Results from the Multicenter Study on Aortoenteric Fistulization After Stent Grafting of the Abdominal Aorta (MAEFISTO)

J Vasc Surg. 2016 Aug;64(2):313-320.e1. doi: 10.1016/j.jvs.2016.04.008. Epub 2016 Jun 9.


Objective: This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR).

Methods: Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR.

Results: A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months.

Conclusions: Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up.

Publication types

  • Comparative Study
  • Multicenter Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aneurysm, False / diagnostic imaging
  • Aneurysm, False / mortality
  • Aneurysm, False / surgery*
  • Aortic Aneurysm, Abdominal / diagnostic imaging
  • Aortic Aneurysm, Abdominal / mortality
  • Aortic Aneurysm, Abdominal / surgery*
  • Blood Vessel Prosthesis Implantation / adverse effects*
  • Blood Vessel Prosthesis Implantation / mortality
  • Elective Surgical Procedures
  • Emergencies
  • Endovascular Procedures / adverse effects*
  • Endovascular Procedures / mortality
  • Female
  • Hospital Mortality
  • Humans
  • Incidence
  • Intestinal Fistula / diagnostic imaging
  • Intestinal Fistula / epidemiology*
  • Intestinal Fistula / mortality
  • Intestinal Fistula / therapy
  • Italy / epidemiology
  • Male
  • Middle Aged
  • Retreatment
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • Vascular Fistula / diagnostic imaging
  • Vascular Fistula / epidemiology*
  • Vascular Fistula / mortality
  • Vascular Fistula / therapy