Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Ronald Reagan UCLA Medical Center, University of California Los Angeles, Los Angeles, Calif.
J Vasc Surg. 2021 Jan;73(1):210-221.e1. doi: 10.1016/j.jvs.2020.04.515. Epub 2020 May 21.
The optimal revascularization modality in secondary aortoenteric 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 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and 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.
During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (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 SAEFs (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 (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality.
These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.
在继发于主动脉肠瘘（SAEF）中，最佳的血运重建方式仍不明确。本研究旨在通过真实世界的数据来确定与最低发病率和死亡率相关的血运重建方法。
使用标准化数据库，对 2002 年至 2014 年期间的 SAEF 进行回顾性、多机构研究。记录基线人口统计学、合并症和手术及术后变量。主要结局是长期死亡率。进行描述性统计、Kaplan-Meier 生存分析以及单变量和多变量分析。
在研究期间，来自 11 个国家的 34 个机构的 182 名患者出现 SAEF（中位数年龄为 72 岁，男性占 79%）。导致 SAEF 的初始主动脉手术分别为 138 例外科移植物（76%）和 42 例血管内移植物（23%），2 例未知；102 例 SAEF（56%）完全切除感染的主动脉移植物材料，随后进行原位（顺行）旁路（ISB），包括抗生素浸泡的移植物（53 例）、自体股静脉（新腹主动脉髂动脉手术；17 例）、冷冻保存同种异体移植物（28 例）和未处理的移植物（4 例）。有 80 例（44%）患者接受了感染移植物切除后的外生旁路（EAB）。总体中位 Kaplan-Meier 估计生存率为 319 天（四分位距，20-2410 天）。按 EAB 与 ISB 分层，Kaplan-Meier 估计生存率无显著差异（P=.82）。比较 EAB 与 ISB，EAB 患者年龄更大（74 岁 vs 70 岁；P=.01），术中出血量更少（1200 毫升 vs 2000 毫升；P=.04），术后 30 天内更可能开始透析（15% vs 5%；P=.02），术后 30 天内发生主动脉相关出血的可能性更小（3%的主动脉残端裂开 vs 11%的吻合口破裂；P=.03）。在表现、合并症以及术中或术后变量方面，无其他显著差异。多变量 Cox 回归显示，抗生素使用时间（风险比，0.92；95%置信区间，0.86-0.98；P=.01）和出院时使用利福平（风险比，0.20；95%置信区间，0.05-0.86；P=.03）独立降低死亡率。
这些数据表明，ISB 与 EAB 相比并不能提供生存优势，也不能降低术后与主动脉相关的出血风险。修复后，<50%的 SAEF 患者能存活 10 个月。每周使用抗生素可降低 8%的死亡率。该人群需要进行风险建模的进一步研究。
