Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 195-197

Infected double graft explantation in graft enteric erosion


1 Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication8-Aug-2018

Correspondence Address:
Dr. Ajay Savlania
Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_80_17

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  Abstract 


Aortoenteric fistula (AEF) is an uncommon entity with high morbidity and mortality associated with it. Primary AEF can occur in the presence of aortic aneurysm but it is less common as compared to the secondary type, which is associated with the presence of prosthetic graft used for repair of aortic aneurysm or aortic bypass for occlusive disease. Multiple strategies have been described in the literature which needs to be individualized to each patient. This patient had undergone aortobifemoral bypass twice in the past, which makes anatomy hostile, followed by graft infection and graft enteric (jejunum) erosion leading to very challenging case to treat. The patient was managed in two stages, first axillobifemoral bypass followed by explantation of two grafts. He is doing fine at >12 months of follow-up.

Keywords: Aortoenteric fistula, graft explantation, infected graft


How to cite this article:
Pandey A, Reddy A, Singh H, Gorsi U, Savlania A. Infected double graft explantation in graft enteric erosion. Indian J Vasc Endovasc Surg 2018;5:195-7

How to cite this URL:
Pandey A, Reddy A, Singh H, Gorsi U, Savlania A. Infected double graft explantation in graft enteric erosion. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2018 Dec 10];5:195-7. Available from: http://www.indjvascsurg.org/text.asp?2018/5/3/195/238739




  Introduction Top


Secondary aortoenteric fistula, albeit a rare catastrophic complication of aortic surgery, is a difficult situation owed to high morbidity and mortality associated with it. Conventional treatment consists of extra-anatomic bypass grafting, followed by subsequent graft removal. This paper describes the successful management of a secondary AEF with extraanatomic bypass and double graft explantation (as patient underwent twice aortobifemoral bypass previously).


  Case Report Top


A 42-year-old male presented with fever and generalized weakness of 2-month duration. He had undergone aortobifemoral bypass (AFBx) twice, 5 years and 8 months ago, respectively, for severe claudication on both occasions. He had reformed smoking 5 years ago and denies a history of black tarry or blood in stools. The patient has been evaluated outside with computerized tomographic angiogram and positron-emission tomogram, which showed gas around the aortic graft [Figure 1] (Bunt's Stage 0 graft infection)[1] and an additional nonopacified graft was noticed along with patent aortofemoral graft. The patient did not improve on prolonged parenteral antibiotics received at referring hospital. He had mild-to-moderate claudication pain in bilateral lower limbs with palpable femoral pulsations and absent pulsations in popliteal artery and distally in both lower limbs with ankle brachial index (ABI) of 0.6 bilaterally. He was nutritionally depleted (serum albumin level 2.8 gm % with body mass index 16.6 kg/m2) with hemoglobin 7.2 gm/dl and elevated total leukocytic count of 16,500/mm3. He was optimized by blood transfusion and started on broad-spectrum antibiotics empirically covering Gram-negative and Gram-positive bacteria (vancomycin and amikacin). He underwent surgery in two stages, in the first stage Blaisdell modification of axillobifemoral bypass (AxFB) was done using 8-mm expanded polytetrafluoroethylene (ePTFA) externally supported graft for right axillo-right femoral bypass and 7-mm ePTFA externally supported for femoro-femoral bypass.[2] During groin dissection, bilaterally femoral limbs of graft were dismantled carefully from femoral arteries, ends of grafts sutured closed with polypropylene sutures, and pushed under the inguinal ligaments after careful circumferential dissection. We sought the help of urologist for stenting ureter bilaterally for intraoperative identification only before the second surgery. He had melena following first surgery and taken up for the second-stage surgery within 24 h with diagnosis of secondary aortoenteric fistula (AEF) which was confirmed during the second surgery (infected graft eroded the adherent jejunum). Due to third time laparotomy, there were dense adhesions of small bowel underside the laparotomy scar site which were separated by careful dissection. A loop of jejunum was adherent to graft, which was separated carefully and found to be eroded. There were clots around the graft and on clearing the clots graft was found to be bile stained [Figure 2]. Jejunal rent was closed in interrupted fashion with absorbable polyglactin suture. Under supraceliac aortic clamping (23 min), two grafts were removed [Figure 3], one complete AFBx graft (polyester) and second bits of PTFE graft which were partially removed during the second AFBx surgery and the infrarenal aortic stump was closed with polypropylene suture and covered with well-vascularized omental flap. Ureteric stents were quite useful to guide the removal of graft limbs distally, as it helped in the identification and safe guarding of ureters bilaterally by palpation in hostile anatomy. His preoperative blood culture report was sterile, and antibiotics were changed to imipenem (carbapenem) after the second procedure as per se nsitivity following graft culture report came out positive with  Escherichia More Details coli. His serum creatinine was mildly elevated from normal preoperative of 0.8 to 1.4 mg% postoperatively which normalized to 1.0 at discharge. His limbs were warm in the postoperative period with palpable femoral pulsations and absent pulsations distally (preoperative status) with ABI of 0.62 bilaterally. The patient made unremarkable recovery and was discharged on 14 postoperative days on oral antibiotic doxycycline (only oral drug to which E. coli was sensitive in culture report) for 3 months. Computed tomography angiogram at 3 months of follow-up showed patent axillobifemoral graft and the intact stump of aorta [Figure 4]. His ureteric stents were removed after 3 months. He is doing fine at 12 months of follow-up with palpable pulses in groins and absent pulses distally in limb. During follow-up, he had claudication distance of 500 m (bilateral femoropopliteal disease diagnosed during admission along with AEF) and kept on antiplatelets, statins, and exercise therapy.
Figure 1: Computerized tomography angiogram coronal section showing the presence of air foci around the graft (arrow)

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Figure 2: Intraoperative picture showing eroded jejunum (ring) with clots over the prosthetic polyester graft

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Figure 3: Picture showing retrieved two grafts, one complete polyester prosthetic graft of previous surgery (second surgery) and two pieces of expanded polytetrafluoroethylene graft of first time aortobifemoral bypass which was explanted partially during the second time aortobifemoral surgery

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Figure 4: Computerized tomographic angiogram and volume-rendered image showing patent axillobifemoral bypass with an intact aortic stump

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  Discussion Top


AEFs, first described in the early 19th century by Sir Astley Cooper,[3] are rare but life-threatening. AEF is defined as an abnormal connection between the aorta and the gastrointestinal tract. It is most often the result of compression of an abdominal aortic aneurysm against (primary cause) or erosion of an aortic prosthetic grafts into (secondary cause) the surrounding gastrointestinal structures. Different strategies of management of graft by explantation only, explantation with in-line graft reconstruction, explantation with extra-anatomic bypasses, and revascularization with neoaortoiliac system can be used as situation demands.[4] We performed revascularization by modified Blaisdell's AxFB[2] as the patient had patent graft preoperatively with severe local infection, followed by explantation of grafts. This case presented a challenge, as it was a third-time aortic surgery with hostile anatomy, and two prosthetic grafts were recovered during explantation of infected prosthesis.

In a review by Sweeney and Gadacz[5] for primary AEF patients, nonoperative management is uniformly fatal. Operative mortality of 36% has been reported in patients who underwent surgical repair, and similar results have been reported in the Netherlands data with in-line reconstruction and primary repair of intestinal rent and it appeared safe in comparison to extra-anatomical repair in primary AEF patients.[6] The natural history of untreated secondary AEF is continued sepsis, hemorrhage, and eventually death. Operative mortality ranges from 13% to 86% with an average mortality of 30%—40%. Amputation rates around 10%, and long-term survival approximates 50% at 3 years. Taken together, these results are proof of the tremendous physiologic stress from the AEF pathology per se and the magnitude of operative repair. Of note, multiple authors have documented higher mortality rates in patients treated for AEF than in those treated for aortic graft infection alone. In a report of 61 patients of AEF, operative treatment required longer hospitalization and more blood transfusion. Furthermore, operative mortality was higher (35% vs. 17%), and 12-month survival diminished (25% vs. 60%) for AEF versus aortic graft infection.[7] Endovascular repair should be used as a bridging therapy to open repair so that acute control of bleeding and relative infection control can be achieved before open surgery or for patients with a limited life expectancy who cannot undergo major surgery and would benefit from a short hospital stay and earlier discharge.[8],[9]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Back MR. Local complications: Graft infection. In: Cronenwett JL, Johnston KW, editors. Rutherford's Vascular Surgery. 7th ed. Philadelphia, PA: Saunders Elsevier; 2010. p. 643-61.  Back to cited text no. 1
    
2.
Blaisdell FW. Extraanatomical bypass procedures. World J Surg 1988;12:798-804.  Back to cited text no. 2
    
3.
Cooper, A. Lectures on the principle and practice of surgery with additional notes and cases by Frederick Tyrell, London: Thomas and George Underwood; Vol. 2. 1824.  Back to cited text no. 3
    
4.
Reilly LM, Stoney RJ, Goldstone J, Ehrenfeld WK. Improved management of aortic graft infection: The influence of operation sequence and staging. J Vasc Surg 1987;5:421-31.  Back to cited text no. 4
    
5.
Sweeney MS, Gadacz TR. Primary aortoduodenal fistula: Manifestation, diagnosis, and treatment. Surgery 1984;96:492-7.  Back to cited text no. 5
    
6.
Voorhoeve R, Moll FL, Bast TJ. The primary aortoenteric fistula in the Netherlands — the unpublished cases. Eur J Vasc Endovasc Surg 1996;11:429-31.  Back to cited text no. 6
    
7.
McCann RL, Schwartz LB, Georgiade GS. Management of abdominal aortic graft complications. Ann Surg 1993;217:729-34.  Back to cited text no. 7
    
8.
Baril DT, Carroccio A, Ellozy SH, Palchik E, Sachdev U, Jacobs TS, et al. Evolving strategies for the treatment of aortoenteric fistulas. J Vasc Surg 2006;44:250-7.  Back to cited text no. 8
    
9.
Burks JA Jr., Faries PL, Gravereaux EC, Hollier LH, Marin ML. Endovascular repair of bleeding aortoenteric fistulas: A 5-year experience. J Vasc Surg 2001;34:1055-9.  Back to cited text no. 9
    


    Figures

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



 

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