Twenty-Year Experience with Aorto-Enteric Fistula Repair: Gastrointestinal Complications Predict Mortality

BACKGROUND: Aorto-enteric fistulas (AEF) represent a lethal subset of aortic graft infections. The optimal management of AEF remains unclear. We aimed to identify predictors of morbidity and mortality. STUDY DESIGN: We performed a single-center retrospective review of consecutive AEF repairs. Demographics, comorbidities, and perioperative variables were obtained. Descriptive statistics, chi-square, Kruskall-Wallis, and Cox proportional-hazards modeling were used where appropriate. RESULTS: Between June 1995 and October 2014, 50 patients (30 male; 60%) presented with AEF, with a median age of 70 years (interquartile range [IQR] 61 to 75 years). Median follow-up for the entire cohort was 14 months (IQR 5 to 27 months). Thirty-four (68%) subjects underwent aortic reconstruction with femoral vein; 12 (24%) with extra-anatomic bypass and aortic ligation; 3 (6%) with rifampin-soaked Dacron graft; and 1 (2%) with cryopreserved aortic allograft. The duodenum was the most common location of the enteric defect (n = 40, 80%). Duodenal leak complicated 6 (12%) of the primary enteric repairs, but none of the complex enteric repairs performed with resection and/or bypass. Twenty-three patients (46%) died by 60 days. Advanced age, chronic renal insufficiency, any complications, and gastrointestinal (GI) complications (n = 13, 26%) were all associated with an increase in overall mortality on univariate analysis (p < 0.05). Gastrointestinal complications (hazard ratio [HR] 3.23; 95% CI 1.27 to 8.25; p = 0.015) and advanced age (HR 1.07; 95% CI 1.01 to 1.13; p = 0.01) were the only independent predictors of mortality on multivariable regression models. CONCLUSIONS: Over 20 years, approximately 50% of patients with AEF repairs died within 60 days. Gastrointestinal complications increase the risk of mortality more than 3-fold, representing an attractive surgically modifiable risk factor. Future multicenter studies are required to clarify optimal methods of arterial and GI reconstruction in AEF. Published by Elsevier Inc. on behalf of the American College of Surgeons.