SECONDARY AORTOENTERIC FISTULA - CONTEMPORARY OUTCOME WITH USE OF EXTRAANATOMIC BYPASS AND INFECTED GRAFT EXCISION

Purpose: The standard treatment for secondary aortoenteric fistula (SA EF) has been infected graft removal (IGR) and extraanatomic bypass (EA B), an approach criticized for its high rate of death, amputation, and disruption of aortic closure. Recently, graft excision and in situ gr aft replacement has been proposed as a safer treatment alternative. Be cause the current outcome that can be achieved by use of the standard treatment of SAEF has really not been established, we reviewed the rec ords of 33 patients treated for SAEF at our institution during a conte mporary time interval (1980 to 1992). Methods: Thirteen patients (39.4 %) were admitted with evidence of gastrointestinal bleeding and infect ion, whereas nine (27.3%) only had bleeding, 10 (30.3%) only had signs of infection, and one SAEE was entirely occult (graft thrombosis). Po ur patients required emergency operation. The fistula type was anastom otic in 13 (39.4%) patients, paraprosthetic in 15 (45.5%), and not spe cified in 4 cases. Thirty-two patients underwent EAB followed immediat ely by IGR (n = 16, 48.5%) or followed by IGR after a short interval, averaging 3.9 days (n = 16, 48.5%). The final patient underwent IGR, f ollowed by EAB. Results: Follow-up on 31 patients (93.9%) averaged 4,4 +/- 3.7 years. There were nine deaths (27.3%) resulting from the SAEF , six perioperative and three late. Three patients (9.1%) had disrupte d aortic closure. There were four amputations in three patients (9.1%) , two perioperative and two late. Late EAB infection occurred in five patients (15.2%), leading to one death and one amputation. EAB failure occurred in six patients, two during operation and four late, leading to one amputation. The cumulative cure rate for this SAEF group was 7 0% at 3 years and thereafter. Compared with our earlier SAEF experienc e, this is a decline of 21% in the mortality rate, 19% in aortic disru ption, and 27% in limb loss. Conclusions: We conclude that outcome rep orts based on SAEF series extending over long time intervals do not ac curately represent the results that are currently achieved with standa rd SAEF treatment with use of EAB plus IGR. This improved outcome is a ttributed to wide debridement of infected tissue beds, reduced interva ls of lower body ischemia, and advances in perioperative management. T o determine whether any new treatment approach actually offers improve d outcome in the management of SAEF, comparison with EAB plus IGR shou ld be limited to patients treated within the last decade at most.