In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas

  • Matthew R Janko
  • Karen Woo
  • Robert I Hacker
  • Donald Baril
  • Jonathan Bath
  • Matthew R Smeds
  • Vikram S Kashyap
  • Zoltan Szeberin
  • Gregory Magee
  • Ramsey Elsayed
  • Andrew Wishy
  • Rebecca St John
  • Adam Beck
  • Mark Farber
  • Fernando Motta
  • Wei Zhou
  • Gary Lemmon
  • Dawn Coleman
  • Christian-Alexander Behrendt
  • Faisal Aziz
  • James Black
  • William Shutze
  • H Edward Garrett
  • Giovanni de Caridi
  • Christos Liapis
  • Stavros Kakkos
  • Hideaki Obara
  • Grace Wang
  • Pascal Rhéaume
  • Victor Davila
  • Reid Ravin
  • Randall DeMartino
  • Ross Milner
  • Sherene Shalhub
  • Jeffrey Jim
  • Jason Lee
  • Celine Dubuis
  • Jean-Baptiste Ricco
  • Joseph Coselli
  • Scott Lemaire
  • Jahvairiah Fatima
  • Jennifer Sanford
  • Winston Yoshida
  • Marc Schermerhorn
  • Matthew Menard
  • Michael Belkin
  • Stuart Blackwood
  • Mark Conrad
  • Linda Wang
  • Sara Crofts
  • Thomas Nixon
  • Timothy Wu
  • Roberto Chiesa
  • Saideep Bose
  • Jason Turner
  • Ryan Moore
  • Justin Smith
  • Rocco Ciocca
  • Jeffrey Hsu
  • Martin Czerny
  • Jonathan Cullen
  • Andrea Kahlberg
  • Carlo Setacci
  • Jin Hyun Joh
  • Eric Senneville
  • Pedro Garrido
  • Timur Sarac
  • Anthony Rizzo
  • Michael Go
  • Martin Bjorck
  • Hamid Gavali
  • Anders Wanhainen
  • Peter F Lawrence
  • Jayer Chung

Abstract

OBJECTIVE: The optimal revascularization modality in secondary abdominal aorto-enteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF.

METHODS: A retrospective, multi-institutional study of SAEF from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed.

RESULTS: 182 patients at 34 institutions from 11 countries presented with SAEF during the study period (median age 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%) with 2 unknown. 102 of the SAEF (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (NAIS) (17), cryopreserved allograft (28), and untreated prosthetic grafts (4). 80 patients (44%) underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier (KM) estimated survival was 319 days (IQR 20, 2410) days. When stratified by EAB versus ISB, there was no significant difference in KM estimated survival (p=0.82). Comparing EAB versus ISB, EAB patients were older (age 74 vs. 70; p=0.01), had less operative hemorrhage (1200mL vs. 2000mL; p=0.04), were more likely to initiate dialysis within 30 days postoperatively (15% vs. 5%, p=0.02), and were less likely to experience aortic-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs. 11% anastomotic rupture, p=0.03). There were otherwise no significant differences in presentation, comorbidities, intra-operative or postoperative variables. Multivariable Cox regression showed the duration of antibiotic use (HR 0.92, 95% CI 0.86-0.98; p = 0.01) and rifampin use at time of discharge (HR 0.20, 0.05-0.86, p = 0.03) independently decreased mortality.

CONCLUSIONS: These data suggest ISB does not offer a survival advantage compared to EAB and does not decrease the risk of postoperative aortic-related hemorrhage. Less than 50% of SAEF patients survive ten months after repair. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling are imperative for this population.

Bibliographical metadata

Original languageEnglish
ISSN0741-5214
DOIs
Publication statusPublished - 01.2021
PubMed 32445832