Re: Aortoduodenal Fistula Three Years After Aortobifemoral Bypass: Case Report and Literature Review.

Marolt et al. have presented a very interesting case of aortoduodenal fi stula and its successful treatment1. I have read the article with great interest since it is one of the worst complications that vascular surgeon may face. We had a case of infected abscess and leakage in the thoracic aorta successfully treated with endovascular graft (TEVAR). Our approach for abdominal aorta is graft removal and axillobifemoral bypass. I completely agree with the authors that it is necessary to cover duodenal lesion with omental fl ap, although we do not perform excision of the duodenal/intestinal wall. So far, we had no thrombosis of the axillofemoral bypass and it is remarkable to see suffi cient infl ow of the blood through narrow bypass (usually PTFE 6 mm) to both legs. In order to prevent thrombosis, we always perform distal anastomosis above deep femoral artery or directly to the bifurcation of the common femoral artery. Outfl ow through deep femoral artery is usually able to keep the fl ow through axillofemoral bypass running. If not, bypass distal to the occlusion of the superfi cial artery (or popliteal artery) should be performed. Th e European Society for Vascular Surgery (ESVS) has issued clinical practice guidelines for the management of abdominal aortic aneurysms2. Unstable patients might benefi t from stent graft (Level 4, Recommendation C); stable patients with aortoenteric fi stula should receive staged procedure with extra-anatomic bypass fi rst (Level 2c, Recommendation B); and fi nally stable patients without aortoenteric fi stula (patients that do not have direct communication between proximal anastomosis and bowel but infected paraanastomotic sinus) should receive in situ revascularization using autogenous superfi cial femoral vein or aortoiliac allograft (Level 2c, Recommendation C)2.