Keunen Bram, Houthoofd Sabrina, Daenens Kim, Hendriks Jeroen, Fourneau Inge
Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium.
Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium.
Ann Vasc Surg. 2016 May;33:230.e5-230.e13. doi: 10.1016/j.avsg.2015.11.033. Epub 2016 Mar 8.
Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity.
A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding.
Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction.
原发性主动脉肠瘘（PAEF）是胃肠道出血的致死原因。它们主要源于腹主动脉瘤侵蚀肠壁。其他已知原因包括恶性肿瘤、感染、异物或放射治疗。传统治疗包括瘘管切除和解剖外重建。原位修复和血管内支架置入为处理这一复杂病症提供了新的治疗选择。
一名79岁女性患有PAEF。她已知患有一个3.9厘米的腹主动脉瘤和风湿性多肌痛。初始治疗包括血管内支架置入。几个月后，她出现主动脉内假体持续炎症。切除假体和炎性组织，并进行自体股浅静脉原位重建和网膜成形术。两年后，她情况良好，无感染或出血迹象。
风湿性多肌痛可能诱发主动脉肠瘘，因为该患者不存在其他诱发因素。不同的治疗选择都有其优缺点。结合本病例，我们建议对主动脉肠瘘采用个体化方法。在血流动力学状态不稳定或预期寿命有限的情况下，应进行血管内治疗。之后，应讨论开放修复的可能性和/或必要性。对于预期寿命可观的稳定患者，自体静脉原位修复或利福平浸泡的假体（根据合并症调整）可能最为合适。解剖外重建在老年患者以及存在任何其他妨碍原位重建的局部因素时，仍然是一种有价值的选择。
