In situ reconstruction using femoral veins is emerging as one of the acceptable options for aortic reconstruction in patients with aortoduodenal fistula. We report a 35-year young male who presented with secondary aortoenteric fistula. His infected aortic graft was removed and was successfully managed by neo-aortic reconstruction, using both femoral veins in a \u27pantaloon\u27 fashion. He had smooth postoperative recovery and did not have graft re-infection. He did not show signs of chronic venous insufficiency on long-term follow-up

Rehman, Zia Ur

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eCommons@AKUSection of Cardiothoracic Surgery Department of SurgeryJune 2019Neoaorta reconstruction using both femoral veinsin a patient with secondary aortoenteric fistulaZia Ur RehmanAga Khan University, ziaur.rehman@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracicRecommended CitationRehman, Z. (2019). Neoaorta reconstruction using both femoral veins in a patient with secondary aortoenteric fistula. Journal of theCollege of Physicians and Surgeons Pakistan, 29(6), s68-S69.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracic/154S68 Journal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (Special Supplement 1 of Case Reports): S68-S69INTRODUCTIONAortoduodenal fistula (ADF), after abdominal aorticaneurysm repair is an infrequent complication.1 Ifuntreated, it is invariably fatal.2 Extra-anatomical bypassafter removal of infected graft is the conventional treat-ment. However, it is associated with limited patency,recurrent infection and repeated procedures.3 There isalso the risk of aortic stump blowout. In situ recons-truction with femoral vein grafts has been suggested asan alternative with good results.2,4-6 Little is reported inlocal literature on this topic.We present a patient who underwent successful neo-aorta reconstruction using both femoral veins for treat-ment of secondary ADF.CASE REPORTA 35-year male, cigarette smoker, developed backacheand hematuria in September 2012. He was worked upoutside our hospital and underwent cystoscopy, followingwhich he developed deep venous thrombosis of theleft leg. During investigations, he was found to haveprotein C deficiency. On performing MRI lumbosacralregion for back pain, he was also found to have saccularabdominal aortic aneurysm. He was referred to us foraneurysm repair, which was measuring more than 6.5 cm.It was repaired with Dacron bifurcated aorto-bi-iliac graft9x18 mm. It was inflammatory in nature and was erodingvertebral body posteriorly. Tissue culture of the inflamedwall did not grow any organism.Four months later, the patient presented again in theemergency room with right lower leg cellulitis. He washaving a high-grade fever and it was associated withrigors and shivering. Calf and thigh muscles were tenderwith intact vascularity. He did not have any gastro-intestinal symptoms and was tolerating diet well. He wasstarted on intravenous antibiotics; to which, he respondedwell. His fever settled and tenderness decreased withinthe next 1-2 weeks. His blood culture grew Candida andE. coli. On the basis of culture results, he was started onintravenous antifungal medications.CT abdomen with intravenous contrast in the sameadmission was performed to evaluate his aortic recons-truction. It showed secondary ADF, as both limbs ofDacron graft were passing through duodenum withsurrounding air (Figure 1).As he was young and nutritionally well preserved, thedecision for in situ reconstruction was made. This was tobe performed after excision of infected graft and bowelrepair. Although, he had deep venous thrombosis ofleft lower leg but recent venous duplex scan showedpatent femoral and popliteal veins. After ensuringCASE REPORTNeoaorta Reconstruction Using Both Femoral Veins in a Patient with Secondary Aortoenteric FistulaZia-ur-RehmanABSTRACTIn situ reconstruction using femoral veins is emerging as one of the acceptable options for aortic reconstruction in patientswith aortoduodenal fistula. We report a 35-year young male who presented with secondary aortoenteric fistula. Hisinfected aortic graft was removed and was successfully managed by neo-aortic reconstruction, using both femoral veinsin a 'pantaloon' fashion. He had smooth postoperative recovery and did not have graft re-infection. He did not show signsof chronic venous insufficiency on long-term follow-up.Key Words: Aortoduodenal fistula, Femoral vein, In situ reconstruction.Department of Surgery, Aga Khan University Hospital,Karachi, PakistanCorrespondence: Dr. Zia-ur-Rehman, Section of VascularSurgery, Department of Surgery, Aga Khan University Hospital,Karachi, PakistanE-mail: ziaur.rehman@aku.eduReceived: October 03, 2018;   Accepted: January 28, 2019 Figure 1: Both limbs of Dacron graft are passing through the duodenum.Neoaorta reconstruction using both femoral veinspatency, it was planned to use both femoral veins as'pantaloon' graft. Risks and benefits were explained tothe patient and family members in detail; to which, theyconsented. Femoral veins on both sides were dissected.Their tributaries were double ligated. The veins weredissected free from its junction from profunda femoralvein to the level of adductor canal and left in situ.Then abdominal cavity was explored through midlinevia previous scar and supra coelic aortic control gained.There was intense, dense fibrosis in the retro-peritoneum. The plane was created over the anterioraspect of Dacron graft, which was taken as a landmarkto identify its junction with the aorta. The abdominalaorta below the renal arteries and both common iliacarteries were dissected and controlled. Infected graftwas separated from the duodenum. A fistulous openinginvolving 50% of circumference between D3 to D4 wasnoted. It was primarily repaired. Femoral veins, whichhad been already dissected, were disconnected fromboth thighs. Both were everted and their valves excised.Proximal ends were split and joined in a 'pantaloon'fashion. Infected graft was removed; the aortic bed wasdebrided. End-to-end anastomoses of graft with theinfrarenal aorta and both common iliac arteries wereperformed.Greater omentum was placed between the duodenumand the venous graft. Venting gastrostomy and feedingjejunostomy were also created.Patient tolerated the procedure. He was followed at onemonth, six months and then annually for 3 years. He isfine with no recurrent symptoms. He did not havesignificant limb swelling. CT scan at one year showedpatent graft (Figure 2).DISCUSSIONFemoral veins are good option for the reconstruction ofneoaorta due to their size and high resistance to infection.4The proximal end of the vein graft is 10 to 15 mm indiameter, and this allows comfortable anastomosis withthe aorta to be constructed without getting any narrowing.Venous insufficiency is a major concern after harvestingboth femoral veins. Different authors have differentexperiences. Nevelsteen et al. reported minimaldisability due to chronic venous insufficiency at a meanfollow-up of 17 months.5 Clagett et al. found significantlimb swelling, requiring compression stocking in only15% of patients.6 One way to minimize this morbidity isto preserve profunda femoris vein during dissection.This patient did not have any significant limb swellingpostoperatively and had no signs of chronic venousinsufficiency on follow-up.There has been evolution of technique of performing thein situ reconstruction from its initial description.4 One iseversion of vein and excising the valves under vision, aswas performed in this case. There is always chance ofincomplete valve lysis with valvulotome. The othermodification is reinforcement of proximal anastomosiswith tense fascia lata.One of the disadvantages of this procedure is longeroperative time. For this reason, one of the groups hassuggested to perform it as staged procedure. On initialvisit, harvest the femoral veins on both sides but keepthem in situ. After 24 hours, on the second visit to theoperation, perform excision of infected graft and neo-aorta reconstruction.In situ reconstruction with superficial femoral veins is anattractive and feasible alternative in the treatment ofsecondary ADF.REFERENCES1. Berger P, Vaartjes I, Moll FL, De Borst GJ, Blankensteijn JD,Bots ML. Cumulative incidence of graft infection after primaryprosthetic aortic reconstruction in the endovascular era. Eur JVasc Endovasc Surg 2015; 49:581-5.2. Yamamoto Y, Igari K, Toyofuku T, Kudo T, Inoue Y. Late stentgraft infection after the emergency endovascular repair of asecondary iliac artery-enteric fistula treated with graft removaland in situ aortic reconstruction using femoral veins. AnnThorac Cardiovasc Surg 2017; 23:113-7. 3. Berger P, Moll FL. Aortic graft infections: Is there still a role foraxillobi-femoral reconstruction? Semin Vasc Surg 2011; 24:205-10.4. Chung J, Clagett GP. Neoaortoiliac system (NAIS) procedurefor the treatment of the infected aortic graft. Semin Vasc Surg2011; 24:220-6. 5. Nevelsteen A, Lacroix H, Suy R. Autogenous reconstructionwith the lower extremity deep veins: An alternative treatment ofprosthetic infection after reconstructive surgery for aortoiliac-disease. J Vasc Surg 1995; 22:129-34.6. Clagett GP, Bowers BL, Lopez-Viego MA, Rossi MB, Valentine RJ,Myers SI, et al. Creation of a neo-aorto-iliac system from lowerextremity deep and superficial veins. Ann Surg 1993; 218:239-48.Figure 2: Follow-up CT scan after 1 year, showing patent graft.Journal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (Special Supplement 1 of Case Reports): S68-S69 S69

Neoaorta reconstruction using both femoral veins in a patient with secondary aortoenteric fistula

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Neoaorta reconstruction using both femoral veins in a patient with secondary aortoenteric fistula

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