Secondary aortoenteric fistulas versus paraprosthetic erosions: is bleeding associated with a worse outcome?

BACKGROUND: Direct communication between an aortic prosthesis and the gastrointestinal (GI) tract may present with GI bleeding (aortoenteric fistulas [AEF]) or be incidental to a graft infection (paraprosthetic erosions [PPE]). The purposes of this study were to compare the outcomes of AEF versus PPE and to determine predictors of mortality associated with these lesions. STUDY DESIGN: Since 1992, 38 patients (23 men, 15 women; mean age 67 years) presented with AEF (n=16) or PPE (n=22). RESULTS: After complete graft excision, 26 patients (8 AEF, 18 PPE) underwent in situ revascularization using femoral vein (n=24) or rifampin-soaked prosthetic graft (n=2); 12 (8 AEF, 4 PPE) underwent extraanatomic bypass. There was no significant difference in mortality for AEF versus PPE (38% versus 36%). Postoperative complications developed in 25 (66%) patients, including 10 (26%) with GI complications requiring reintervention (5 colon necrosis, 5 duodenal bleed or leak). There were no differences between AEF and PPE in operative transfusions, operative times, GI complications, ICU stay, hospital stay, or final discharge status. Multivariate stepwise logistic regression analysis revealed that GI complications (odds ratio [OR], 52.5; 95% CI, 3.5 to 781; p=0.004) and age (OR, 1.2; 95% CI, 1.02 to 1.3; p=0.026) were the only independent predictors of in-hospital mortality. CONCLUSIONS: Surgical management of AEF and PPE should be tailored to patient illness and the extent of graft infection. Mortality from both lesions is dependent on patient and technical factors, not on the mode of presentation.

Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair.

OBJECTIVE: Small abdominal aortic aneurysms (AAAs; 4-5.4 cm) are more likely to be suitable for endovascular aneurysm repair (EVAR) than large aortic aneurysms (>5.5 cm). The purpose of this study was to determine whether small AAA growth is associated with the development of morphologic characteristics that decrease eligibility for EVAR. METHODS: We studied 54 patients who underwent 2 or more computed tomography scans with 3-dimensional reconstruction during surveillance of small AAAs. Morphologic aortic aneurysm features and changes were measured according to Society for Vascular Surgery reporting standards. Suitability for EVAR was determined by neck anatomy (diameter, length, and angulations), iliac artery morphology, and total aortic aneurysm angulation and tortuosity. RESULTS: The median age of the study cohort was 73 years (interquartile range [IQR], 65-77 years). The median follow-up period was 24 months (IQR, 15-36 months). The median small AAA diameter increased from 44.5 mm (IQR, 41-48 mm) to 48.9 mm (IQR, 45.7-52.0 mm). The median aortic neck diameter increased from 23.0 to 24.0 mm (P = .002), whereas median neck length decreased from 26.5 to 20.0 mm (P = .001). Aortic aneurysm median tortuosity index increased from 1.09 to 1.11 (P = .05). No significant changes in iliac artery morphology occurred. Overall, the anatomic suitability for endovascular repair did not significantly change during the study period (74% vs 69%; McNemar test; P = .25). CONCLUSIONS: Changes in aortic morphology are frequently associated with small AAA growth at mid-term follow-up, but such changes are minor and do not affect overall anatomic suitability for EVAR. These data reveal that continued surveillance of small AAAs does not threaten the window of opportunity for EVAR.