVAR vs surgical repair

• Report on 25 pts during 12 year period

• Preoperative sepsis in 76% (19)

• EVAR: 8 pts – OR: 17 pts

• In-hospital mortality better in EVAR (0% VS 35%)

• Recurrence-free, sepsis-free & overall long-term

survival similar in both groups

• 2-year overall survival in pts with pre-op sepsis was

worse (24% vs 50%)

Kakkos SK, Antoniadis PN, Clonaris C, Papazoglou KO, Giannoukas AD, Matsagas MI, Kotsis T,

Dervisis K, Gerasimidis T, Tsolakis IA, Liapis CD.

Presented at ESVS 2010 Annual meeting in Amsterdam

Aorto-enteric fistulaIn-situ surgical repair with homografts

• 57 patients treated with cryopreserved arterial homografts for

the in situ reconstruction of abdominal aortic infections.

• Thirty-day mortality was 9% (5 of 57 patients).

• Median follow-up was 36 months (range, 4-118 months);

• 3-year survival was 81%, and freedom from reoperation was

89%.

• Five patients (9%) required reoperation, in one patient each

for postoperative bleeding, acute cholecystitis, homograft

occlusion, homograft-duodenum fistula, and aneurysmal

degeneration.

• No recurrence of infection was reported.

Bisdas T et al. J Vasc Surg 2010;52:323

EVAR: bridge therapy or complete treatment?

Do we need RCT?

Aorto-enteric fistulaEVAR vs surgical repair

Aorto-caval communication

• Rare clinical condition

• Abnormal communication between the aorta or the

iliac arteries and the inferior vena cava or the iliac

veins

• Primary (80%) – Secondary (iatrogenic or traumatic)

Historical aspects

• 1st description by Syme in 1831

Syme J. Edinb Med Surg J 1831;36:104-6

• 1st surgical repair by Cooley

Cooley DA. Ann Surg 1955;142:623

Open surgical repair

• Associated with high morbidity and mortality

• Problems

arterialisation of venous structures

perivascular inflammation blood loss

risk of pulmonary embolism

cardiac decompensation because of hyperdynamic state

Adjuncts to open surgery

• Percutaneous balloon occlusion of the IVC to

facilitate open surgery and minimise blood loss

Laureys M et al. J Vasc Interv Radiol 2002;13:211-3

Espinel CF et al. J Vasc Surg 2006;43:834-5

Endovascular repair

• Systematic review

• English literature from 1/1990 – 1/2009

• 21 articles reporting on 22 pts plus 1 pt in our own

report Total 23 pts

Antoniou GA, Koutsias S, Karathanos Ch, Sfyroeras G, Vretzakis G,

Giannoukas AD. J Endovasc Ther 2009;16:514-23

Endovascular repair

• Primary 65%

• Secondary 35%22% (5 pts ) after AAA open repair (2) or EVAR (3)

9% (2) previous open abdo trauma

4% iatrogenic trauma in lumbar disc surgery

Condition initially misdiagnosed in 22% (5 cases)

Endovascular repair

• Technical success 96%

Failure in 1 case with primary aorto-left renal vein fistula

• No 30-day mortality

• Mean ICU stay 2 days (0-9)

• Mean post-intervention in –hospital stay 9 days (2-24)

• 1 death to unrelated reasons in mean f-up 9 mths (7-24)

Endovascular repair

J Endovasc Ther 2009;16:514-23

Endovascular repairour own case

Endovascular repairour own case

Bifurcated Gore Excluder

No ICU stay

5 days in-hospital post-procedural stay

No morbidity

F-Up 24 mths: no procedure related

complications

Thanks for the attention

Documents

Endovascular treatment for aorto-enteric fistula and aorto ... · Aorto-enteric fistula Conventional surgical repair •Primary: Aortic ligation and extra-anatomic bypass •Secondary: