Aorto-duodenal fistulas after EVAR and open aortic repair.

Abstract Objective To report and compare secondary aorto-duodenal fistulas (ADF) after EVAR (ADF-EVAR) and open aortic repair (ADF-OAR). Methods We retrospectively analyzed the data of the patients treated for aorto-duodenal fistulas between January 2015 and May 2020 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoint of this study was 30-day and one-year mortality; secondary endpoints were major postoperative complications. Results Twenty-four patients (20 males; median age 69 years, range, 53- 82 years) were admitted with aorto-duodenal fistulas after EVAR (n=9) or open aortic repair (n=15), accounting for about 4.3% of all abdominal aortic repairs in our hospital. The median time between initial aortic repair and the ADF diagnosis was 68 months (range, 6-83 months) for the ADF-EVAR group and 80 months (range, 1-479 months) for the ADF-OAR group. Three patients with ADF-EVAR refused surgical treatment due to the high surgical risk. One patient with ADF-OAR underwent removal of the aortic prosthesis without replacement. Twelve patients (ADF-EVAR=4, ADF-OAR=8) underwent in situ replacement of the aorta, and eight patients (ADF-EVAR=2, ADF-OAR=6) got extra-anatomic reconstruction with aortic ligation. After a mean follow-up of 26 months, there were no cases of early limb loss, one case of rupture of the venous graft (ADF-EVAR), one case of aortic stump blowout (ADF-OAR), and one case of an uretero-arterial fistula with a homograft (ADF-OAR). Overall postoperative complications were significantly higher after ADF-OAR (93% to 33%, P .036). The most frequent bacteria involved in blood cultures were Escherichia coli in 25% of the patients, while candida Spp (61%) were the predominant pathogens in intraabdominal smears. Patient in-hospital mortality rates for the patients with ADF-EVAR and ADF-OAR were 22% and 13%, respectively, and one-year mortality rates 22% and 33%, respectively. Conclusions Patients with aorto-duodenal fistulas after EVAR or open aortic surgery have limited overall survival. Besides similar therapeutic approaches, there were no significant differences in postoperative mortality between these two uncommon pathologies. Overall postoperative morbidity seems to be higher after ADF-OAR.