Aortic Paraprosthetic-colonic Fistulae: A Review of the Literature

Article Outline

• Abstract
• Background
• Literature Search
• Results of Literature Review
  • Incidence
  • Intestinal site of involvement
  • Indication for initial operation
  • Type of initial operation
  • Graft material for the initial operation
  • Time interval for diagnosis
  • Clinical presentation
  • Diagnosis
  • Treatment
  • Morbidity and mortality
• Conclusions
• References
• Copyright

Background

Aortic graft-colonic fistulae are a rare complication of aortic reconstructive surgery.

Methods and findings

A comprehensive review of this entity was performed based on the available literature from 1950 until 2006. Available reports were analyzed with respect to demographics, prior surgical intervention and its indication, prosthetic material used during the initial intervention, clinical presentation, the time interval in between the initial operation and symptoms, the method of treatment of the aortic graft-colonic fistula and its outcome.

Keywords: Aorto-enteric fistula, Aorto-colonic fistula, Aorto-intestinal fistula, Aortoenteric erosion, Paraprosthetic-enteric fistula, Paraprosthetic-colonic fistula

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Background 

Aortic graft-colonic fistulae are rare and dreaded complications of aortic surgery. We performed an exhaustive literature review of this entity.

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Literature Search 

A MEDLINE search was carried out in all languages. A manual search was also performed using bibliographies from relevant publications. Search terms included aorto-enteric/aorto-colonic/aorto-intestinal fistula or erosion, paraprosthetic-enteric/paraprosthetic-colonic fistula, aortic graft infection, septic aortitis, diagnosis, presentation and management. Cases including the caecum or appendix were excluded; only cases involving the ascending, transverse, descending, sigmoid and were included (Table 1).¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ³⁹, ⁴⁰, ⁴¹, ⁴², ⁴³, ⁴⁴, ⁴⁵ All studies identified were retrospective series or case reports. Data were analyzed for demographics, prior surgical intervention and indication, prosthetic material used during the first intervention, presentation and the time between the initial operation and development of symptoms or intervention, the treatment of the secondary aortoenteric fistula (SAEF), and outcomes (morbidity and mortality). Data were compared to the reported data concerning SAEFs involving all bowel segments, given that an analysis specifically of colonic SAEFs has not been previously performed.

Table 1. Aortic paraprosthetic-colonic fistulae¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³², ³³, ³⁴, ³⁵, ³⁶, ³⁷, ³⁸, ³⁹, ⁴⁰, ⁴¹, ⁴², ⁴³, ⁴⁴, ⁴⁵

Paper	Age	Sex	Number/total PEF number	Follow-up (months)	Prior surgery	Indication	Presentation/time between 1st surgery and PEF diagnosis (months)	Colon site involved	Treatment	Outcome
Ferris 19651	50	M	1/3	Unknown	Left ileofemoral bypass graft	Peripheral arterial disease	Left groin abscess/25	Sigmoid	Graft ligation; above-the-knee amputation; colostomy	Unknown
Beach 19662	69	M	1/1	0	Aortoiliac Dacron graft	Presumed symptomatic abdominal aortic aneurysm	Hematochezia, tender abdominal mass/2	Sigmoid	Graft removal; aortoiliac oversewing; proximal and distal colon stomas	Death four days postoperatively
Mannick 19683	62	M	1/1	15	Aortoiliac Dacron graft	Ruptured abdominal aortic aneurysm	GI bleeding/36	Sigmoid	Partial colectomy; omental vascular interposition; axillofemoral bypass+graft excision	Initial recovery; infected pseudoaneurysm 6 months postoperatively; bilateral limb thrombosis
Shucksmith 19684	64	M	1/2	0	Aortoiliac Dacron graft	Abdominal aortic aneurysm and aortocaval fistula	Right iliac fossa pain and blood in bowel movements/16	Sigmoid	Primary repair of colon and Dacron graft ligation	Death six days postoperatively
Dalinka 19765	47	F	1/1	Unknown	Aortofemoral bypass graft	Unknown	GI bleeding/1	Sigmoid	Graft revision	Did well
Thompson 19766	59	F	1/10	Unknown	Aortobifemoral graft	Peripheral arterial disease	Pain, left groin mass, sepsis/7	Sigmoid	Unknown	Unknown
Thompson 19777	Unknown	Unknown	1/2	Unknown	Aorticbifurcation graft	Unknown	Unknown/unknown	Sigmoid	Graft removal and axillofemoral bypass	Unknown
Kron 19798	83	M	1/1	16	Aortoiliac Dacron graft	Abdominal aortic aneurysm	Hematochezia, pulsatile abdominal mass/23	Sigmoid	Limb excision, sigmoid loop colostomy, femorofemoral crossover bypass graft	Did well
Bergkvist 19809	56	M	1/1	0	Aortoiliac Dacron graft	Peripheral arterial disease	Melena/60	Sigmoid	Sigmoid resection; transverse colon stoma; re-suturing of graft-iliac anastomosis	Death 18 days postoperatively (pulmonary embolism)
Cranston 198010	69	M	1/1	Unknown	Tube Dacron graft	Ruptured aortic aneurysm	Bleeding per rectum/60	Unknown	Primary repair of colon and proximal anastomosis	Did well
Criado 198111	53	M	1/4	0.3	Left aortoiliac Dacron bypass graft	Peripheral arterial disease	Left leg rash, swelling and pain, left lower quadrant pain, sweating/108	Sigmoid	Axillobifemoral bypass+ligation of proximal left common femoral artery; later needed near-total graft excision; infrarenal aorta, right common iliac and left external iliac arteries ligation; sigmoid resection+primary anastomosis	Did well
Dobbs 198212	66	M	1/1	0	Aortobifemoral graft	Peripheral arterial disease	Fever, hematochezia/10	Sigmoid	Sigmoid resection, graft limb excision	Unknown
Flye 198313	Unknown	Unknown	2/21	Unknown	Dacron bifurcation graft	Unknown	Unknown/unknown	Sigmoid×2	Excision of left graft limb in both; one needed a subsequent axillobifemoral and the other a femorofemoral bypass	Both survivors
Robbins 198414	Unknown	Unknown	1/14	Unknown	Unknown	Unknown	Unknown/unknown	Unknown	Unknown	Unknown
Reilly 198515	Unknown	Unknown	1/39	Unknown	Unknown	Unknown	Unknown/unknown	Unknown	Unknown	Unknown
Paaske 198516	56	M	1/9	72	Aortoiliac Dacron graft	Peripheral arterial disease	Unknown/31	Sigmoid	Resection of right prosthetic limb and external iliac artery	Did well (presumably)
Yeager 198517	73	M	1/8	0	End-to-end, aortoiliac	Unknown	GI hemorrhage/12	Unknown	Ax-fem-fem with total graft removal and colectomy	Died from sepsis, colon ischemia, renal failure
Bergkvist 198718	Unknown	Unknown	4/42	Unknown	Unknown	Unknown	Unknown/unknown	Sigmoid×3; 1 unknown	Unknown	Unknown
Bergkvist 198718	Unknown	Unknown	1/42	Unknown	Unknown	Aortic aneurysm	Abdominal pain, diarrhea, pulsatile abdominal mass/1.8	Sigmoid	Unknown	Unknown
D'Souza 198719	57	M	1/5	24	Thoracoabdominal Dacron aortoiliac graft	Aortic aneurysm	Massive GI bleeding+hypotension/24	Sigmoid	Excision infrarenal portion of graft and insertion of axillobifemoral graft; colostomy	Did well
Harris 198720	Unknown	Unknown	1/14	Unknown	Unknown	Unknown	Unknown/unknown	Sigmoid	Unknown	Unknown
Travis 198721	68	M	1/10	0	Aortoiliac Dacron graft	Unknown	Red blood per rectum/6	Sigmoid	Unknown	Intraoperative death
Vollmar 198722	Unknown	Unknown	1/11	Unknown	Unknown	Unknown	Unknown/unknown	Sigmoid	Unknown	Unknown
Demaerel 198823	68	M	1/1	Unknown	Aortofemoral Dacron graft	Peripheral arterial disease	Hematochezia, tenesmus, low back pain, diarrhea, vomiting, fever, chills/60	Sigmoid	Left axillofemoral bypass; graft removal; sigmoid resection	Discharged 2 weeks after procedure (presumably well)
Aarnio 198924	73	M	1/3	1.5	Aortobifemoral Dacron graft	Peripheral arterial disease	GI bleeding/156	Transverse	Graft removal; sigmoid resection+primary anastomosis	Death
Higgins 199025	Unknown	Unknown	1/15	Unknown	Unknown	Unknown	Unknown/unknown	Rectum	Unknown	Unknown
Wilcox 199026	66	F	1/1	0	Right aortoiliac Dacron graft	Peripheral arterial disease	Pseudomonas sepsis, hematochezia/144	Sigmoid	Primary repair of colon; graft removal; right ileofemoral bypass with vein	Unknown
Wilcox 199026	58	F	1/1	0	Aortoiliac Dacron graft	Abdominal aortic aneurysm	Fever, chills, left calf pain/48	Sigmoid	Primary repair of colon; graft removal; left axillo-iliac bypass+iliac-iliac crossover graft	Unknown
Peters 199127	74	M	1/1	Unknown	Aortoiliac Sauvage-velour graft	Abdominal aortic aneurysm	Pneumonia, E.coli sepsis, hematochezia/60	Sigmoid	Left prosthetic limb replaced by Dacron prosthesis	Did well
Barman 199228	62	M	1/1	24	Dacron graft	Abdominal aortic aneurysm	Left sided abdominal pain+hematochezia/12	Transverse	Axillary bifemoral bypass; colon resection+end-to-end anastomosis	Presumably did well
Peck 199229	Unknown	Unknown	1/25	Unknown	Unknown	Unknown	Unknown/unknown	Unknown	Unknown	Died from sepsis
Fernandez 199330	63	M	1/2	18	Left ileofemoral bypass	Peripheral arterial disease	Hematochezia/unknown	Sigmoid	Sigmoid resection+omentum coverage of prosthesis; had recurrent infection needing graft removal+left axillofemoral bypass	Left above-the-knee amputation
Li 199331	65	M	1/1	12	Right aortopopliteal and left aortofemoral bypass graft	Peripheral arterial disease	Fever, chills, hematochezia/5	Sigmoid	Left axillofemoral bypass; graft removal; sigmoid resection	Did well
Shindo 199332	69	M	1/1	6	Right aortofemoral bypass with Teflon graft	Peripheral arterial disease	Melena/324	Ascending	Left extra-anatomic bypass (Dacron),right femoral and left common iliac artery ligation, aortic stump suture with prevertebral ligament reinforcement+omental flap coverage; right colectomy. Also needed femoro-femoral crossover bypass 2 weeks after	Did well
Chan 199433	72	M	1/1	0	Aortobiiliac Dacron graft	Abdominal aortic aneurysm	Abdominal pain/108	Sigmoid	Exploratory laparotomy	Died in operating room
Floriani 199534*	65	M	1/1	9	Aortobifemoral graft	Peripheral arterial disease	Fever/156	Sigmoid	Exploratory laparotomy	Did well
Hamdani 199535	67	M	1/1	2	Aortobifemoral graft	Abdominal aortic aneurysm	Fever, chills, left leg swelling/120	Sigmoid	Hartmann's procedure, graft removal, axillobifemoral bypass	Did well
Kuestner 199536	Unknown	F	1/33	Unknown	Unknown	Unknown	Unknown/unknown	Sigmoid	Redo in-line aortic reconstruction	Death due to SAEF after redo in-line aortic reconstruction because of infection involving prosthetic axillofemoral graft
Novali 199637*	65	F	1/2	2	Aortobifemoral graft	Peripheral arterial disease	Cutaneous fistula/28	Sigmoid	Graft excision; sigmoid resection; aortobifemoral homograft. Later needed colostomy+replacement of iliac homograft with saphenous vein	Did well
Van Baalen 199638	Unknown	Unknown	1/31	Unknown	Unknown	Unknown	Unknown/unknown	Sigmoid	Unknown	Unknown
Davidovic 200139**	64	M	1/5	Unknown	Aortobiiliac bypass	Unknown	Fever, hematochezia, elevated sedimentation rate and white cell count/24	Sigmoid	Graft removal, colostomy, ascending aorta to femoral artery bypass graft	Unknown
Davidovic 200139**	65	M	1/5	Unknown	Aortobiiliac bypass	Unknown	Fever, melena, elevated sedimentation rate and white cell count/24	Transverse	Dacron axillobifemoral graft	Unknown
Blomberg 200440	80	M	1/1	Several	Unknown	Abdominal aortic aneurysm	Recurrent painless, hematochezia/60	Sigmoid	Graft oversewn, omental patch+subtotal colectomy+end-ileostomy	Did well; died from unrelated cause
Cendan 200441	Unknown	Unknown	2/20	Unknown	Unknown	Unknown	Unknown/unknown	Unknown×2	Resection+diverting end-colostomy	Unknown
Ramanujam 200442	83	M	1/4	0	Aortobiiliac Dacron graft	Abdominal aortic aneurysm	Hematochezia+lightheadedness/unknown	Sigmoid	Emergent endograft+2 stents placement	Death after endovascular treatment
Armstrong 200543	Unknown	Unknown	1/29	Unknown	Unknown	Unknown	Sepsis/unknown	Transverse	Resection and proximal diversion	Unknown
Perez 200544	62	M	1/1	6	Aortobiiliac Dacron graft	Aortoiliac aneurysm	Rectal bleeding+perirectal pain/192	Sigmoid	Hartmann's procedure, graft removal, aortic stump oversewing, axillobifemoral bypass	Did well
Leon 200645	58	M	1/1	2	Aortobifemoral Dacron graft	Peripheral arterial disease	Sepsis/3	Sigmoid	Femorofemoral crossover graft; left limb excision; sigmoid colon resection	Did well

*Italian language; ** Serbian language. F: female; GI: gastrointestinal; M: male; PEF: paraprosthetic-enteric fistula; SAEF: secondary aortoenteric fistula.

*A total of 53 cases (45 papers) of secondary aorto-colonic fistulae were identified. Two papers were written in Italian,³⁴, ³⁷ one in Serbian,³⁹ and the remainder in English.¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³², ³³, ³⁵, ³⁶, ³⁸, ⁴⁰, ⁴¹, ⁴², ⁴³, ⁴⁴, ⁴⁵ Twenty reports were single cases; the others included ≥2 cases of paraprosthetic-enteric fistulae (PEF). Most reports were published between 1980-1989 (16 papers).

Our gratitude to Dr. Rifat Latifi for translating the articles in foreign languages.

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Results of Literature Review 

Incidence 

Aortic reconstruction has been performed for aortoiliac occlusive or aneurysmal disease for >50 years, with excellent results in terms of patency, morbidity and mortality.⁴⁶, ⁴⁷ Kalman et al.⁴⁶ studied 94 patients after non-ruptured abdominal aortic aneurysm (AAA) repair with CT scans obtained 8 to 9 years after repair. Abnormal findings were frequent, but were mostly clinically insignificant (65% of patients had evidence of aneurysmal dilatation, but in only 14% was surgical repair a consideration). Hallett et al.⁴⁸ analyzed 307 AAA operations over 33 years for graft-related complications. At a mean follow-up of 6 years (range: <1 month-36 years), 9% of patients had a graft-related complication.

Gastrointestinal (GI) tract erosion by an adjacent vascular prosthesis is a rare complication of aortic reconstruction, known as SAEF. Cases of erosion of a native vessel and the bowel (without prosthesis) are classified as primary aortoenteric fistulae. Some have made a distinction between SAEF, which is a true fistulous tract from the proximal suture line to the bowel lumen, and a paraprosthetic enteric fistula (PEF), also known as prosthetic or aortoenteric erosion, which is a communication between the GI tract and the external prosthetic graft body surface without actual fistulization into the lumen.⁴⁹ Brock first described a case of SAEF to the duodenum that was identified 6 months after implantation of an aortic homograft.⁵⁰ In 1958, Mackenzie et al.⁵¹ successfully treated a patient with a SAEF after AAA homograft replacement.

The pathogenesis of colonic SAEF rather than small bowel involvement remains speculative.⁴³ Erosion into the adjacent colon is thought to result from pressure necrosis due to constant graft pulsation eventuating in graft body erosion into the bowel.⁵² This may be facilitated by the lack of interposed tissue or excessive pulsation of redundantly placed⁴³ or kinked⁵³ grafts. Indolent graft infections⁴³, ⁵⁴ may promote inflammatory adherence and subsequent erosion into the bowel wall. Additionally, retroperitoneal infectious processes (i.e. diverticular abscess or pancreatic pseudocysts) may predispose to graft erosion into the bowel wall. Our review identified colonic involvement almost exclusively after aortic reconstructions using bifurcated prosthetic grafts and rarely after the use of tube grafts.

The incidence of SAEF involving any enteric segment ranges from 0.4–1.6%;⁴, ³⁶ the overwhelming majority involve the 3^rd and 4^th portions of the duodenum. Kalman et al.⁴⁶ noted that bowel was found to be intimately associated with the prosthetic graft in 7% (which did not imply a true fistulous connection). Hallett et al.⁴⁸ identified graft-enteric erosion/fistula in 1.6% of cases after AAA repair, with a median follow-up of 4.3 years. With regard to colonic involvement, Bergqvist⁵⁵ analyzed 631 cases of SAEFs, reporting sigmoid involvement in 2.4% of cases and appendix-colon (colon site not further specified) involvement in 4.2%. We were unable to precisely define the prevalence of SAEFs involving the colon given the paucity of large series and the multitude of case reports. We identified 53 colonic PEF cases (12.3%) among 430 reported PEFs involving all bowel segments. Affected patients tended to be elderly (mean age=65 years; range 47–83; age unknown in 19 cases) with strong male gender predilection (4.8:1; unknown in 18 cases), reflecting the patient population undergoing open aortic reconstruction.

Intestinal site of involvement 

The most frequent site of SAEF is the duodenum,⁵¹ related to its proximity to the infrarenal aorta. Other segments⁵⁶, ⁵⁷, ⁵⁸ have been infrequently reported. Aorto-colonic erosions are especially uncommon. O'Mara and Imbembo⁵¹ only identified 1/21 patients with sigmoid involvement in their SAEF review. Among cases of colonic SAEF in our review, 3/4 cases involved the sigmoid (39/53; 73.6%); the transverse colon was involved in 4 cases (7.6%), whereas the ascending colon and a rectal stump were involved in one instance each (1.9% each). The site of involvement was not reported in 8 cases (15.1%).

Indication for initial operation 

The initial indication for aortic reconstruction was equally divided between occlusive and aneurysmal disease with 15 cases each (11 intact and 4 ruptures; one of the 4 ruptured cases was associated with an aortocaval fistula⁴). Several papers have reported that SAEF are more likely to occur after surgery for ruptured AAA than for elective AAA,⁴⁴, ⁵⁹, ⁶⁰ and almost insignificant when the graft is placed for aortoiliac occlusive disease.¹⁷ This statement seems to arise from observations made by Elliott et al.,⁶⁰ based on their reported series of 17 PEF cases, 14 of which developed after AAA repair. This assertion has not been universally confirmed. Although Armstrong et al.⁴³ concurred with Elliott's observations (identifying as the indication for aortic reconstruction an aneurysm in 72% of their patients (21) with SAEFs, and aortoiliac occlusive disease in 28%). Vollmar and Kogel²² found a higher incidence of SAEFs after reconstruction for occlusive disease (1.1% vs. 0.2% for aneurysms). Six of Vollmar's initial procedures for aneurysms were performed for rupture AAA, while 15 were elective. Kuestner et al.³⁶ noted that >50% of the patients with SAEF in their series had occlusive disease as the indication for the original operation. O'Mara⁵¹ found that among 21 cases of PEF, AAA had been the indication in 14 (6 ruptured and 8 elective) and the remaining 7 followed therapy for aortoiliac occlusive disease. Our review of aorto-colonic fistulae identified an equal proportion of cases recognized after operations for occlusive disease and AAA.

Type of initial operation 

In 17 cases, the type of surgery was not cited (an additional 4 cases had an imprecise description of the procedure). Precise proximal and distal anastomotic sites were not generally stated. We were able to infer that the procedure most commonly performed was an aortoiliac graft in 17 cases (unilateral aortoiliac in 12, aortobiiliac in 5), followed by aortofemoral grafts in 11 cases (aortobifemoral in 7; unilateral aortofemoral in 4). Other operations reported included left iliofemoral (2), thoracoabdominal-iliac (1) and aorto-popliteal (1) bypass grafts. An association between the specific types of aortic reconstruction and the subsequent development of a SAEF has not been previously reported. In the series collected by Armstrong et al.⁴³ an aortobifemoral bypass configuration was most commonly noted (n=19), with aortobiiliac (n=7) and aortic tube grafts (n=3) less frequently reported.

Several reports have related their experience with alternative surgical reconstructive techniques. A 10-year experience with 831 patients (761 elective, 70 urgent) undergoing the retroperitoneal exclusion technique to treat infrarenal AAA was reviewed.⁶¹ During follow-up (5–103 months), no cases of graft infection or SAEF were identified in patients reconstructed by this approach. Connolly et al.⁶² suggested that the use of paramedian retroperitoneal incisions for aortic reconstructions provides an intact peritoneum and retroperitoneal fat tissue layer to protect the graft from the viscera. They also preferred an end-to-end over end-to-side anastomosis in aortobifemoral bypasses, in order to allow placement of prosthetic cuff slid over the proximal anastomosis to cover the suture line. The latter technique is controversial.

Graft material for the initial operation 

In the report of Armstrong et al.⁴³ most repairs had been performed using Dacron grafts (n=27) except two cases with polytetrafluoroethylene (PTFE) conduits. Our review identified Dacron as the most frequent material used, with only one report involving PTFE.³² This reflects the preference for the use of Dacron for inflow arterial reconstructions. Dacron is thought to promote a foreign body reaction to adjacent bowel and eventually erode into it.⁶³ Suture material has also been related to SAEFs. Silk sutures, historically used for arterial-graft anastomosis, degenerate over time, resulting in primary suture failure with pseudoaneurysm formation and eventual SAEF.¹⁰, ⁶⁴ Permanent synthetic sutures have reduced the incidence of suture line failure.

Time interval for diagnosis 

SAEF tends to present late. This information was available for 33 cases. The mean interval between the initial operation and symptom development was 59.5 months (range: 1–324). This is in agreement with prior reports, the average being approximately 72 months.⁶⁵, ⁶⁶ Kuestner et al.³⁶ reported a mean interval between placement of the original aortic graft and definitive treatment of SAEF of 73.2±49.2 months. O'Mara and Imbembo reported an average of 22 months (range: 1–84).⁵¹ Vollmar and Kogel²² published similar results in their series of 11 SAEFs (1–73 months; mean 34).

Clinical presentation 

The most frequent presenting sign of SAEF is massive upper GI bleeding. SAEF should always be suspected in a patient after aortic prosthetic reconstruction who presents with GI hemorrhage. In colonic PEF cases, massive bleeding is not seen as often given that there is no true communication between the prosthesis lumen and the bowel. Therefore, absence of GI bleeding does not rule out the presence of PEF. Other reported presentations include sepsis, malaise, weight loss and other non-specific symptoms.⁵⁴ Our review indicates that GI bleeding is the most prevalent presentation (in 24 instances: melena [3], hematochezia [15] and non-specified GI bleed [6]), but it was not frequently massive. When seen, bleeding is often the result of exposed bowel mucosa surrounding the eroding prosthetic limb.⁵¹

Sepsis has been previously reported as a relatively infrequent presentation.⁶⁷, ⁶⁸ However, we noted that sepsis was the 2^nd most commonly reported presentation in patients with SAEF (n=14). O'Mara and Imbembo⁵¹ noted that 14/21 of patients with PEFs present with sepsis, regardless of the involved bowel segment. At the same time, overt GI bleeding as the presenting symptom occurred in 19% (4/21) and abdominal pain in 14%. Rosenthal et al.⁶⁷ suggested that whenever patients present with a history of aortic reconstruction and fever, aerobic and anaerobic blood cultures are indicated. If these are positive for enteric organisms, the diagnosis of SAEF should be strongly suspected. Clostridial graft infection also has been rarely reported.⁴⁵, ⁶⁹

The most frequent symptoms and signs reported in our series include abdominal pain (6), leg pain or edema (4), chills (4), abdominal mass (3) and diarrhea (2). A high index of suspicion is essential for diagnosis, since there is a substantial subset of patients with nonspecific clinical findings in whom routine studies are not diagnostic. This is especially true for colonic as opposed to duodenal PEF.

Diagnosis 

Following development of signs and symptoms, SAEF diagnosis is typically delayed, by as long as 1 month in 50% of patients in one report, with the diagnosis being made within 10 days of hospitalization in only 15% of cases.⁶⁵ Diagnostic studies include plain radiography,⁷⁰ computed tomography scan (CT),²⁷, ⁷¹, ⁷² barium GI series,⁶, ¹³, ⁵¹ endoscopy,³⁵ 18-fluorodeoxyglucose positron emission tomography,⁷³ gallium 67 scanning⁶², ⁷⁴ and angiography.⁶, ⁵¹ However, it is not unusual for these studies to be negative or equivocal and for the diagnosis to be established only at surgical exploration.

CT findings are frequently of great diagnostic utility. Perigraft fluid, soft tissue⁷² or gas (“black dots”),⁷¹ contrast extravasation,⁷⁵ peri-prosthetic inflammatory tissue in contact with adjacent bowel,²³, ²⁷ bowel thickening, pseudoaneurysms,⁷² aneurysmal wrap disruption,⁷² or intraluminal gas within the graft >3 months after graft implantation are suggestive findings.⁷¹

Tagged white cell scans have excellent sensitivity but low specificity for diagnosis.⁵⁴ However, when applied by experienced personnel, they can be very useful in the early diagnosis of PEF, as shown by Causey et al.⁷⁴ These techniques are not definitive, but provide useful supportive information when other findings are inconclusive.

Whereas upper endoscopy is very helpful in both visualizing a possible SAEF and excluding other causes of GI bleeding, the benefits of colonoscopy have been infrequently reported. Nevertheless, lower endoscopy was the definitive diagnostic study of SAEF in a patient we recently reported (Fig. 1).⁴⁵ Malaki et al.⁷⁶ visualized the limb of an aortobifemoral graft within the patient's cecum following an inflammatory AAA repair. Hamdani and Summers³⁵ diagnosed a PEF involving the limb of an aortobifemoral graft and the sigmoid in a patient 10 years after an open AAA repair.

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• Fig. 1 

  Colonoscopy finding in a 58 year-old male patient who presented to our institution with a history of aortobifemoral graft performed two years prior due to critical limb ischemia. Computed tomography and a white blood cell scan performed previously suggested the presence of an aortic paraprosthetic-colonic fistula. The Figure shows the left limb of the graft within the colonic lumen, which undoubtedly established the diagnosis.

Interestingly, even with surgical exploration, the relationship between the graft and the intestinal site involved in some cases cannot be established. Bergqvist et al.¹⁸ reported four such cases where the graft was lying in a pool of pus and the site of GI involvement could not be precisely identified. Interestingly, in about 7% of cases, more than one fistula in the same patient was identified.¹⁸

Treatment 

The mortality rate for surgical treatment of SAEFs ranges from 14% to 70%.⁷⁷ The choice of surgical repair remains controversial. Multiple approaches have been described,⁵¹ including non-operative management,⁵⁰, ⁷⁸ graft excision alone, local repair with the original prosthetic left in-situ or graft excision with in-situ replacement using a new prosthesis with or without antibiotic-bonding. Reported outcomes using these approaches are variable. More aggressive strategies, with enteric excision and GI tract restoration, prosthesis removal, infrarenal aortic stump closure and immediate extra-anatomic axillobifemoral bypass (EAB) have also been described. The latter approach has been the most traditional recommendation. SAEF is associated with a high operative mortality (about 52%) and significant morbidity (e.g. recurrent infection; aortic stump blowout). Graft excision and EAB either as a single or staged procedure is still the most commonly used treatment for SAEF.⁷⁹

In situ reconstruction has recently been utilized with increasing frequency using deep⁸⁰ or superficial⁸¹ veins, rifampin-bonded Dacron grafts⁸² or cryopreserved arterial⁸³ or venous allografts.⁸⁴ Endovascular techniques to repair SAEFs in high-risk patients⁸⁵ have been used as a bridge to more definitive therapy after hemodynamic stabilization.⁸⁶

Other approaches have been individually considered. For instance, GI defect closure, partial excision and replacement of the inserted vascular prosthesis, an encircling omental sleeve covering the prosthesis and anastomoses has been used.²² A seromuscular jejunal patch for securing closure of the proximal aortic stump after removal of prosthetic grafts has also been suggested.⁸⁷ D'Souza et al.¹⁹ have recommended stapling the bowel loops involved in the SAEF with a GIA device in cases of massive bleeding. This is done to tamponade the bleeding, allowing time to dissect the graft and to clamp the infrarenal aorta. They also recommended this technique for cases of undiagnosed GI bleeding in a hospital with no vascular units, in order to stabilize the patient for transfer to a tertiary center.

The technique for GI tract reconstruction differs in cases of colonic compared to duodenal or jejunal involvement. For the latter, either a lateral bowel repair¹⁰ or resection and end-to-end anastomosis of grossly normal bowel usually suffices, given the lower virulence of the bacteria populating the upper GI tract compared with the lower. The bowel can be hand sewn, or anastomosed end-to-end with an EEA stapler or side-to-side with a GIA stapler.¹⁹ Duodenal exclusion is not generally needed, and is reserved for cases of extensive tissue loss.⁴¹ Proximal bowel decompression by a gastrostomy has also been recommended.¹³ A route for nutrition, such as a feeding jejunostomy is also important.¹³, ⁴¹

Colonic defects are managed differently. They can be repaired with either direct closure, or resection with either primary anastomosis or stoma creation. During surgical exploration, it is crucial to fully mobilize the bowel; despite a normal appearing anterior bowel wall, a posterior wall erosion could be missed.¹¹, ¹³ Resection should be performed back to grossly normal colon.¹³ In general, primary colonic anastomosis is not advised, although successful outcomes have been also reported with its use.²⁸ If severe contamination is noted at exploration, or if the patient is malnourished or acutely ill, a temporary colostomy is preferred.⁴¹ Colostomies in the sigmoid (Hartmann's procedure) or transverse colon are thought to allow immediate fistula control with minimal intraperitoneal contamination. The colostomy site should be placed away from the axillofemoral graft and can be left closed, to be opened postoperatively to avoid further intraoperative contamination.⁸ Omental interposition is universally advocated.¹⁹, ³⁰, ⁴⁴ Finally, bowel repairs are assessed by some with contrast studies prior to restarting oral intake.⁴³

SAEFs tax the ingenuity of vascular surgeons. Our review showed a wide variety of therapies, including intestinal stomas or primary colonic repair; graft removal with extra-anatomic bypass for revascularization or graft revision (the latter by replacing the involved graft with homograft or with a new prosthetic graft, aided by omental interposition, re-suturing of a previously involved anastomosis, or endovascular placement of a stent-graft). The wide variety of approaches and the small number of patients treated are not sufficient to provide evidence-based recommendations.

Morbidity and mortality 

Most reports failed to cite follow-up periods (28 papers). For those studies that did so, the time span was very wide (0–72 months; average 8.4). All but three investigators documented follow-up periods of <2 years. The short-term outcomes in patients with aorto-colonic fistulae were generally favorable (22). In 19 cases the outcome was unknown. Ten patients died of a cause directly related to the SAEF or to its therapy. One patient was reported dead from unrelated causes (not specified). Complications reported after treatment of a PEF include pulmonary embolism, infected pseudoaneurysm, bilateral graft limb thrombosis, above-the-knee amputations, recurrent infection, limb or colon ischemia and renal failure.

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Conclusions 

SAEF involving the colon is a rare but well-known complication of aortic reconstructive surgery. It is a dreaded one, associated with high morbidity and mortality. High clinical suspicion and prompt therapy are essential in the management of these patients to avoid catastrophic consequences due to a delayed recognition of a highly treatable condition.

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