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1/141. In situ repair of a secondary aortoappendiceal fistula with a rifampin-bonded Dacron graft.

    Secondary aortoenteric fistulas remain challenging diagnostic and therapeutic problems. Although the duodenum is most frequently involved, other intestinal segments are possible sites for fistulization. We report here a case of graft-appendiceal fistula revealed by recurrent gastrointestinal bleeding 11 years after abdominal aortic aneurysm replacement. The preoperative diagnosis was not achieved by endoscopy or imaging assessment. Despite recommended principles of total graft excision and extraanatomic bypass, appendectomy and in situ rifampin-bonded graft reconstruction were performed because of the advanced age and poor arterial runoff. The postoperative course was uneventful and the patient remains well 17 months after operation.
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2/141. Chronic aortic dissection: stenting of aortic true lumen obliteration with late dynamic variations of both lumens.

    Percutaneous endovascular techniques were used to treat an arteriovenous fistula (AVF) associated with pancreatic transplantation. A pancreatic transplant superior mesenteric artery-to-superior mesenteric-vein AVF was successfully embolized while flow to the pancreas transplant was preserved. The embolization was aided by the use of Guglielmi detachable coils and a detachable balloon. No complications were encountered. At 23 months follow-up, the patient is doing well with no recurrence.
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3/141. Primary aortoduodenal fistula.

    The aortoenteric fistula is a well-known but uncommon cause of gastrointestinal haemorrhage. It is usually secondary to previous reconstructive surgery of an abdominal aortic aneurysm. Primary aortoenteric fistula is a rare disorder which predominantly occurs in the duodenum. We report the case of a 76-year-old patient who presented with melaena and hypovolaemic shock due to a primary aortoduodenal fistula. Pathogenesis, diagnostic procedures and postmortem pathologic examination of this condition are discussed. The value of computed tomography in establishing the diagnosis is emphasized.
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4/141. Primary aorto-duodenal fistula secondary to infected abdominal aortic aneurysms: the role of local debridement and extra-anatomic bypass.

    Gastrointestinal bleeding secondary to spontaneous rupture of an infected abdominal aortic aneurysm into the duodenum is a rare and highly lethal clinical occurrence, representing roughly a third of all primary aortoduodenal fistulas. diagnosis is problematic due to the subtleties in the clinical presentation and course, and surgical treatment is usually delayed, representing a challenge even for the experienced vascular surgeon. The overall mortality is over 30% and the operative approaches are still controversial. Two cases of ruptured infrarenal aortic aneurysms complicated with aortoduodenal fistula were recently treated at our institution. Bacterial aortitis was documented by arterial wall cultures positive for klebsiella and salmonella species respectively. The clinical courses and outcomes of the two patients (one survivor ) treated with retroperitoneal debridement and extra-anatomic bypass and a review of the modern surgical treatment are herein described.
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5/141. Aortocaval fistula in ruptured aneurysms.

    OBJECTIVES: to study incidence, clinical presentation and problems in management of aortocaval fistula in our series. DESIGN: retrospective study. MATERIALS: during a seven-year period, 112 patients operated on for abdominal aortic aneurysm, including four patients with aortocaval fistula. methods: standard repair of aortocaval fistula from inside the aneurysmal sac was the preferred operative technique. RESULTS: the incidence of aortocaval fistula was 3.6%. Three cases were found incidentally during emergency surgery for ruptured aneurysms; the fourth case was an isolated aortocaval fistula associated with inferior vena cava thrombosis, diagnosed preoperatively by angiography. In this case, inferior vena cava ligation instead of standard aortocaval repair was performed. CONCLUSIONS: Aortocaval fistulas, although rare, should be kept in mind, because clinical diagnosis is often difficult. Furthermore, unsuspected problems during repair may necessitate appropriate change in operative technique.
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6/141. Aortoduodenal fistula arising from the dilatation of a knitted Dacron graft: report of a case.

    A fatal aortoduodenal fistula occurred in a 72-year-old man who underwent a repair of an abdominal aortic aneurysm 16 years previously with a 20 x 10 mm bifurcated knitted Dacron graft. The aortic part of his bifurcated graft had dilated to 40 mm in diameter, with a discrepancy of 20 mm in the diameter between the graft and infrarenal aorta. The fourth portion of the duodenum adhered to the left side of the anastomosis, where the aortoenteric fistula had occurred. We believe that the graft dilatation was the cause of the anastomotic failure, although other factors such as atherosclerotic degeneration of the host aorta should also be considered. Knitted Dacron grafts that have been implanted for more than 10 years should therefore be monitored carefully because they have an inherent tendency to dilate, especially those manufactured before 1981.
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7/141. Cavernous aneurysm rupture with balloon occlusion of a direct carotid cavernous fistula: postmortem examination.

    We present a unique case of a patient with a symptomatic carotid cavernous fistula treated successfully with balloon embolization. Her subsequent death from other disease processes allowed direct visualization of the balloon occlusion in situ at postmortem examination.
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8/141. Aortoduodenal fistula: a late complication of intraluminal exclusion of an infrarenal aortic aneurysm.

    During recent years, considerable clinical experience has been gained with endoluminal stent-graft procedures. Several studies have shown promising results up to a period of 4.5 years. However, long-term follow-up studies are still limited. Late endoleaks caused by stent-graft migration, disconnection of single components in modular stent-grafts, and limb thrombosis have been observed as long-term complications. We report a case in which a migrated and kinked bifurcated stent-graft caused an aortoduodenal fistula 20 months after stent-graft insertion. To our knowledge, such a complication has not been reported before.
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9/141. Successful surgical treatment of primary aorto-duodenal fistula associated with inflammatory abdominal aortic aneurysm: A case report.

    We report a rare case of a 50-year-old woman with intermittent gastrointestinal (GI) bleeding and diagnosed as having primary aortoenteric fistula (PAEF) with inflammatory abdominal aortic aneurysm (IAAA). She was transferred to our institution with suspected PAEF as assessed by duodenoscopy and CT scan. As the patient was in shock due to massive GI-bleeding two days after admission, we performed an emergency laparotomy. The fistula was closed and the aneurysm replaced by a Woven Dacron Graft with an inter-positioning omental flap. A high index of suspicion is the most important diagnostic aid to prevent overlooking this often fatal disease.
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10/141. Two cases of aorto-gastrointestinal fistula.

    We report two cases of aorto-gastrointestinal fistula. Case 1, a 60-year-old man, suffered from repeat hematemesis. He was preoperatively diagnosed as aortoesophageal fistula with thoracic aortic aneurysm and was successfully treated by graft replacement of the aneurysm. Case 2, a 73-year-old man, presented with massive gastrointestinal bleeding, yet repeat endoscopical examination did not reveal the origin of the bleeding. He died of catastrophic hematochezia. The pathological findings at autopsy revealed an aortoduodenal fistula. These two cases suggested the importance to consider an aorto-gastrointestinal fistula in the differential diagnosis of patients presenting gastrointestinal hemorrhage.
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