In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas

Matthew R. Janko, Karen Woo, Robert I. Hacker, Donald Baril, Jonathan Bath, Matthew R. Smeds, Vikram S. Kashyap, Zoltan Szeberin, Gregory A. Magee, Ramsey Elsayed, Andrew Wishy, Rebecca St. John, Adam Beck, Mark Farber, Fernando Motta, Wei Zhou, Gary Lemmon, Dawn Coleman, Christian Alexander Behrendt, Faisal AzizJames Black, William Shutze, H. Edward Garrett, Giovanni De Caridi, Christos D. Liapis, George Geroulakos, John Kakisis, Konstantinos Moulakakis, Stavros K. Kakkos, Hideaki Obara, Grace Wang, Pascal Rhéaume, Victor Davila, Reid Ravin, Randall DeMartino, Ross Milner, Sherene Shalhub, Jeffrey Jim, Jason Lee, Celine Dubuis, Jean Baptiste Ricco, Joseph Coselli, Scott Lemaire, Javairiah Fatima, Jennifer Sanford, Winston Yoshida, Marc L. Schermerhorn, Matthew Menard, Michael Belkin, Stuart Blackwood, Mark Conrad, Linda Wang, Sara Crofts, Thomas Nixon, Timothy Wu, Roberto Chiesa, Saideep Bose, Jason Turner, Ryan Moore, Justin Smith, Rocco Ciocca, Jeffrey Hsu, Martin Czerny, Jonathan Cullen, Andrea Kahlberg, Carlo Setacci, Jin Hyun Joh, Eric Senneville, Pedro Garrido, Timur P. Sarac, Anthony Rizzo, Michael R. Go, Martin Bjorck, Hamid Gavali, Anders Wanhainen, Peter F. Lawrence, Jayer Chung

Research output: Contribution to journalArticlepeer-review

Abstract

Objective: 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. Methods: 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. Results: 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. Conclusions: 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.

Original languageEnglish (US)
JournalJournal of Vascular Surgery
DOIs
StateAccepted/In press - 2020

All Science Journal Classification (ASJC) codes

  • Surgery
  • Cardiology and Cardiovascular Medicine

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