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In-situ Bypass and Extra-anatomic Bypass Procedures Result in Similar Survival in Patients with Secondary Aorto-Enteric Fistulae. Journal of vascular surgery Janko, M. R., Woo, K. n., Hacker, R. I., Baril, D. n., Bath, J. n., Smeds, M. R., Kashyap, V. S., Szeberin, Z. n., Magee, G. n., Elsayed, R. n., Wishy, A. n., St John, R. n., Beck, A. n., Farber, M. n., Motta, F. n., Zhou, W. n., Lemmon, G. n., Coleman, D. n., Behrendt, C. A., Aziz, F. n., Black, J. n., Shutze, W. n., Garrett, H. E., de Caridi, G. n., Liapis, C. n., Kakkos, S. n., Obara, H. n., Wang, G. n., Rhéaume, P. n., Davila, V. n., Ravin, R. n., DeMartino, R. n., Milner, R. n., Shalhub, S. n., Jim, J. n., Lee, J. n., Dubuis, C. n., Ricco, J. B., Coselli, J. n., Lemaire, S. n., Fatima, J. n., Sanford, J. n., Yoshida, W. n., Schermerhorn, M. n., Menard, M. n., Belkin, M. n., Blackwood, S. n., Conrad, M. n., Wang, L. n., Crofts, S. n., Nixon, T. n., Wu, T. n., Chiesa, R. n., Bose, S. n., Turner, J. n., Moore, R. n., Smith, J. n., Ciocca, R. n., Hsu, J. n., Czerny, M. n., Cullen, J. n., Kahlberg, A. n., Setacci, C. n., Joh, J. H., Senneville, E. n., Garrido, P. n., Sarac, T. n., Rizzo, A. n., Go, M. n., Bjorck, M. n., Gavali, H. n., Wanhainen, A. n., Lawrence, P. F., Chung, J. n. 2020

Abstract

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.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.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.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.

View details for DOI 10.1016/j.jvs.2020.04.515

View details for PubMedID 32445832