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Aortic Paraprosthetic-colonic Fistulae: A Review of the Literature

  • L.R. Leon Jr.
    Correspondence
    Corresponding author. L. R. Leon Jr., MD, RVT, SAVAHCS – Department of Vascular Surgery, Chief AHSC – Assistant Professor of Clinical Surgery, 3601 South 6th Avenue. Vascular Surgery Section Room N259, Tucson, AZ 85723, USA.
    Affiliations
    Southern Arizona Veteran Affairs Health Care System (SAVAHCS) – Vascular Surgery Section, Tucson, Arizona, USA

    University of Arizona Health Science Center (AHSC) – Division of Vascular Surgery, Tucson, Arizona, USA
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  • J.L. Mills Sr.
    Affiliations
    Southern Arizona Veteran Affairs Health Care System (SAVAHCS) – Vascular Surgery Section, Tucson, Arizona, USA

    University of Arizona Health Science Center (AHSC) – Division of Vascular Surgery, Tucson, Arizona, USA
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  • S.B. Psalms
    Affiliations
    Southern Arizona Veteran Affairs Health Care System (SAVAHCS) – Vascular Surgery Section, Tucson, Arizona, USA
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  • J. Kasher
    Affiliations
    Southern Arizona Veteran Affairs Health Care System (SAVAHCS) – Gastroenterology Section, Tucson, Arizona, USA
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  • J. Kim
    Affiliations
    Southern Arizona Veteran Affairs Health Care System (SAVAHCS) – Gastroenterology Section, Tucson, Arizona, USA
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  • D.M. Ihnat
    Affiliations
    Southern Arizona Veteran Affairs Health Care System (SAVAHCS) – Vascular Surgery Section, Tucson, Arizona, USA

    University of Arizona Health Science Center (AHSC) – Division of Vascular Surgery, Tucson, Arizona, USA
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Open ArchivePublished:August 23, 2007DOI:https://doi.org/10.1016/j.ejvs.2007.07.003

      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

      Background

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

      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).
      • Ferris E.J.
      • Szego Koltay M.R.
      • Koltay O.P.
      • Sciammas F.D.
      Abdominal aortic and iliac graft fistulae.
      • Beach P.M.
      • Risley T.S.
      Aorticosigmoid fistulization following aortic resection.
      • Mannick J.A.
      • Nabseth D.C.
      Axillofemoral bypass graft. A safe alternative to aortoiliac reconstruction.
      • Shucksmith H.S.
      Duodenal, sigmoid, and ureteric fistulas resulting from aorto-iliac grafts or endarterectomy.
      • Dalinka M.K.
      • Gohel V.K.
      • Schaffer B.
      • Hernberg J.
      Gastrointestinal complications of aortic bypass surgery.
      • Thompson W.M.
      • Jackson D.C.
      • Johnsrude I.S.
      Aortoenteric and paraprosthetic-enteric fistulas: radiologic findings.
      • Thompson W.M.
      • Johnsrude I.S.
      • Jackson D.C.
      • Older R.A.
      • Wechsler A.S.
      Late complications of abdominal aortic reconstructive surgery: roentgen evaluation.
      • Kron I.L.
      • Dillihunt R.C.
      Arterial sigmoid fistula: treatment by fistula exclusion without graft excision.
      • Bergkvist L.
      • Aberg C.
      Fistula between false aneurysm in the left iliac artery and the sigmoid. Case report.
      • Cranston D.
      • Vowles K.D.
      Aorto-duodenal and subsequent aorto-colonic fistula following operation for ruptured aortic aneurysm.
      • Criado F.J.
      • Classen J.N.
      • Wilson Jr., T.H.
      Secondary aorto-enteric fistulas: prosthetic and paraprosthetic.
      • Dobbs S.M.
      • Jordan P.H.
      • Cain G.D.
      • Schwartz J.T.
      • Graham D.Y.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      • Robbins J.A.
      • Ashmore J.D.
      Aortoenteric fistula: diagnosis and management.
      • Reilly L.M.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Gastrointestinal tract involvement by prosthetic graft infection. The significance of gastrointestinal hemorrhage.
      • Paaske W.P.
      • Hansen H.J.
      Graft-enteric fistulas and erosions.
      • Yeager R.A.
      • McConnell D.B.
      • Sasaki T.M.
      • Vetto R.M.
      Aortic and peripheral prosthetic graft infection: differential management and causes of mortality.
      • Bergqvist D.
      • Alm A.
      • Claes G.
      • Drott C.
      • Forsberg O.
      • Larsson M.
      • et al.
      Secondary aortoenteric fistulas–an analysis of 42 cases.
      • D'Souza C.R.
      • Hebert R.J.
      • Trautman A.F.
      • Kilam S.
      Aortoenteric fistula: case review and a new surgical technique.
      • Harris J.P.
      • Sheil A.G.
      • Stephen M.S.
      • Storey D.W.
      • May J.
      Lessons learnt in the management of aortoenteric fistulae.
      • Travis R.C.
      • Wattie W.J.
      Aorto-enteric fistula.
      • Vollmar J.F.
      • Kogel H.
      Aorto-enteric fistulas as postoperative complication.
      • Demaerel P.
      • Wilms G.
      • Suy R.
      • Nevelsteen A.
      • Penninckx F.
      • Baert A.L.
      Computed tomography in paraprosthetic sigmoid fistula.
      • Aarnio P.
      • Hannukainen J.
      Aortic graft–enteric fistula.
      • Higgins R.S.
      • Steed D.L.
      • Julian T.B.
      • Makaroun M.S.
      • Peitzman A.B.
      • Webster M.W.
      The management of aortoenteric and paraprosthetic fistulae.
      • Wilcox C.M.
      • Ostroff J.W.
      Colonoscopic diagnosis of paraprosthetic-enteric fistula.
      • Peters J.J.
      • Verbeeten Jr., B.
      • Kromhout J.
      Intrasigmoidal aorta-bifurcation prosthesis diagnosed on CT.
      • Barman A.A.
      • Kerr P.
      Primary and secondary aortoenteric fistula and thoracic aortic aneurysm.
      • Peck J.J.
      • Eidemiller L.R.
      Aortoenteric fistulas.
      • Fernandez C.
      • Calvete J.
      • Garcia J.
      • Buch E.
      • Castells P.
      • Lledo S.
      Intestinal complications from vascular prostheses.
      • Li S.C.
      • Burton F.R.
      • Burton M.S.
      • Hallett J.
      The endoscopic diagnosis of iliac colonic fistula and review of literature.
      • Shindo S.
      • Tada Y.
      • Sato O.
      • Idezuki Y.
      • Nobori M.
      • Tanaka N.
      A case of an aortocolic fistula occurring 27 years after aorto-femoral bypass surgery, treated successfully by surgical management.
      • Chan L.
      • McErlean M.
      Secondary arterioenteric fistula involving the sigmoid colon.
      • Floriani M.
      • Fortis D.
      • Lazzerini R.
      • Tiberio G.
      Infection of aorto-bifemoral vascular prosthesis complicated by multiple visceral fistulas. A case report.
      • Hamdani R.
      • Summers R.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      • Kuestner L.M.
      • Reilly L.M.
      • Jicha D.L.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.
      • Novali C.
      • Locati P.
      • Morlacchi E.
      • Costantini S.
      Our experience in the emergency treatment of secondary aortoenteric fistulae. The preliminary results of the use of aortic homografts.
      • van Baalen J.M.
      • Kluit A.B.
      • Maas J.
      • Terpstra J.L.
      • van Bockel J.H.
      Diagnosis and therapy of aortic prosthetic fistulas: trends over a 30-year experience.
      • Davidovic L.B.
      • Spasic D.S.
      • Lotina S.I.
      • Kostic D.M.
      • Cinara I.S.
      • Svetkovic S.D.
      • et al.
      Aorto-enteric fistulas.
      • Blomberg D.N.
      • Leslie G.
      • Ngo Q.D.
      • Boseto F.
      • Jamnagerwalla M.
      • Tran V.
      Atypical endoscopic finding in a case of secondary aorto-colonic fistula.
      • Cendan J.C.
      • Thomas 4th, J.B.
      • Seeger J.M.
      Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.
      • Ramanujam S.
      • Shiels A.
      • Zuckerman G.
      • Prakash C.
      Unusual presentations of aorto-enteric fistula.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      • Perez R.O.
      • Katayama F.F.
      • Bresciani C.
      • Jacob C.E.
      • Coser R.B.
      • Alves P.R.
      • et al.
      Aortoenteric fistula to the sigmoid colon-case report.

      Leon LR, Psalms SB, Ihnat DM, Kasher JA, Kim J, Mills Sr JL. Vascular images: aortic paraprosthetic-colonic fistulae. J Vasc Surg, in press.

      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 1Aortic paraprosthetic-colonic fistulae
      • Ferris E.J.
      • Szego Koltay M.R.
      • Koltay O.P.
      • Sciammas F.D.
      Abdominal aortic and iliac graft fistulae.
      • Beach P.M.
      • Risley T.S.
      Aorticosigmoid fistulization following aortic resection.
      • Mannick J.A.
      • Nabseth D.C.
      Axillofemoral bypass graft. A safe alternative to aortoiliac reconstruction.
      • Shucksmith H.S.
      Duodenal, sigmoid, and ureteric fistulas resulting from aorto-iliac grafts or endarterectomy.
      • Dalinka M.K.
      • Gohel V.K.
      • Schaffer B.
      • Hernberg J.
      Gastrointestinal complications of aortic bypass surgery.
      • Thompson W.M.
      • Jackson D.C.
      • Johnsrude I.S.
      Aortoenteric and paraprosthetic-enteric fistulas: radiologic findings.
      • Thompson W.M.
      • Johnsrude I.S.
      • Jackson D.C.
      • Older R.A.
      • Wechsler A.S.
      Late complications of abdominal aortic reconstructive surgery: roentgen evaluation.
      • Kron I.L.
      • Dillihunt R.C.
      Arterial sigmoid fistula: treatment by fistula exclusion without graft excision.
      • Bergkvist L.
      • Aberg C.
      Fistula between false aneurysm in the left iliac artery and the sigmoid. Case report.
      • Cranston D.
      • Vowles K.D.
      Aorto-duodenal and subsequent aorto-colonic fistula following operation for ruptured aortic aneurysm.
      • Criado F.J.
      • Classen J.N.
      • Wilson Jr., T.H.
      Secondary aorto-enteric fistulas: prosthetic and paraprosthetic.
      • Dobbs S.M.
      • Jordan P.H.
      • Cain G.D.
      • Schwartz J.T.
      • Graham D.Y.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      • Robbins J.A.
      • Ashmore J.D.
      Aortoenteric fistula: diagnosis and management.
      • Reilly L.M.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Gastrointestinal tract involvement by prosthetic graft infection. The significance of gastrointestinal hemorrhage.
      • Paaske W.P.
      • Hansen H.J.
      Graft-enteric fistulas and erosions.
      • Yeager R.A.
      • McConnell D.B.
      • Sasaki T.M.
      • Vetto R.M.
      Aortic and peripheral prosthetic graft infection: differential management and causes of mortality.
      • Bergqvist D.
      • Alm A.
      • Claes G.
      • Drott C.
      • Forsberg O.
      • Larsson M.
      • et al.
      Secondary aortoenteric fistulas–an analysis of 42 cases.
      • D'Souza C.R.
      • Hebert R.J.
      • Trautman A.F.
      • Kilam S.
      Aortoenteric fistula: case review and a new surgical technique.
      • Harris J.P.
      • Sheil A.G.
      • Stephen M.S.
      • Storey D.W.
      • May J.
      Lessons learnt in the management of aortoenteric fistulae.
      • Travis R.C.
      • Wattie W.J.
      Aorto-enteric fistula.
      • Vollmar J.F.
      • Kogel H.
      Aorto-enteric fistulas as postoperative complication.
      • Demaerel P.
      • Wilms G.
      • Suy R.
      • Nevelsteen A.
      • Penninckx F.
      • Baert A.L.
      Computed tomography in paraprosthetic sigmoid fistula.
      • Aarnio P.
      • Hannukainen J.
      Aortic graft–enteric fistula.
      • Higgins R.S.
      • Steed D.L.
      • Julian T.B.
      • Makaroun M.S.
      • Peitzman A.B.
      • Webster M.W.
      The management of aortoenteric and paraprosthetic fistulae.
      • Wilcox C.M.
      • Ostroff J.W.
      Colonoscopic diagnosis of paraprosthetic-enteric fistula.
      • Peters J.J.
      • Verbeeten Jr., B.
      • Kromhout J.
      Intrasigmoidal aorta-bifurcation prosthesis diagnosed on CT.
      • Barman A.A.
      • Kerr P.
      Primary and secondary aortoenteric fistula and thoracic aortic aneurysm.
      • Peck J.J.
      • Eidemiller L.R.
      Aortoenteric fistulas.
      • Fernandez C.
      • Calvete J.
      • Garcia J.
      • Buch E.
      • Castells P.
      • Lledo S.
      Intestinal complications from vascular prostheses.
      • Li S.C.
      • Burton F.R.
      • Burton M.S.
      • Hallett J.
      The endoscopic diagnosis of iliac colonic fistula and review of literature.
      • Shindo S.
      • Tada Y.
      • Sato O.
      • Idezuki Y.
      • Nobori M.
      • Tanaka N.
      A case of an aortocolic fistula occurring 27 years after aorto-femoral bypass surgery, treated successfully by surgical management.
      • Chan L.
      • McErlean M.
      Secondary arterioenteric fistula involving the sigmoid colon.
      • Floriani M.
      • Fortis D.
      • Lazzerini R.
      • Tiberio G.
      Infection of aorto-bifemoral vascular prosthesis complicated by multiple visceral fistulas. A case report.
      • Hamdani R.
      • Summers R.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      • Kuestner L.M.
      • Reilly L.M.
      • Jicha D.L.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.
      • Novali C.
      • Locati P.
      • Morlacchi E.
      • Costantini S.
      Our experience in the emergency treatment of secondary aortoenteric fistulae. The preliminary results of the use of aortic homografts.
      • van Baalen J.M.
      • Kluit A.B.
      • Maas J.
      • Terpstra J.L.
      • van Bockel J.H.
      Diagnosis and therapy of aortic prosthetic fistulas: trends over a 30-year experience.
      • Davidovic L.B.
      • Spasic D.S.
      • Lotina S.I.
      • Kostic D.M.
      • Cinara I.S.
      • Svetkovic S.D.
      • et al.
      Aorto-enteric fistulas.
      • Blomberg D.N.
      • Leslie G.
      • Ngo Q.D.
      • Boseto F.
      • Jamnagerwalla M.
      • Tran V.
      Atypical endoscopic finding in a case of secondary aorto-colonic fistula.
      • Cendan J.C.
      • Thomas 4th, J.B.
      • Seeger J.M.
      Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.
      • Ramanujam S.
      • Shiels A.
      • Zuckerman G.
      • Prakash C.
      Unusual presentations of aorto-enteric fistula.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      • Perez R.O.
      • Katayama F.F.
      • Bresciani C.
      • Jacob C.E.
      • Coser R.B.
      • Alves P.R.
      • et al.
      Aortoenteric fistula to the sigmoid colon-case report.

      Leon LR, Psalms SB, Ihnat DM, Kasher JA, Kim J, Mills Sr JL. Vascular images: aortic paraprosthetic-colonic fistulae. J Vasc Surg, in press.

      PaperAgeSexNumber/total PEF numberFollow-up (months)Prior surgeryIndicationPresentation/time between 1st surgery and PEF diagnosis (months)Colon site involvedTreatmentOutcome
      Ferris 1965
      • Ferris E.J.
      • Szego Koltay M.R.
      • Koltay O.P.
      • Sciammas F.D.
      Abdominal aortic and iliac graft fistulae.
      50M1/3UnknownLeft ileofemoral bypass graftPeripheral arterial diseaseLeft groin abscess/25SigmoidGraft ligation; above-the-knee amputation; colostomyUnknown
      Beach 1966
      • Beach P.M.
      • Risley T.S.
      Aorticosigmoid fistulization following aortic resection.
      69M1/10Aortoiliac Dacron graftPresumed symptomatic abdominal aortic aneurysmHematochezia, tender abdominal mass/2SigmoidGraft removal; aortoiliac oversewing; proximal and distal colon stomasDeath four days postoperatively
      Mannick 1968
      • Mannick J.A.
      • Nabseth D.C.
      Axillofemoral bypass graft. A safe alternative to aortoiliac reconstruction.
      62M1/115Aortoiliac Dacron graftRuptured abdominal aortic aneurysmGI bleeding/36SigmoidPartial colectomy; omental vascular interposition; axillofemoral bypass+graft excisionInitial recovery; infected pseudoaneurysm 6 months postoperatively; bilateral limb thrombosis
      Shucksmith 1968
      • Shucksmith H.S.
      Duodenal, sigmoid, and ureteric fistulas resulting from aorto-iliac grafts or endarterectomy.
      64M1/20Aortoiliac Dacron graftAbdominal aortic aneurysm and aortocaval fistulaRight iliac fossa pain and blood in bowel movements/16SigmoidPrimary repair of colon and Dacron graft ligationDeath six days postoperatively
      Dalinka 1976
      • Dalinka M.K.
      • Gohel V.K.
      • Schaffer B.
      • Hernberg J.
      Gastrointestinal complications of aortic bypass surgery.
      47F1/1UnknownAortofemoral bypass graftUnknownGI bleeding/1SigmoidGraft revisionDid well
      Thompson 1976
      • Thompson W.M.
      • Jackson D.C.
      • Johnsrude I.S.
      Aortoenteric and paraprosthetic-enteric fistulas: radiologic findings.
      59F1/10UnknownAortobifemoral graftPeripheral arterial diseasePain, left groin mass, sepsis/7SigmoidUnknownUnknown
      Thompson 1977
      • Thompson W.M.
      • Johnsrude I.S.
      • Jackson D.C.
      • Older R.A.
      • Wechsler A.S.
      Late complications of abdominal aortic reconstructive surgery: roentgen evaluation.
      UnknownUnknown1/2UnknownAorticbifurcation graftUnknownUnknown/unknownSigmoidGraft removal and axillofemoral bypassUnknown
      Kron 1979
      • Kron I.L.
      • Dillihunt R.C.
      Arterial sigmoid fistula: treatment by fistula exclusion without graft excision.
      83M1/116Aortoiliac Dacron graftAbdominal aortic aneurysmHematochezia, pulsatile abdominal mass/23SigmoidLimb excision, sigmoid loop colostomy, femorofemoral crossover bypass graftDid well
      Bergkvist 1980
      • Bergkvist L.
      • Aberg C.
      Fistula between false aneurysm in the left iliac artery and the sigmoid. Case report.
      56M1/10Aortoiliac Dacron graftPeripheral arterial diseaseMelena/60SigmoidSigmoid resection; transverse colon stoma; re-suturing of graft-iliac anastomosisDeath 18 days postoperatively (pulmonary embolism)
      Cranston 1980
      • Cranston D.
      • Vowles K.D.
      Aorto-duodenal and subsequent aorto-colonic fistula following operation for ruptured aortic aneurysm.
      69M1/1UnknownTube Dacron graftRuptured aortic aneurysmBleeding per rectum/60UnknownPrimary repair of colon and proximal anastomosisDid well
      Criado 1981
      • Criado F.J.
      • Classen J.N.
      • Wilson Jr., T.H.
      Secondary aorto-enteric fistulas: prosthetic and paraprosthetic.
      53M1/40.3Left aortoiliac Dacron bypass graftPeripheral arterial diseaseLeft leg rash, swelling and pain, left lower quadrant pain, sweating/108SigmoidAxillobifemoral 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 anastomosisDid well
      Dobbs 1982
      • Dobbs S.M.
      • Jordan P.H.
      • Cain G.D.
      • Schwartz J.T.
      • Graham D.Y.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      66M1/10Aortobifemoral graftPeripheral arterial diseaseFever, hematochezia/10SigmoidSigmoid resection, graft limb excisionUnknown
      Flye 1983
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      UnknownUnknown2/21UnknownDacron bifurcation graftUnknownUnknown/unknownSigmoid×2Excision of left graft limb in both; one needed a subsequent axillobifemoral and the other a femorofemoral bypassBoth survivors
      Robbins 1984
      • Robbins J.A.
      • Ashmore J.D.
      Aortoenteric fistula: diagnosis and management.
      UnknownUnknown1/14UnknownUnknownUnknownUnknown/unknownUnknownUnknownUnknown
      Reilly 1985
      • Reilly L.M.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Gastrointestinal tract involvement by prosthetic graft infection. The significance of gastrointestinal hemorrhage.
      UnknownUnknown1/39UnknownUnknownUnknownUnknown/unknownUnknownUnknownUnknown
      Paaske 1985
      • Paaske W.P.
      • Hansen H.J.
      Graft-enteric fistulas and erosions.
      56M1/972Aortoiliac Dacron graftPeripheral arterial diseaseUnknown/31SigmoidResection of right prosthetic limb and external iliac arteryDid well (presumably)
      Yeager 1985
      • Yeager R.A.
      • McConnell D.B.
      • Sasaki T.M.
      • Vetto R.M.
      Aortic and peripheral prosthetic graft infection: differential management and causes of mortality.
      73M1/80End-to-end, aortoiliacUnknownGI hemorrhage/12UnknownAx-fem-fem with total graft removal and colectomyDied from sepsis, colon ischemia, renal failure
      Bergkvist 1987
      • Bergqvist D.
      • Alm A.
      • Claes G.
      • Drott C.
      • Forsberg O.
      • Larsson M.
      • et al.
      Secondary aortoenteric fistulas–an analysis of 42 cases.
      UnknownUnknown4/42UnknownUnknownUnknownUnknown/unknownSigmoid×3; 1 unknownUnknownUnknown
      Bergkvist 1987
      • Bergqvist D.
      • Alm A.
      • Claes G.
      • Drott C.
      • Forsberg O.
      • Larsson M.
      • et al.
      Secondary aortoenteric fistulas–an analysis of 42 cases.
      UnknownUnknown1/42UnknownUnknownAortic aneurysmAbdominal pain, diarrhea, pulsatile abdominal mass/1.8SigmoidUnknownUnknown
      D'Souza 1987
      • D'Souza C.R.
      • Hebert R.J.
      • Trautman A.F.
      • Kilam S.
      Aortoenteric fistula: case review and a new surgical technique.
      57M1/524Thoracoabdominal Dacron aortoiliac graftAortic aneurysmMassive GI bleeding+hypotension/24SigmoidExcision infrarenal portion of graft and insertion of axillobifemoral graft; colostomyDid well
      Harris 1987
      • Harris J.P.
      • Sheil A.G.
      • Stephen M.S.
      • Storey D.W.
      • May J.
      Lessons learnt in the management of aortoenteric fistulae.
      UnknownUnknown1/14UnknownUnknownUnknownUnknown/unknownSigmoidUnknownUnknown
      Travis 1987
      • Travis R.C.
      • Wattie W.J.
      Aorto-enteric fistula.
      68M1/100Aortoiliac Dacron graftUnknownRed blood per rectum/6SigmoidUnknownIntraoperative death
      Vollmar 1987
      • Vollmar J.F.
      • Kogel H.
      Aorto-enteric fistulas as postoperative complication.
      UnknownUnknown1/11UnknownUnknownUnknownUnknown/unknownSigmoidUnknownUnknown
      Demaerel 1988
      • Demaerel P.
      • Wilms G.
      • Suy R.
      • Nevelsteen A.
      • Penninckx F.
      • Baert A.L.
      Computed tomography in paraprosthetic sigmoid fistula.
      68M1/1UnknownAortofemoral Dacron graftPeripheral arterial diseaseHematochezia, tenesmus, low back pain, diarrhea, vomiting, fever, chills/60SigmoidLeft axillofemoral bypass; graft removal; sigmoid resectionDischarged 2 weeks after procedure (presumably well)
      Aarnio 1989
      • Aarnio P.
      • Hannukainen J.
      Aortic graft–enteric fistula.
      73M1/31.5Aortobifemoral Dacron graftPeripheral arterial diseaseGI bleeding/156TransverseGraft removal; sigmoid resection+primary anastomosisDeath
      Higgins 1990
      • Higgins R.S.
      • Steed D.L.
      • Julian T.B.
      • Makaroun M.S.
      • Peitzman A.B.
      • Webster M.W.
      The management of aortoenteric and paraprosthetic fistulae.
      UnknownUnknown1/15UnknownUnknownUnknownUnknown/unknownRectumUnknownUnknown
      Wilcox 1990
      • Wilcox C.M.
      • Ostroff J.W.
      Colonoscopic diagnosis of paraprosthetic-enteric fistula.
      66F1/10Right aortoiliac Dacron graftPeripheral arterial diseasePseudomonas sepsis, hematochezia/144SigmoidPrimary repair of colon; graft removal; right ileofemoral bypass with veinUnknown
      Wilcox 1990
      • Wilcox C.M.
      • Ostroff J.W.
      Colonoscopic diagnosis of paraprosthetic-enteric fistula.
      58F1/10Aortoiliac Dacron graftAbdominal aortic aneurysmFever, chills, left calf pain/48SigmoidPrimary repair of colon; graft removal; left axillo-iliac bypass+iliac-iliac crossover graftUnknown
      Peters 1991
      • Peters J.J.
      • Verbeeten Jr., B.
      • Kromhout J.
      Intrasigmoidal aorta-bifurcation prosthesis diagnosed on CT.
      74M1/1UnknownAortoiliac Sauvage-velour graftAbdominal aortic aneurysmPneumonia, E.coli sepsis, hematochezia/60SigmoidLeft prosthetic limb replaced by Dacron prosthesisDid well
      Barman 1992
      • Barman A.A.
      • Kerr P.
      Primary and secondary aortoenteric fistula and thoracic aortic aneurysm.
      62M1/124Dacron graftAbdominal aortic aneurysmLeft sided abdominal pain+hematochezia/12TransverseAxillary bifemoral bypass; colon resection+end-to-end anastomosisPresumably did well
      Peck 1992
      • Peck J.J.
      • Eidemiller L.R.
      Aortoenteric fistulas.
      UnknownUnknown1/25UnknownUnknownUnknownUnknown/unknownUnknownUnknownDied from sepsis
      Fernandez 1993
      • Fernandez C.
      • Calvete J.
      • Garcia J.
      • Buch E.
      • Castells P.
      • Lledo S.
      Intestinal complications from vascular prostheses.
      63M1/218Left ileofemoral bypassPeripheral arterial diseaseHematochezia/unknownSigmoidSigmoid resection+omentum coverage of prosthesis; had recurrent infection needing graft removal+left axillofemoral bypassLeft above-the-knee amputation
      Li 19933165M1/112Right aortopopliteal and left aortofemoral bypass graftPeripheral arterial diseaseFever, chills, hematochezia/5SigmoidLeft axillofemoral bypass; graft removal; sigmoid resectionDid well
      Shindo 1993
      • Shindo S.
      • Tada Y.
      • Sato O.
      • Idezuki Y.
      • Nobori M.
      • Tanaka N.
      A case of an aortocolic fistula occurring 27 years after aorto-femoral bypass surgery, treated successfully by surgical management.
      69M1/16Right aortofemoral bypass with Teflon graftPeripheral arterial diseaseMelena/324AscendingLeft 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 afterDid well
      Chan 1994
      • Chan L.
      • McErlean M.
      Secondary arterioenteric fistula involving the sigmoid colon.
      72M1/10Aortobiiliac Dacron graftAbdominal aortic aneurysmAbdominal pain/108SigmoidExploratory laparotomyDied in operating room
      Floriani 1995
      • Floriani M.
      • Fortis D.
      • Lazzerini R.
      • Tiberio G.
      Infection of aorto-bifemoral vascular prosthesis complicated by multiple visceral fistulas. A case report.
      *
      65M1/19Aortobifemoral graftPeripheral arterial diseaseFever/156SigmoidExploratory laparotomyDid well
      Hamdani 1995
      • Hamdani R.
      • Summers R.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      67M1/12Aortobifemoral graftAbdominal aortic aneurysmFever, chills, left leg swelling/120SigmoidHartmann's procedure, graft removal, axillobifemoral bypassDid well
      Kuestner 1995
      • Kuestner L.M.
      • Reilly L.M.
      • Jicha D.L.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.
      UnknownF1/33UnknownUnknownUnknownUnknown/unknownSigmoidRedo in-line aortic reconstructionDeath due to SAEF after redo in-line aortic reconstruction because of infection involving prosthetic axillofemoral graft
      Novali 1996
      • Novali C.
      • Locati P.
      • Morlacchi E.
      • Costantini S.
      Our experience in the emergency treatment of secondary aortoenteric fistulae. The preliminary results of the use of aortic homografts.
      *
      65F1/22Aortobifemoral graftPeripheral arterial diseaseCutaneous fistula/28SigmoidGraft excision; sigmoid resection; aortobifemoral homograft. Later needed colostomy+replacement of iliac homograft with saphenous veinDid well
      Van Baalen 1996
      • van Baalen J.M.
      • Kluit A.B.
      • Maas J.
      • Terpstra J.L.
      • van Bockel J.H.
      Diagnosis and therapy of aortic prosthetic fistulas: trends over a 30-year experience.
      UnknownUnknown1/31UnknownUnknownUnknownUnknown/unknownSigmoidUnknownUnknown
      Davidovic 2001
      • Davidovic L.B.
      • Spasic D.S.
      • Lotina S.I.
      • Kostic D.M.
      • Cinara I.S.
      • Svetkovic S.D.
      • et al.
      Aorto-enteric fistulas.
      **
      64M1/5UnknownAortobiiliac bypassUnknownFever, hematochezia, elevated sedimentation rate and white cell count/24SigmoidGraft removal, colostomy, ascending aorta to femoral artery bypass graftUnknown
      Davidovic 2001
      • Davidovic L.B.
      • Spasic D.S.
      • Lotina S.I.
      • Kostic D.M.
      • Cinara I.S.
      • Svetkovic S.D.
      • et al.
      Aorto-enteric fistulas.
      **
      65M1/5UnknownAortobiiliac bypassUnknownFever, melena, elevated sedimentation rate and white cell count/24TransverseDacron axillobifemoral graftUnknown
      Blomberg 2004
      • Blomberg D.N.
      • Leslie G.
      • Ngo Q.D.
      • Boseto F.
      • Jamnagerwalla M.
      • Tran V.
      Atypical endoscopic finding in a case of secondary aorto-colonic fistula.
      80M1/1SeveralUnknownAbdominal aortic aneurysmRecurrent painless, hematochezia/60SigmoidGraft oversewn, omental patch+subtotal colectomy+end-ileostomyDid well; died from unrelated cause
      Cendan 2004
      • Cendan J.C.
      • Thomas 4th, J.B.
      • Seeger J.M.
      Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.
      UnknownUnknown2/20UnknownUnknownUnknownUnknown/unknownUnknown×2Resection+diverting end-colostomyUnknown
      Ramanujam 2004
      • Ramanujam S.
      • Shiels A.
      • Zuckerman G.
      • Prakash C.
      Unusual presentations of aorto-enteric fistula.
      83M1/40Aortobiiliac Dacron graftAbdominal aortic aneurysmHematochezia+lightheadedness/unknownSigmoidEmergent endograft+2 stents placementDeath after endovascular treatment
      Armstrong 2005
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      UnknownUnknown1/29UnknownUnknownUnknownSepsis/unknownTransverseResection and proximal diversionUnknown
      Perez 2005
      • Perez R.O.
      • Katayama F.F.
      • Bresciani C.
      • Jacob C.E.
      • Coser R.B.
      • Alves P.R.
      • et al.
      Aortoenteric fistula to the sigmoid colon-case report.
      62M1/16Aortobiiliac Dacron graftAortoiliac aneurysmRectal bleeding+perirectal pain/192SigmoidHartmann's procedure, graft removal, aortic stump oversewing, axillobifemoral bypassDid well
      Leon 2006

      Leon LR, Psalms SB, Ihnat DM, Kasher JA, Kim J, Mills Sr JL. Vascular images: aortic paraprosthetic-colonic fistulae. J Vasc Surg, in press.

      58M1/12Aortobifemoral Dacron graftPeripheral arterial diseaseSepsis/3SigmoidFemorofemoral crossover graft; left limb excision; sigmoid colon resectionDid 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,
      • Floriani M.
      • Fortis D.
      • Lazzerini R.
      • Tiberio G.
      Infection of aorto-bifemoral vascular prosthesis complicated by multiple visceral fistulas. A case report.
      • Novali C.
      • Locati P.
      • Morlacchi E.
      • Costantini S.
      Our experience in the emergency treatment of secondary aortoenteric fistulae. The preliminary results of the use of aortic homografts.
      one in Serbian,
      • Davidovic L.B.
      • Spasic D.S.
      • Lotina S.I.
      • Kostic D.M.
      • Cinara I.S.
      • Svetkovic S.D.
      • et al.
      Aorto-enteric fistulas.
      and the remainder in English.
      • Ferris E.J.
      • Szego Koltay M.R.
      • Koltay O.P.
      • Sciammas F.D.
      Abdominal aortic and iliac graft fistulae.
      • Beach P.M.
      • Risley T.S.
      Aorticosigmoid fistulization following aortic resection.
      • Mannick J.A.
      • Nabseth D.C.
      Axillofemoral bypass graft. A safe alternative to aortoiliac reconstruction.
      • Shucksmith H.S.
      Duodenal, sigmoid, and ureteric fistulas resulting from aorto-iliac grafts or endarterectomy.
      • Dalinka M.K.
      • Gohel V.K.
      • Schaffer B.
      • Hernberg J.
      Gastrointestinal complications of aortic bypass surgery.
      • Thompson W.M.
      • Jackson D.C.
      • Johnsrude I.S.
      Aortoenteric and paraprosthetic-enteric fistulas: radiologic findings.
      • Thompson W.M.
      • Johnsrude I.S.
      • Jackson D.C.
      • Older R.A.
      • Wechsler A.S.
      Late complications of abdominal aortic reconstructive surgery: roentgen evaluation.
      • Kron I.L.
      • Dillihunt R.C.
      Arterial sigmoid fistula: treatment by fistula exclusion without graft excision.
      • Bergkvist L.
      • Aberg C.
      Fistula between false aneurysm in the left iliac artery and the sigmoid. Case report.
      • Cranston D.
      • Vowles K.D.
      Aorto-duodenal and subsequent aorto-colonic fistula following operation for ruptured aortic aneurysm.
      • Criado F.J.
      • Classen J.N.
      • Wilson Jr., T.H.
      Secondary aorto-enteric fistulas: prosthetic and paraprosthetic.
      • Dobbs S.M.
      • Jordan P.H.
      • Cain G.D.
      • Schwartz J.T.
      • Graham D.Y.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      • Robbins J.A.
      • Ashmore J.D.
      Aortoenteric fistula: diagnosis and management.
      • Reilly L.M.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Gastrointestinal tract involvement by prosthetic graft infection. The significance of gastrointestinal hemorrhage.
      • Paaske W.P.
      • Hansen H.J.
      Graft-enteric fistulas and erosions.
      • Yeager R.A.
      • McConnell D.B.
      • Sasaki T.M.
      • Vetto R.M.
      Aortic and peripheral prosthetic graft infection: differential management and causes of mortality.
      • Bergqvist D.
      • Alm A.
      • Claes G.
      • Drott C.
      • Forsberg O.
      • Larsson M.
      • et al.
      Secondary aortoenteric fistulas–an analysis of 42 cases.
      • D'Souza C.R.
      • Hebert R.J.
      • Trautman A.F.
      • Kilam S.
      Aortoenteric fistula: case review and a new surgical technique.
      • Harris J.P.
      • Sheil A.G.
      • Stephen M.S.
      • Storey D.W.
      • May J.
      Lessons learnt in the management of aortoenteric fistulae.
      • Travis R.C.
      • Wattie W.J.
      Aorto-enteric fistula.
      • Vollmar J.F.
      • Kogel H.
      Aorto-enteric fistulas as postoperative complication.
      • Demaerel P.
      • Wilms G.
      • Suy R.
      • Nevelsteen A.
      • Penninckx F.
      • Baert A.L.
      Computed tomography in paraprosthetic sigmoid fistula.
      • Aarnio P.
      • Hannukainen J.
      Aortic graft–enteric fistula.
      • Higgins R.S.
      • Steed D.L.
      • Julian T.B.
      • Makaroun M.S.
      • Peitzman A.B.
      • Webster M.W.
      The management of aortoenteric and paraprosthetic fistulae.
      • Wilcox C.M.
      • Ostroff J.W.
      Colonoscopic diagnosis of paraprosthetic-enteric fistula.
      • Peters J.J.
      • Verbeeten Jr., B.
      • Kromhout J.
      Intrasigmoidal aorta-bifurcation prosthesis diagnosed on CT.
      • Barman A.A.
      • Kerr P.
      Primary and secondary aortoenteric fistula and thoracic aortic aneurysm.
      • Peck J.J.
      • Eidemiller L.R.
      Aortoenteric fistulas.
      • Fernandez C.
      • Calvete J.
      • Garcia J.
      • Buch E.
      • Castells P.
      • Lledo S.
      Intestinal complications from vascular prostheses.
      • Li S.C.
      • Burton F.R.
      • Burton M.S.
      • Hallett J.
      The endoscopic diagnosis of iliac colonic fistula and review of literature.
      • Shindo S.
      • Tada Y.
      • Sato O.
      • Idezuki Y.
      • Nobori M.
      • Tanaka N.
      A case of an aortocolic fistula occurring 27 years after aorto-femoral bypass surgery, treated successfully by surgical management.
      • Chan L.
      • McErlean M.
      Secondary arterioenteric fistula involving the sigmoid colon.
      • Hamdani R.
      • Summers R.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      • Kuestner L.M.
      • Reilly L.M.
      • Jicha D.L.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.
      • van Baalen J.M.
      • Kluit A.B.
      • Maas J.
      • Terpstra J.L.
      • van Bockel J.H.
      Diagnosis and therapy of aortic prosthetic fistulas: trends over a 30-year experience.
      • Blomberg D.N.
      • Leslie G.
      • Ngo Q.D.
      • Boseto F.
      • Jamnagerwalla M.
      • Tran V.
      Atypical endoscopic finding in a case of secondary aorto-colonic fistula.
      • Cendan J.C.
      • Thomas 4th, J.B.
      • Seeger J.M.
      Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.
      • Ramanujam S.
      • Shiels A.
      • Zuckerman G.
      • Prakash C.
      Unusual presentations of aorto-enteric fistula.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      • Perez R.O.
      • Katayama F.F.
      • Bresciani C.
      • Jacob C.E.
      • Coser R.B.
      • Alves P.R.
      • et al.
      Aortoenteric fistula to the sigmoid colon-case report.

      Leon LR, Psalms SB, Ihnat DM, Kasher JA, Kim J, Mills Sr JL. Vascular images: aortic paraprosthetic-colonic fistulae. J Vasc Surg, in press.

      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.

      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.
      • Kalman P.G.
      • Rappaport D.C.
      • Merchant N.
      • Clarke K.
      • Johnston K.W.
      The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair.
      • Szilagyi D.E.
      • Elliott Jr., J.P.
      • Smith R.F.
      • Reddy D.J.
      • McPharlin M.
      A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease.
      Kalman et al.
      • Kalman P.G.
      • Rappaport D.C.
      • Merchant N.
      • Clarke K.
      • Johnston K.W.
      The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair.
      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.
      • Hallett Jr., J.W.
      • Marshall D.M.
      • Petterson T.M.
      • Gray D.T.
      • Bower T.C.
      • Cherry Jr., K.J.
      • et al.
      Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience.
      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.
      • O'Mara C.
      • Imbembo A.L.
      Paraprosthetic-enteric fistula.
      Brock first described a case of SAEF to the duodenum that was identified 6 months after implantation of an aortic homograft.
      • Brock R.C.
      Aortic homografting; a report of six successful cases.
      In 1958, Mackenzie et al.
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      successfully treated a patient with a SAEF after AAA homograft replacement.
      The pathogenesis of colonic SAEF rather than small bowel involvement remains speculative.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      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.
      • Bunt T.J.
      Synthetic vascular graft infections. II. Graft-enteric erosions and graft-enteric fistulas.
      This may be facilitated by the lack of interposed tissue or excessive pulsation of redundantly placed
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      or kinked
      • Sheil A.G.
      • Reeve T.S.
      • Little J.M.
      • Coupland G.A.
      • Loewenthal J.
      Aorto-intestinal fistulas following operations on the abdominal aorta and iliac arteries.
      grafts. Indolent graft infections
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      • Busuttil S.J.
      • Goldstone J.
      Diagnosis and management of aortoenteric fistulas.
      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%;
      • Shucksmith H.S.
      Duodenal, sigmoid, and ureteric fistulas resulting from aorto-iliac grafts or endarterectomy.
      • Kuestner L.M.
      • Reilly L.M.
      • Jicha D.L.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.
      the overwhelming majority involve the 3rd and 4th portions of the duodenum. Kalman et al.
      • Kalman P.G.
      • Rappaport D.C.
      • Merchant N.
      • Clarke K.
      • Johnston K.W.
      The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair.
      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.
      • Hallett Jr., J.W.
      • Marshall D.M.
      • Petterson T.M.
      • Gray D.T.
      • Bower T.C.
      • Cherry Jr., K.J.
      • et al.
      Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience.
      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, Bergqvist
      • Bergqvist D.
      Arterioenteric fistula. Review of a vascular emergency.
      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,
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      related to its proximity to the infrarenal aorta. Other segments
      • Arrington E.R.
      • Eisenberg B.
      • Hartshorne M.F.
      Paraprosthetic cecal fistula: CT demonstration–a case report.
      • Fieve G.
      • Bour P.
      Aortoappendicular fistula after aortoiliac prosthetic replacement.
      • Longo J.M.
      • Lopez-Rasines G.
      • Ortega E.
      • Pagola M.A.
      CT demonstration of an aortoesophageal fistula.
      have been infrequently reported. Aorto-colonic erosions are especially uncommon. O'Mara and Imbembo
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      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 fistula
      • Shucksmith H.S.
      Duodenal, sigmoid, and ureteric fistulas resulting from aorto-iliac grafts or endarterectomy.
      ). Several papers have reported that SAEF are more likely to occur after surgery for ruptured AAA than for elective AAA,
      • Perez R.O.
      • Katayama F.F.
      • Bresciani C.
      • Jacob C.E.
      • Coser R.B.
      • Alves P.R.
      • et al.
      Aortoenteric fistula to the sigmoid colon-case report.
      • Busuttil R.W.
      • Rees W.
      • Baker J.D.
      • Wilson S.E.
      Pathogenesis of aortoduodenal fistula: experimental and clinical correlates.
      • Elliott Jr., J.P.
      • Smith R.F.
      • Szilagyi D.E.
      Proceedings: aortoenteric and paraprosthetic-enteric fistulas. Problems of diagnosis and management.
      and almost insignificant when the graft is placed for aortoiliac occlusive disease.
      • Yeager R.A.
      • McConnell D.B.
      • Sasaki T.M.
      • Vetto R.M.
      Aortic and peripheral prosthetic graft infection: differential management and causes of mortality.
      This statement seems to arise from observations made by Elliott et al.,
      • Elliott Jr., J.P.
      • Smith R.F.
      • Szilagyi D.E.
      Proceedings: aortoenteric and paraprosthetic-enteric fistulas. Problems of diagnosis and management.
      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.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      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 Kogel
      • Vollmar J.F.
      • Kogel H.
      Aorto-enteric fistulas as postoperative complication.
      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.
      • Kuestner L.M.
      • Reilly L.M.
      • Jicha D.L.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.
      noted that >50% of the patients with SAEF in their series had occlusive disease as the indication for the original operation. O'Mara
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      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.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      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.
      • Resnikoff M.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Lloyd W.E.
      • Paty P.S.
      • Leather R.P.
      • et al.
      Fate of the excluded abdominal aortic aneurysm sac: long-term follow-up of 831 patients.
      During follow-up (5–103 months), no cases of graft infection or SAEF were identified in patients reconstructed by this approach. Connolly et al.
      • Connolly J.E.
      • Kwaan J.H.
      • McCart P.M.
      • Brownell D.A.
      • Levine E.F.
      Aortoenteric fistula.
      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.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      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.
      • Shindo S.
      • Tada Y.
      • Sato O.
      • Idezuki Y.
      • Nobori M.
      • Tanaka N.
      A case of an aortocolic fistula occurring 27 years after aorto-femoral bypass surgery, treated successfully by surgical management.
      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.
      • Deweese M.S.
      • Fry W.J.
      Small-bowel erosion following aortic resection.
      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.
      • Cranston D.
      • Vowles K.D.
      Aorto-duodenal and subsequent aorto-colonic fistula following operation for ruptured aortic aneurysm.
      • Donovan T.J.
      • Bucknam C.A.
      Aorto-enteric fistula.
      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.
      • Pipinos I.I.
      • Carr J.A.
      • Haithcock B.E.
      • Anagnostopoulos P.V.
      • Dossa C.D.
      • Reddy D.J.
      Secondary aorto-enteric fistula.
      • Barry P.A.
      • Molland J.G.
      • Falk G.L.
      Primary aortoduodenal fistula.
      Kuestner et al.
      • Kuestner L.M.
      • Reilly L.M.
      • Jicha D.L.
      • Ehrenfeld W.K.
      • Goldstone J.
      • Stoney R.J.
      Secondary aortoenteric fistula: contemporary outcome with use of extraanatomic bypass and infected graft excision.
      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).
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      Vollmar and Kogel
      • Vollmar J.F.
      • Kogel H.
      Aorto-enteric fistulas as postoperative complication.
      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.
      • Busuttil S.J.
      • Goldstone J.
      Diagnosis and management of aortoenteric fistulas.
      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.
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      Sepsis has been previously reported as a relatively infrequent presentation.
      • Rosenthal D.
      • Deterling Jr., R.A.
      • O'Donnell Jr., T.F.
      • Callow A.D.
      Positive blood culture as an aid in the diagnosis of secondary aortoenteric fistula.
      • Arzuaga Torre J.A.
      • Tebas Medrano P.
      • Simal Anton A.
      • et al.
      Fever and recurrent bacteremia as presentation form of secondary aortoenteric fistula.
      However, we noted that sepsis was the 2nd most commonly reported presentation in patients with SAEF (n=14). O'Mara and Imbembo
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      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.
      • Rosenthal D.
      • Deterling Jr., R.A.
      • O'Donnell Jr., T.F.
      • Callow A.D.
      Positive blood culture as an aid in the diagnosis of secondary aortoenteric fistula.
      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.

      Leon LR, Psalms SB, Ihnat DM, Kasher JA, Kim J, Mills Sr JL. Vascular images: aortic paraprosthetic-colonic fistulae. J Vasc Surg, in press.

      • Holland F.W.
      • Darling 3rd, R.C.
      • Chang B.B.
      • Shah D.M.
      • Leather R.P.
      Clostridial aortic graft infection.
      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.
      • Pipinos I.I.
      • Carr J.A.
      • Haithcock B.E.
      • Anagnostopoulos P.V.
      • Dossa C.D.
      • Reddy D.J.
      Secondary aorto-enteric fistula.
      Diagnostic studies include plain radiography,
      • Wyatt G.M.
      • Rauchway M.I.
      • Spitz H.B.
      Roentgen findings in aorto-enteric fistulae.
      computed tomography scan (CT),
      • Peters J.J.
      • Verbeeten Jr., B.
      • Kromhout J.
      Intrasigmoidal aorta-bifurcation prosthesis diagnosed on CT.
      • Mark A.S.
      • Moss A.A.
      • McCarthy S.
      • McCowin M.
      CT of aortoenteric fistulas.
      • Low R.N.
      • Wall S.D.
      • Jeffrey Jr., R.B.
      • Sollitto R.A.
      • Reilly L.M.
      • Tierney Jr., L.M.
      Aortoenteric fistula and perigraft infection: evaluation with CT.
      barium GI series,
      • Thompson W.M.
      • Jackson D.C.
      • Johnsrude I.S.
      Aortoenteric and paraprosthetic-enteric fistulas: radiologic findings.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      endoscopy,
      • Hamdani R.
      • Summers R.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      18-fluorodeoxyglucose positron emission tomography,
      • Krupnick A.S.
      • Lombardi J.V.
      • Engels F.H.
      • Kreisel D.
      • Zhuang H.
      • Alavi A.
      • et al.
      18-fluorodeoxyglucose positron emission tomography as a novel imaging tool for the diagnosis of aortoenteric fistula and aortic graft infection–a case report.
      gallium 67 scanning
      • Connolly J.E.
      • Kwaan J.H.
      • McCart P.M.
      • Brownell D.A.
      • Levine E.F.
      Aortoenteric fistula.
      • Causey D.A.
      • Fajman W.A.
      • Perdue G.D.
      • Constantino M.J.
      • Sones P.J.
      • Tarcan Y.A.
      67Ga scintigraphy in postoperative synthetic graft infections.
      and angiography.
      • Thompson W.M.
      • Jackson D.C.
      • Johnsrude I.S.
      Aortoenteric and paraprosthetic-enteric fistulas: radiologic findings.
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      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 tissue
      • Low R.N.
      • Wall S.D.
      • Jeffrey Jr., R.B.
      • Sollitto R.A.
      • Reilly L.M.
      • Tierney Jr., L.M.
      Aortoenteric fistula and perigraft infection: evaluation with CT.
      or gas (“black dots”),
      • Mark A.S.
      • Moss A.A.
      • McCarthy S.
      • McCowin M.
      CT of aortoenteric fistulas.
      contrast extravasation,
      • Kukora J.S.
      • Rushton F.W.
      • Cranston P.E.
      New computed tomographic signs of aortoenteric fistula.
      peri-prosthetic inflammatory tissue in contact with adjacent bowel,
      • Demaerel P.
      • Wilms G.
      • Suy R.
      • Nevelsteen A.
      • Penninckx F.
      • Baert A.L.
      Computed tomography in paraprosthetic sigmoid fistula.
      • Peters J.J.
      • Verbeeten Jr., B.
      • Kromhout J.
      Intrasigmoidal aorta-bifurcation prosthesis diagnosed on CT.
      bowel thickening, pseudoaneurysms,
      • Low R.N.
      • Wall S.D.
      • Jeffrey Jr., R.B.
      • Sollitto R.A.
      • Reilly L.M.
      • Tierney Jr., L.M.
      Aortoenteric fistula and perigraft infection: evaluation with CT.
      aneurysmal wrap disruption,
      • Low R.N.
      • Wall S.D.
      • Jeffrey Jr., R.B.
      • Sollitto R.A.
      • Reilly L.M.
      • Tierney Jr., L.M.
      Aortoenteric fistula and perigraft infection: evaluation with CT.
      or intraluminal gas within the graft >3 months after graft implantation are suggestive findings.
      • Mark A.S.
      • Moss A.A.
      • McCarthy S.
      • McCowin M.
      CT of aortoenteric fistulas.
      Tagged white cell scans have excellent sensitivity but low specificity for diagnosis.
      • Busuttil S.J.
      • Goldstone J.
      Diagnosis and management of aortoenteric fistulas.
      However, when applied by experienced personnel, they can be very useful in the early diagnosis of PEF, as shown by Causey et al.
      • Causey D.A.
      • Fajman W.A.
      • Perdue G.D.
      • Constantino M.J.
      • Sones P.J.
      • Tarcan Y.A.
      67Ga scintigraphy in postoperative synthetic graft infections.
      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).

      Leon LR, Psalms SB, Ihnat DM, Kasher JA, Kim J, Mills Sr JL. Vascular images: aortic paraprosthetic-colonic fistulae. J Vasc Surg, in press.

      Malaki et al.
      • Malaki M.
      • Perkins J.M.
      • Mortensen N.J.
      • Hands L.J.
      Graft-enteric erosion: an unusual colonoscopic diagnosis.
      visualized the limb of an aortobifemoral graft within the patient's cecum following an inflammatory AAA repair. Hamdani and Summers
      • Hamdani R.
      • Summers R.
      Vascular-enteric fistula: diagnosis by colonoscopy.
      diagnosed a PEF involving the limb of an aortobifemoral graft and the sigmoid in a patient 10 years after an open AAA repair.
      Figure thumbnail gr1
      Fig. 1Colonoscopy 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.
      • Bergqvist D.
      • Alm A.
      • Claes G.
      • Drott C.
      • Forsberg O.
      • Larsson M.
      • et al.
      Secondary aortoenteric fistulas–an analysis of 42 cases.
      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.
      • Bergqvist D.
      • Alm A.
      • Claes G.
      • Drott C.
      • Forsberg O.
      • Larsson M.
      • et al.
      Secondary aortoenteric fistulas–an analysis of 42 cases.

      Treatment

      The mortality rate for surgical treatment of SAEFs ranges from 14% to 70%.
      • Giordanengo F.
      • Boneschi M.
      • Miani S.
      • Erba M.
      • Beretta L.
      Secondary aorto-enteric fistula.
      The choice of surgical repair remains controversial. Multiple approaches have been described,
      • Mackenzie R.J.
      • Buell A.H.
      • Pearson S.C.
      Aneurysm of aortic homograft with rupture into the duodenum.
      including non-operative management,
      • Brock R.C.
      Aortic homografting; a report of six successful cases.
      • Wierman W.H.
      • Strahan R.W.
      • Spencer J.R.
      Small bowel erosion by synthetic aortic grafts.
      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.
      • Reilly L.M.
      • Stoney R.J.
      • Goldstone J.
      • Ehrenfeld W.K.
      Improved management of aortic graft infection: the influence of operation sequence and staging.
      In situ reconstruction has recently been utilized with increasing frequency using deep
      • Clagett G.P.
      • Valentine R.J.
      • Hagino R.T.
      Autogenous aortoiliac/femoral reconstruction from superficial femoral-popliteal veins: feasibility and durability.
      or superficial
      • Lauwers G.
      • Nevelsteen A.
      • Kerremans R.
      • Suy R.
      Paraprosthetic fistula after aortobifemoral prosthetic reconstruction: treatment by autogenous saphenous venous replacement. A case report.
      veins, rifampin-bonded Dacron grafts
      • Chiche L.
      • Pitre J.
      • Sarfati P.O.
      In situ repair of a secondary aortoappendiceal fistula with a rifampin-bonded Dacron graft.
      or cryopreserved arterial
      • Zhou W.
      • Lin P.H.
      • Bush R.L.
      • Terramani T.T.
      • Matsumura J.H.
      • Cox M.
      • et al.
      In situ reconstruction with cryopreserved arterial allografts for management of mycotic aneurysms or aortic prosthetic graft infections: a multi-institutional experience.
      or venous allografts.

      Sivamurthy N, Hiramoto JS, Schneider DB, Eichler CM, Reilly LM. Cryopreserved superficial femoral vein: the optimal conduit for the in situ treatment of aortic graft infection? [Abstract]. In: Western Vascular Society, Annual Meeting, 2006.

      Endovascular techniques to repair SAEFs in high-risk patients
      • Deshpande A.
      • Lovelock M.
      • Mossop P.
      • Denton M.
      • Vidovich J.
      • Gurry J.
      Endovascular repair of an aortoenteric fistula in a high-risk patient.
      have been used as a bridge to more definitive therapy after hemodynamic stabilization.
      • Burks Jr., J.A.
      • Faries P.L.
      • Gravereaux E.C.
      • Hollier L.H.
      • Marin M.L.
      Endovascular repair of bleeding aortoenteric fistulas: a 5-year experience.
      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.
      • Vollmar J.F.
      • Kogel H.
      Aorto-enteric fistulas as postoperative complication.
      A seromuscular jejunal patch for securing closure of the proximal aortic stump after removal of prosthetic grafts has also been suggested.
      • Shah D.M.
      • Buchbinder D.
      • Leather R.P.
      • Corson J.
      • Karmody A.M.
      Clinical use of the seromuscular jejunal patch for protection of the infected aortic stump.
      D'Souza et al.
      • D'Souza C.R.
      • Hebert R.J.
      • Trautman A.F.
      • Kilam S.
      Aortoenteric fistula: case review and a new surgical technique.
      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 repair
      • Cranston D.
      • Vowles K.D.
      Aorto-duodenal and subsequent aorto-colonic fistula following operation for ruptured aortic aneurysm.
      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.
      • D'Souza C.R.
      • Hebert R.J.
      • Trautman A.F.
      • Kilam S.
      Aortoenteric fistula: case review and a new surgical technique.
      Duodenal exclusion is not generally needed, and is reserved for cases of extensive tissue loss.
      • Cendan J.C.
      • Thomas 4th, J.B.
      • Seeger J.M.
      Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.
      Proximal bowel decompression by a gastrostomy has also been recommended.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      A route for nutrition, such as a feeding jejunostomy is also important.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      • Cendan J.C.
      • Thomas 4th, J.B.
      • Seeger J.M.
      Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.
      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.
      • Criado F.J.
      • Classen J.N.
      • Wilson Jr., T.H.
      Secondary aorto-enteric fistulas: prosthetic and paraprosthetic.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      Resection should be performed back to grossly normal colon.
      • Flye M.W.
      • Thompson W.M.
      Aortic graft-enteric and paraprosthetic-enteric fistulas.
      In general, primary colonic anastomosis is not advised, although successful outcomes have been also reported with its use.
      • Barman A.A.
      • Kerr P.
      Primary and secondary aortoenteric fistula and thoracic aortic aneurysm.
      If severe contamination is noted at exploration, or if the patient is malnourished or acutely ill, a temporary colostomy is preferred.
      • Cendan J.C.
      • Thomas 4th, J.B.
      • Seeger J.M.
      Twenty-one cases of aortoenteric fistula: lessons for the general surgeon.
      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.
      • Kron I.L.
      • Dillihunt R.C.
      Arterial sigmoid fistula: treatment by fistula exclusion without graft excision.
      Omental interposition is universally advocated.
      • D'Souza C.R.
      • Hebert R.J.
      • Trautman A.F.
      • Kilam S.
      Aortoenteric fistula: case review and a new surgical technique.
      • Fernandez C.
      • Calvete J.
      • Garcia J.
      • Buch E.
      • Castells P.
      • Lledo S.
      Intestinal complications from vascular prostheses.
      • Perez R.O.
      • Katayama F.F.
      • Bresciani C.
      • Jacob C.E.
      • Coser R.B.
      • Alves P.R.
      • et al.
      Aortoenteric fistula to the sigmoid colon-case report.
      Finally, bowel repairs are assessed by some with contrast studies prior to restarting oral intake.
      • Armstrong P.A.
      • Back M.R.
      • Wilson J.S.
      • Shames M.L.
      • Johnson B.L.
      • Bandyk D.F.
      Improved outcomes in the recent management of secondary aortoenteric fistula.
      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.

      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.

      References

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