Burks J A, Faries P L, Gravereaux E C, Hollier L H, Marin M L
Division of Vascular Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
J Vasc Surg. 2001 Dec;34(6):1055-9. doi: 10.1067/mva.2001.119752.
Aortoenteric fistula (AEF) is an uncommon but catastrophic complication that can occur either primarily or after aortic reconstruction. Untreated, it is uniformly fatal. Conventional surgical management is associated with a perioperative mortality rate of 25% to 90% and frequent major complications. We reviewed our experience with the endovascular treatment of both primary and secondary AEFs in an effort to determine whether endovascular repair is a less morbid alternative to traditional surgical treatment in select patients.
In a 5-year period, seven high-risk patients who had bleeding and an AEF documented by means of radiology or endoscopy (2 primary, 5 secondary) were treated with coil embolization (1) or placement of an endovascular aortic stent graft (3 aortouniiliac, 2 tube, 1 bifurcated). One patient underwent computed tomography (CT)-guided percutaneous catheter drainage of an infected perigraft collection. The average follow-up period was 27 months (range, 11-66 months), and follow-up consisted of physical examination, complete blood count, and contrast-enhanced helical CT scanning at 3, 6, and 12 months and yearly thereafter. All patients were treated with intravenous antibiotics perioperatively and were prescribed life-long oral antibiotics on discharge.
There was one perioperative death (14%) caused by fungal sepsis. Persistent sepsis after stent-graft placement necessitated laparotomy and bowel resection in one patient. One patient had three bouts of recurrent sepsis that were successfully treated with a change of antibiotic. There were three late deaths (43%) unrelated to the procedure or AEF. Three patients (43%) were alive and well an average of 36 months (range, 23-67 months) after the procedure, with no clinical or radiologic evidence of recurrent bleeding or infection.
Endovascular management of AEFs is technically feasible and may be the preferred treatment in select patients with bleeding and no signs of sepsis. In the setting of gross infection, it may also be considered in high-risk patients as a bridge to more definitive treatment after hemodynamic stabilization and optimization.
主动脉肠瘘（AEF）是一种罕见但灾难性的并发症，可原发发生或在主动脉重建术后出现。若不治疗，其必然致命。传统手术治疗的围手术期死亡率为25%至90%，且常伴有严重并发症。我们回顾了我们对原发性和继发性AEF进行血管内治疗的经验，以确定血管内修复在特定患者中是否是比传统手术治疗创伤更小的替代方法。
在5年期间，7例经放射学或内镜检查证实有出血且患有AEF的高危患者（2例原发性，5例继发性）接受了弹簧圈栓塞治疗（1例）或血管内主动脉支架移植物置入术（3例主动脉单髂动脉型、2例直管型、1例分叉型）。1例患者接受了计算机断层扫描（CT）引导下经皮导管引流感染性移植物周围积液。平均随访期为27个月（范围11 - 66个月），随访包括体格检查、全血细胞计数，以及在3、6和12个月时进行对比增强螺旋CT扫描，此后每年进行一次。所有患者围手术期均接受静脉抗生素治疗，出院时开具终身口服抗生素。
1例患者因真菌败血症在围手术期死亡（14%）。1例患者在支架移植物置入后持续发生败血症，需要进行剖腹手术和肠切除术。1例患者发生3次复发性败血症，通过更换抗生素成功治疗。有3例晚期死亡（43%）与手术或AEF无关。3例患者（43%）在手术后平均36个月（范围23 - 67个月）存活且状况良好，无复发出血或感染的临床或影像学证据。
AEF的血管内治疗在技术上是可行的，对于有出血且无败血症迹象的特定患者可能是首选治疗方法。在存在严重感染的情况下，对于高危患者，在血流动力学稳定和优化后，也可将其视为过渡到更确定性治疗的桥梁。
