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Page 4 of 5 Wang et al. Vessel Plus 2018;2:3. I http://dx.doi.org/10.20517/2574-1209.2017.38

Figure 4. Five weeks post-operatively, the patient remained bleed-free without leukocytosis or fever. Computed tomography angiogram
demonstrated improvement in peri-aortic inflammation and stable positioning of the intraluminal vascular plug (black arrow) and the
microcoils (white arrow)
[2-4]
instrumentation, enteric contact with aortic wall or graft, and persistent inflammation . Spontaneous
rupture of the aorta through the fistulous connection can present as subclinical, persistent bleeding, or life
[5,6]
threatening exsanguination and carries a mortality rate approaching 100% if left untreated .
Patients developing AEF may prove to be difficult to diagnose as they tend to present with episodic
bleeding. Therefore, a high index of suspicion must be maintained. Other clinical manifestations may
[2]
include abdominal pain, palpable abdominal mass, and nausea . However, these symptoms are either
vague or often absent. Our patient presented with episodic bleeding without other accompanying
symptoms for 6 months and underwent multiple CTAs and endoscopies before he was diagnosed. This
illustrates well the difficulty in making the diagnosis and locating the site of pathology.

[5]
High-quality evidence regarding outcomes after treatment of AEFs are severely lacking . One of the
[7]
larger experiences was published by Armstrong et al. in 2005. In this study, the authors described their
experience with secondary AEFs in 29 patients. The most common procedures performed were excision
with extra-anatomic bypass including axillo-femoral and cross-femoral bypass grafting (n = 25), aorto-
femoral grafting with additional lower-limb bypasses (n = 2), and in situ reconstruction with rifampin-
[7]
soaked Dacron (n = 2). Perioperative mortality in those who received an operation at 30-day was 21% .

A European meta-analysis of both endovascular and open intervention for secondary AEFs was published
[8]
in 2016 by Kakkos et al. . The authors included 98 patients who received endovascular intervention
along with 725 open repairs from 1999 to 2015. In-hospital mortality was 7.1% in the endovascular group
compared to the 33.9% in the open repair cohort, though this would be expected given the intent of each
treatment modality, specifically palliation versus definitive repair. Interestingly, there was no difference
in recurrence between the two treatment modalities. While the early survival benefit dampened during
follow-up, it continued to remain significant. Not surprisingly, late sepsis was twice as high in the
endovascular group compared to open repair at two years postoperatively (42% vs. 19%). The authors
conclude that endovascular repair is associated with early benefit which is lost over time; therefore, they
argue for staged repair with eventual conversion to in situ vein grafting in selected patients .
[8]
Based on our previous experience and the established literature, we did not believe our patient would
have survived an open operation and therefore reserved open repair initially. He had multiple abdominal
procedures stemming from his original aortic reconstruction which resulted in takebacks, ostomies, and