Aortoenteric fistulas: a preventable problem?

The results of management in 22 patients with secondary aortoenteric fistula are reviewed to determine whether this condition can be prevented. In 14 patients who had resection of an aneurysm, the fistula developed in spite of adequate coverage of the synthetic graft. Most fistulas occurred at sites of anastomosis (81%). Half the patients presented with sudden massive gastrointestinal hemorrhage; however, in 40% hemorrhage had occurred up to 18 months before admission. Endoscopy is the most useful diagnostic modality, but the condition must first be suspected. The most successful definitive management of this problem was removal of the graft and revasoularization of the lower limbs by insertion of an extra-anatomic bypass graft. The overall mortality in the series was 60% and the operative mortality 47%. The preventive aspects of this complication and technical details of the aortic and duodenal closure are discussed. The authors believe that this serious complication of aortic bypass grafting may be prevented by ensuring that the suture line is adequately separated from the small bowel and duodenum.