Interact CardioVasc Thorac Surg 2008;7:121-125. doi:10.1510/icvts.2007.162982
© 2008 European Association of Cardio-Thoracic Surgery
ESCVS article - Aortic and aneurysmal |
Complications of open abdominal aortic surgery: the endovascular solution
Karim El Sakka*,
Mustafa Halawa,
Carl Kotze,
Ian Francis,
Tim Doyle and
Waquar Yusuf
Department of Vascular and Endovascular Surgery, Brighton and Sussex University Hospital, UK
Received 17 July 2007;
received in revised form 1 September 2007;
accepted 3 September 2007
 Presented at the 56th International Congress of the European Society for Cardiovascular Surgery, Venice, Italy, May 17–20, 2007.
*Corresponding author. Flat 18 Stonehaven, 37 Wickham Road, Beckenham, Kent, BR3 6LZ, UK. Tel.: +44 786 7502508; fax: +44 208 6509622.
E-mail address: elsakka{at}doctors.org.uk (K. El Sakka).
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Abstract
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Objective: Aorto-enteric fistulas (AEFs) and para-anastomotic aneurysms (PAAs) are uncommon complications of open aortic surgery (0.5–2.5%) and (0.2–15%), respectively. AEF if untreated is often fatal and surgical management is associated with mortality up to 90%. The risk of PAA rupture carries a mortality of 58%. We present our experience in ten patients with the endovascular treatment of these complications to define the role of endovascular repair in this high-risk group. Methods: This is a retrospective review of patients presenting acutely with complications of open aortic surgery. From January 2003 to March 2006, ten patients, all males with a mean age of 73 years presented through the Accident and Emergency department and were assessed with contrast enhanced CT. Five patients presented with secondary AEFs. Three patients with PAAs. Another patient presented with a secondary mycotic aneurysm of the thoracic aorta following open repair of abdominal aortic aneurysm and finally a patient with a femoral pseudoaneurysm. The mean time from the original procedure to presentation was 50 months. All patients were offered endovascular management after stabilisation as they were deemed as high-risk surgical patients. Results: No intra-procedural complications were recorded. The in-hospital 30-day mortality was 1 (10%) patient due to multiple organ failure. One patient died six months later due to an unrelated event. The average in-hospital stay was 5.4 days; median follow-up period was 28 months. All patients were repeatedly admitted after discharge due to septic episodes for which they received IV antibiotics. Repeated cultures for all patients were only positive on four occasions. Conclusion: Endovascular stent-graft repair of AEF and PAAs is a viable alternative to open surgery. It is likely to be associated with less mortality and morbidity and in-hospital stay. It should be considered as an alternative in high-risk patients. Persistence of the infection remains a problem, however, in our experience; it can be well controlled through long-term antibiotics.
Key Words: Endovascular; Aortic; Aneurysm; Complications
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1. Introduction
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Despite numerous strategies for surgical treatment, AEFs remain a catastrophic complication with a high morbidity and mortality. The more common secondary AEFs are caused by aortic prosthesis erosion into the duodenum with an incidence of 0.5–2.5% of aortic prosthetic graft repairs. Time to formation of an AEF after initial aortic surgery is variable (range, 2 weeks to over 10 years) [1].
Conventional treatment of an AEF consists of extra-anatomic bypass grafting, aortic ligation, and, for a secondary AEF, subsequent graft removal. This technique is associated with a 25–90% operative mortality rate [2], an amputation rate of 5–25% [3] and an aortic stump rupture rate of 10–50% [4]. In-situ aortic reconstruction has been proposed as a less-morbid alternative to ligation and bypass grafting. However, the average peri-operative mortality rate for in-situ reconstruction is reported to be 27–30% [5].
With advances in the field of interventional radiology, there have been increasing reports of patients with AEFs managed successfully with various per-cutaneous techniques when medical co-morbidities prohibit surgical repair. In addition to temporizing the acute bleeding before definitive therapy as described, the sole management of these patients by aortic endografts has been previously described [6–9].
Para-anastomotic aneurysms are another complication of open aortic surgery. True aneurysms in the para-anastomotic region have been reported to occur more frequently after treatment of aneurysmal disease, however, para-anastomotic aneurysms following reconstruction in post-occlusive disease are believed to be more often false aneurysms [10].
The incidence of para-anstomotic aneurysms after aortic reconstruction ranges from 0.2 to 15%. An incidence of at least 10% was suggested after routine ultra-sound scanning in one series of 100 patients after aortic reconstruction [8].
Para-anastomotic aneurysms may go on to expand and rupture. The mortality rate associated with attempted repair of ruptured para-anastomotic aneurysms varies from 67 to 100% [11].
In this paper, the authors are presenting their experience in the endovascular treatment of ten consecutive patients presenting with complications of open aortic surgery. Five patients presenting with secondary aorto-enteric fistula, four patients with para-anastomotic aneurysms and one patient with a thoracic aneurysm following open repair of AAA.
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2. Patients and methods
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During the period from January 2003 up to March 2006, ten patients with complications of open aortic surgery presented to our department. All patients were males with a median age of 73 years (range 67–80 years). Median time from the original procedure to presentation was 48 months (range 5–168 months). The mode of presentation was mainly bleeding per rectum in the AEFs and with an abdominal pulsating swelling in the PAAs. All patients were categorized as a grade 4 or 5 ASA according to the American Society of Anesthesiologists classification and were considered unfit for any form of open surgical intervention (Table 1).
Out of the ten patients, nine had their original open procedure performed in our institution. The aortic grafts used in the original procedure, three grafts were bifurcated and the rest were straight tube grafts.
CT-scan was the primary modality for investigation and was performed for all patients. Other investigations included routine blood investigations, electrocardiography. Blood cultures were taken from all patients. All patients were suitable anatomically for endovascular exclusion of their pathology and were offered and consented for this treatment modality.
All procedures were performed in the operating suite under general anaesthesia through bilateral femoral artery exposure. Zenith Cook® (Zenith, Cook, Bjaerskov, Denmark) graft was used in eight patients and a Gore Excluder® (W.L. Gore and Associates, Flagstaff, AZ) in one patient. Another patient with the femoral pseudo-aneurysm had a Haemobahn stent (W.L. Gore and Associates, Flagstaff, AZ) (Table 2).
Follow-up was arranged using CT-scan prior to discharge and then at 3, 6, 12 months and then yearly thereafter. All patients were discharged on oral antibiotic combinations of co amoxiclav-clavulanic acid and ciprofloxacin according to the advice of the microbiologist based on the most common pathogens isolated as well as according to the literature.
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3. Results
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No intra-procedural complications were recorded, all aneurysms were successfully excluded (Fig. 2). All patients were successfully extubated and admitted to the high dependency unit for 24 h.
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Fig. 2. Two years after endovascular repair of a recurrent aorto-enteric fistula. The graft remains exposed to bowel. This results in recurrent bouts of fever with rigors that respond to antibiotics. However, there has been no further bleeding.
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The 30-day mortality was one patient (10%) that died of multiorgan failure in the intensive care unit. This patient presented with bleeding per rectum due to an aorto-enteric fistula. Co-morbidities included, decompensated heart failure, atrial fibrillation and kidney failure.
One-year mortality included another patient that died six months after discharge due to an unrelated cause as he sustained a fall that resulted in vertebral fractures and paralysis and died in hospital due to pneumonia. The average in-hospital stay was 5.4 days.
Median follow-up period was 28 months (range 6–51 months). All patients in the aorto-enteric fistula were repeatedly admitted with attacks of bacteraemia in the form of spiking fever, rigors and malaise. The average frequency of these attacks was one attack every six months. All blood cultures taken at the time of admission were negative except one positive culture of candida. All patients received intra-venous antibiotics (Timentin and Vancomycin) during admission for a minimum of 48 h. Symptoms usually resolved within 24 h from commencing treatment.
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4. Discussion
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Secondary aorto-enteric fistulas and para-anstomotic aneurysms are rare, however, grave complications of open abdominal aortic surgery. The open surgical intervention in these situations is associated with a very high mortality and morbidity.
A series of ten consecutive patients with these complications were treated by endovascular repair in our institution over a period of two years. The overall results were considered satisfactory with one peri-operative mortality (1/10).
4.1. Technical consideration
The use of stent-graft in these patients relies on the presence of an aortic cuff between the renal arteries and the suture line but also complicates the management by adding more foreign material. This is present in most but not all cases. It is not possible to delineate the suture line on CT-scan. Even in the presence of a false aneurysm, the site of communication cannot be accurately defined. The Dacron graft dilates quite significantly within months of implantation. It is therefore possible to guess the distance from the lower renal artery to the beginning of the graft. However, in late cases the native infra-renal aorta may also be markedly dilated and this distinction between the neck and graft may be lost. In most cases, the site of fistula is between the proximal suture line and the duodenum. However, one must remain open to the possibility of communication directly through the graft material or distal suture line. In one series the proximal anastomosis of the prior vascular repair was the site of AEF origin in 62% of cases, the distal anastomosis accounted for 19% and the body of the graft for 14% [12]. It is therefore our practice to use a bifurcated graft that excludes the entire graft from renal artery to iliac arteries.
4.2. Selection of stent-graft
Any commercial stent-graft could be used. The authors prefer the Zenith Tri-Fab (Cook Europe) graft, with supra-renal fixation. The top cap that keeps the supra-renal uncovered stent retrained even after the release of the rest of the graft allows precise positioning of the covered stent immediately below the renal artery. The old Dacron graft usually dilates by more than 50% and a wide stent-graft, over 30 mm in diameter, is usually required. The presence of a short body in a bifurcated graft may pose another problem (Fig. 1). Most commercial grafts have a body length of at least 70 mm in length and careful measurement is required. The proximal extension cuffs that are available with commercial grafts may be useful in such a situation. The use of supra-renal fixation makes subsequent removal very difficult. If the removal of such a graft is attempted the aorta will need to be clamped high or a balloon used to gain control. The covered section of the graft can be excised by dividing the sutures that articulate it to the bare supra-renal stent and the bare stent is left behind as it is firmly attached to the aorta with the barbs.
It is important to position the stent-graft immediately at the lower edge of the origin of the renal artery. The cuff may be short and the entire available neck length needs to be utilized for a reasonable overlap and seal with the stent-graft.
The aortic neck too dilates with time and in some cases there may not be a 10–15 mm cuff available to achieve a seal. In such a case a fenestrated graft could be used or a renal sacrificed if it is at a lower level. The authors have no experience of use of a fenestrated graft in the management of aorto-enteric fistula. The time required in planning and manufacturing of such a made-to-measure graft precludes its use in these urgent cases.
All patients were discharged on long-term combinations of oral antibiotics mainly a combination of augmentin and ciprofloxacin. The antibiotics were empirically prescribed in agreement and upon the advice of the microbiology department in our institution. These advices were aimed at the most common organisms isolated whether in our laboratories or upon information derived from published literature [13–15].
All patients with secondary aortic fistulas were re-admitted to hospital for a number of times with septic episodes in the form of spiking fever, rigors and general malaise. CT-scans performed revealed the endografts on some occasions directly exposed to bowel, however, there was no further attacks of bleeding (Fig. 2). All patients received IV antibiotics and were subsequently discharged. No organisms were isolated from the blood cultures taken in any of these occasions.
To our knowledge, this experience is the largest single UK series published to date.
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5. Conclusion
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Endovascular treatment is one modality in the management of aorto-enteric fistula, which should be studied, especially in terms of controlling acute haemorrhage and the care of patients deemed high-risk for open surgical intervention. Recurrent infection may remain a problem and patients treated with this modality will require long-term antibiotics. The outcome of this approach over time will have to be evaluated.
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References
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Abstract
1. Introduction
