Aortoenteric Fistulas Following Endovascular Aortic Aneurysm Repair (EVAR): A Rare and potential Lethal Complication
Georgios Spentzouris, MD1, George Hines, MD2, Reese Wain, MD3.
1Stony Brook University Hospital, Stony Brook, NY, USA, 2Winthrop University Hospital, Mineola, NY, USA, 3Winthrop University Hospital, MIneola, NY, USA.
Aortoenteric Fistulas Following Endovascular Aortic Aneurysm Repair (EVAR): A Rare and Potentially Lethal Complication
Objective: To describe the incidence, treatment and outcomes of patients found to have aortoenteric fistula(AEF) following EVAR in a community hospital setting.
Methods: A retrospective review of all patients undergoing EVAR over a 4-year interval (2013-2016) was undertaken.
Results: Three (3.8%) of 88 patients who underwent EVAR for abdominal aortic aneurysm (AAA) repair were diagnosed with AEF during follow-up. At initial EVAR, two patients were asymptomatic and the third presented as a rupture. The average aneurysm sac size was 6.9cm (6.0-8.0cm). Two patients had a Medtronic Endurant stent graft implanted, and one patient had a Gore Excluder device. The mean time between EVAR and AEF diagnosis was 16.7 months (5-39 months). All patients presented with back pain and fevers, and one patient ruptured. CT demonstrated air around the endovascular graft in all cases (figure 1). All patients were found to have fistulas between the native aneurysm sac and the sigmoid colon. The ruptured aneurysm case underwent emergent stent graft explantation with axillo-bifemoral bypass, and survived. The two other patients were treated semi-electively. One patient underwent graft explantation with extra-anatomic bypass, and subsequently died after discharge to rehabilitation from sepsis and gastrointestinal bleed. The other patient was treated conservatively with antibiotics and percutaneous drainage, and survived. The two patients who underwent graft explantation were found to have gross purulence within the aneurysm sac; one required primary repair of the sigmoid colon, and the other sigmoid resection with colostomy. Excision of the infected aneurysm sac was also performed after infrarenal aortic ligation in both cases.
Conclusions: Aortoenteric fistulas following EVAR for AAA are uncommon and fistulization to the sigmoid colon is rarely reported. AEFs can cause significant patient morbidity or death. This experience highlights the importance of ongoing long term surveillance of endografts not only to diagnose endoleaks, monitor sac size and conformational changes, but to assess for evidence of early graft infection and AEF as well.
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