Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 112-114

Asymptomatic Para-prosthetic Graft to Bowel Fistula Following Aorto-bifemoral Bypass Grafting Detected Incidentally


Department of Cardiothoracic and Vascular Surgery, Gobind Ballabh Pant Hospital, Maulana Azad Medical College, New Delhi, India

Date of Web Publication8-Oct-2015

Correspondence Address:
Sunil Kumar
Department of Cardiothoracic and Vascular Surgery, Gobind Ballabh Pant Hospital, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.166941

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  Abstract 

Secondary aorto-enteric fistula (SAFE) is a late but dreaded complication of abdominal aortic surgery with an overall mortality ranging from 30% to 70% in different series. Most commonly the patients with SAFE, present with the massive gastrointestinal bleed or other symptoms such as sepsis, lower extremity ischemia, abdominal pain, septic arthritis, and multicentric osteomyelitis. Treatment requires prompt diagnosis, and surgery. We present a case of para-prosthetic graft to bowel fistula in a patient who was asymptomatic and has presented for treatment of ventral wall incisional hernia.

Keywords: Aorto-bifemoral bypass grafting, aorto-enteric fistula, prosthetic graft fistula


How to cite this article:
Kumar S, Mangukia C, Geelani MA, Satsangi DK. Asymptomatic Para-prosthetic Graft to Bowel Fistula Following Aorto-bifemoral Bypass Grafting Detected Incidentally. Indian J Vasc Endovasc Surg 2015;2:112-4

How to cite this URL:
Kumar S, Mangukia C, Geelani MA, Satsangi DK. Asymptomatic Para-prosthetic Graft to Bowel Fistula Following Aorto-bifemoral Bypass Grafting Detected Incidentally. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2019 Oct 21];2:112-4. Available from: http://www.indjvascsurg.org/text.asp?2015/2/3/112/166941


  Introduction Top


Secondary aorto-enteric fistula (SAFE) are an uncommon late complication of abdominal aortic reconstructive surgeries, occurring months to years after the primary surgery, but the disease perse has a high mortality even after prompt surgery is done. Its incidence ranges from 0.3% to 2%.[1]

The first reported case of SAFE was by Brock, involving the aortic homograft to the duodenum.[2] In 1956, Clayton et al. presented the first case of SAFE caused by a prosthetic graft of aorta.[3] In 1958, Mackenzie et al. presented the first successful repair of a case of SAFE between prosthetic graft and intestine.[4]

Generally two types of SAFE are described:

  • Type-I: Termed a true SAFE with or without a pseudoaneurysm, develops between the proximal aortic suture line and the bowel, this type of fistula is the most common and often initiates a massive gastrointestinal (GI) haemorrhage. The main clinical manifestation of these type of SAFE is massive upper GI bleed, which might be either hematemesis or melena with equal frequency. Sepsis and abdominal pain are relatively rare with this type of fistula
  • Type-II: These are para-prosthetic fistula and do not develop communication between the bowel lumen and the graft lumen. These account for 15–20% of cases. In these type of fistulas, bleeding occurs from the edge of eroded bowel by the mechanical pulsations of the aortic graft. Sepsis is more common in this type of fistula (75%). In addition to sepsis, GI haemorrhage (30%), abdominal pain (20%), septic emboli to the lower extremity, septic arthritis, multicentric osteomyelitis, and hypertrophic osteoarthropathy can occur.[5],[6]


Here, we present a case of SAFE diagnosed incidentally in an asymptomatic patient who presented for repair of an incisional ventral wall hernia.


  Case Report Top


A 45-year-old patient who had undergone an aorto-bifemoral bypass grafting 4 years ago in the same centre for aorto-iliac occlusive disease presented for the repair of an incisional hernia which had developed 6 months after the primary grafting. The patient was asymptomatic with no symptoms of any claudication in both lower limb or any abdominal symptoms other than the visible mass in the lower abdomen.

On examination, the femoral pulse was absent on the right side but was present on the left side, the ankle brachial pressure index was 0.95 on the right side, and was 1.0 on the left side. The patient had a mass in the lower abdomen over the previous incision site with visible bowel movements over it. Suspecting a thrombosed right graft limb, a Doppler of the bilateral lower limb was done which revealed monophasic flow in the right graft limb, and biphasic flow in the left graft limb. A contrast enhanced computed tomography (CT) of the lower abdomen, and bilateral lower limb was done which revealed the small intestinal loop adhered to the right graft limb with gas shadow in the right graft limb, with no contrast opacification of the right graft limb. The upper and lower GI endoscopies were done neither of which showed any fistula. The patient was planned of an exploratory laparotomy in conjunction with the GI surgical team.

Intra-operatively the bowel loops were seen adhered to each other, the striking finding was the right graft limb was seen eroding into the lumen of the distal jejunal loop, there was no pus or pseudoaneurysm surrounding the fistula, the left limb of the graft was also adhered to a separate loop of jejunum without any fistulisation. There was no flow in both the graft limb and on explanting the graft, the main aortic portion of the graft was thrombosed. Whole of the graft was explanted, the aortic end was oversewed, and both the femoral ends were closed with vein patch. The fistulizing segment of jejunum was resected, and anastomosed end to end, and an extra-anatomical axillo-bifemoral bypass grafting was done [Figure 1], [Figure 2], [Figure 3], [Figure 4]. And the incisional hernia was repaired with primary closure of the rectus sheath. The patient remained well in the postoperative period and was given broad spectrum antibiotics. The patient was discharged on the 15th postoperative day and presently is doing well.
Figure 1: Contrast enhanced computed tomography of abdomen showing gas shadow in the right graft limb

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Figure 2: Contrast enhanced computed tomography angiogram of the abdominal aorta and bilateral lower limb showing cut off in the right graft with distal reformation by collaterals

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Figure 3: Intra-operative image showing the right graft limb which had eroded into the lumen of the distal jejunum

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Figure 4: Intra-operative image showing the resected specimen of distal jejunum containing the fistulous tract

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  Discussion Top


SAFE should be considered in any patient who has undergone an abdominal aortic surgery and present with the symptoms of GI haemorrhage, unexplained blood loss, and recurrent attacks of sepsis. To diagnose, SAFE requires a high index for suspicion, and no single investigation has a very high sensitivity or specificity to diagnose SAFE, including CT, angiography, gallium 67 CT. GI endoscopy, if positive is the most helpful method to diagnose, though the presence of aneurysmal mass around the graft, gas shadow around the graft or blood clots in the distal half of duodenum on ultrasound are suggestive of SAFE.

In a patient with active GI bleed, prompt diagnosis, and urgent surgical management id of prime importance for patient's survival. Even after the adequate surgical therapy mortality remains very high ranging up to 50–60%. Surgical option includes the division of the fistula, excision of the ancient grafts, restoration of bowel continuity, and extra-anatomical bypass grafting. It is of the importance to interpose omentum between the anastomotic site and duodenum at the time of aorto-bifemoral grafting to prevent aorto-enteric fistula by preventing the contact between anastomotic site and the bowel.

In our patient, who was completely asymptomatic, the suspicion of a SAFE was possible because of the CT images showing gas in the right graft limb. As there was no sign of sepsis, and the patient was preserved without any bleed, the patient had a better outcome. This case emphasizes the need to keep a very high index of suspicion in aorto-bifemoral grafting for SAFE even in the presence of a thrombosed graft limb. And a CT scan is a possible investigation to screen the patient for SAFE.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sierra J, Kalangos A, Faidutti B, Christenson JT. Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy. Cardiovasc Surg 2003;11:185-8.  Back to cited text no. 1
    
2.
Brock RC. Aortic homografting; a report of six successful cases. Guys Hosp Rep 1953;102:204-28.  Back to cited text no. 2
[PUBMED]    
3.
Birch L, Cardwell ES, Claytor H, Zimmerman SL. Suture-line rupture of a nylon aortic bifurcation graft into the small bowel. AMA Arch Surg 1956;73:947-50.  Back to cited text no. 3
[PUBMED]    
4.
Mackenzie RJ, Buell AH, Pearson SC. Aneurysm of aortic homograft with rupture into the duodenum. AMA Arch Surg 1958;77:965-9.  Back to cited text no. 4
    
5.
Dachs RJ, Berman J. Aortoenteric fistula. Am Fam Physician 1992;45:2610-6.  Back to cited text no. 5
    
6.
Chang MW, Chan YL, Hsieh HC, Chang SS. Secondary aortoduodenal fistula. Chang Gung Med J 2002;25:626-30.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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