Aortoesophageal fistula: a comprehensive review of the literature

Aorto-oesophageal fistula: an unusual complication of oesophageal biopsies

The authors report a case of an aorto-oesophageal fistula presenting in a patient undergoing investigation for possible oesophageal malignancy who underwent multiple oesophageal biopsies. A 73-year-old gentleman underwent endoscopic biopsy of an oesophageal lesion. Histology showed only inflammatory changes, endoscopy was repeated and again biopsy showed only inflammatory changes. The patient then presented with severe haematemesis, which was shown by CT angiogram to be due to an aorto-oesophageal fistula. This was treated with endovascular stenting, and the patient recovered well. Sequential imaging has shown gradual resolution of the submucosal swelling and lymphadenopathy, excluding the possibility of underlying oesophageal malignancy. This is the first reported case of aorto-oesophageal fistulation as a complication of endoscopic oesophageal biopsies. Aorto-oesophageal fistula is an uncommon but potentially life-threatening cause of haematemesis. It is a potential complication of endoscopic oesophageal biopsy.

Risk factors and clinical courses of chemoradiation-related arterio-esophageal fistula in esophageal cancer patients with clinical invasion of the aorta

BACKGROUND

Although concurrent chemoradiotherapy (CRT) is a standard treatment for esophageal cancer invading adjacent structures (T4-EC), arterio-esophageal fistula (AEF) occurs occasionally as a critical adverse event of T4-EC with CRT. The frequency, clinical course, and risk factors of AEF related to CRT are not well known.

METHODS

We retrospectively analyzed 48 patients with T4-EC invasion of the aorta who were treated with 5-fluorouracil, cisplatin, and concurrent radiotherapy at our institution between September 2002 and April 2009. Treatment-related AEF was defined as AEF without obvious tumor progression. We evaluated the frequency, clinical courses, and risk factors of AEF.

RESULTS

The median survival time was 10.6 months with a median follow-up time of 33.3 months. The 2-year survival rate was 25%. Treatment-related AEF was observed in 7 patients (14.6%) and 4 of them died of massive bleeding due to aortic AEF. In the other 3 patients with non-aortic AEF, hemorrhage could be arrested by transcatheter arterial embolization (TAE). In the univariate analysis of risk factors for AEF, lower serum cholesterol level was a risk factor for AEF (OR 14.7; 95% CI 1.58-137; P = 0.008).

CONCLUSIONS

Although CRT has a curative potential even for patients with T4-EC invading the aorta, we should be aware of the relatively high incidence of treatment-related AEF. TAE may be successful in rescuing a non-aortic AEF patient. Low serum cholesterol level may be a risk factor for AEF, but further investigation is needed.

Survival following Treatment of Aortoesophageal Fistula with Dual Esophageal and Aortic Intervention

Aortoesophageal fistulas are a rare but commonly fatal complication of esophageal cancer. Reports of successfully managed cases are few, with high mortality and morbidity usually resulting from failure to control the initial massive haemodynamic insult. We report the case of a 47-year-old Caucasian man with recently diagnosed advanced esophageal cancer who suffered an episode of massive haematemesis. Emergency gastroscopy revealed an arterial bleeding point in the proximal esophagus. A self-expanding metal esophageal stent was placed to achieve initial partial haemostasis. CT angiography confirmed an aortoesophageal fistula. An endoluminal stent device was thus inserted within the thoracic aorta stabilising the bleeding point. The patient subsequently made an uneventful recovery and was discharged on long-term antibiotics for palliative care. He survived for 2 months at home before dying of disseminated malignancy. The successful use of esophageal stenting as a means of achieving haemostasis, allowing time for endovascular intervention, is as yet a relatively unexplored area of management of this rare condition.

Acute Infectious Pseudoaneurysm of the Descending Thoracic Aorta and Review of Infectious Aortitis

Thoracic aortic wall disruptions may occur secondary to trauma, surgical interventions, infection, or autoimmune or idiopathic inflammatory disorders. Such vessel wall disruption can lead to aortic dissections, aneurysm development, or more commonly, pseudoaneurysm (PSA) formation. Although aortic wall infections as an antecedent to mycotic aneurysms have been recognized since the 17th century, there has been a temporal evolution in the development of this disease. Prior to the antibiotic era they were commonly associated with endocarditis or syphilis. More recently, however, they are associated with infection of a damaged atherosclerotic area of the aorta and secondary hematogenous or contiguous seeding. We report the first case of the rapid development of a pseudoaneurysm in the descending thoracic aorta attributable to an infection of a contiguous esophageal duplication cyst by a diagnostic esophageal ultrasound (EUS) fine-needle aspiration. A literature review of mycotic thoracic aortic aneurysms and pseudoaneurysms is also presented.

Aortoesophageal fistula secondary to placement of an esophageal stent: emergent treatment with cyanoacrylate and endovascular stent graft

We report on N-butyl 2-cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of an aortoesophageal fistula secondary to placement of an esophageal stent. A 53-year-old man with lung cancer was admitted with massive hematemesis due to the formation of an aortoesophageal fistula 20 days after esophageal stent placement. Injection of N-butyl 2-cyanoacrylate into the aortoesophageal fistula was performed as emergent treatment for this hemodynamically unstable condition, and an endovascular stent graft was subsequently placed via the right femoral artery. The patient was well without hematemesis until he died of pneumonia 45 days later. Cyanoacrylate embolization and subsequent endovascular stent graft placement for the treatment of massive hemorrhage caused by an aortoesophageal fistula is a prompt, effective method and can be an alternative to surgical repair.

Endovascular treatment of aortoesophageal and aortobronchial fistulae

BACKGROUND

Even when promptly recognized and treated, aortoesophageal (AEF) and aortobronchial (ABF) fistulae are highly lethal conditions. Open surgical repair also carries a high risk of mortality and morbidity. Several alternative strategies have been recently reported in the literature including thoracic endovascular aortic repair (TEVAR). However, relatively little is known about results of TEVAR for AEF and ABF due to their rarity and the lack of large surveys.

METHODS

A voluntary national survey was conducted among Italian universities and hospital centers with an endovascular program. Questionnaires were distributed by e-mail to participating centers and aimed to evaluate the results of endovascular repair of established AEF or ABF.

RESULTS

Seventeen centers agreed to participate and provided data on their patients. Between 1998 and 2008, a total of 1138 patients were treated with TEVAR. In 25 patients (2.2%), the indication to treatment was an AEF and/or an ABF. In 10 of these cases (40%), an associated open surgical procedure was also performed. Thirty-day mortality rate of AEF/ABF endovascular repair was 28% (7 cases). No cases of paraplegia or stroke were observed. Mean follow-up was 22.6 months (range, 1-62). Actuarial survival at 2 years was 55%. Among the 18 initial survivors, five patients (28%) underwent reintervention due to late TEVAR failure.

CONCLUSIONS

Stent grafting for AEF and ABF represents a viable option in emergent and urgent settings. However, further esophageal or bronchial repair is necessary in most cases. Despite less invasive attempts, mortality associated with these conditions remains very high.

Arterial-esophageal fistula: a severe complication in children with cardiovascular abnormalities

Fistulae between esophagus and major arteries are an extremely rare and severe condition. They have been described in patients with previous impairment or abnormalities of mediastinal vessels and intraesophageal increased pressure or as a complication of cardiovascular procedures. We report three cases of children with an aorto-esophageal fistula, a collateral pulmonary artery-esophageal fistula and an aberrant right subclavian artery-esophageal fistula that were successfully managed in coordination with pediatricians, anesthesiologists and both cardiovascular and pediatric surgeons. The severity of this pathology makes it important to suspect it and treat it by a multidisciplinary group of physicians.

Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: a national survey

OBJECTIVE

We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results.

METHODS

We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme.

RESULTS

Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 +/- 12.5 months, overall survival was 16% (3/19).

CONCLUSIONS

The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

An unusual presentation of thoracic aortic aneurysm rupturing into the esophagus: an autopsy case report

Ruptured aortic aneurysms often present with sudden death, and have varied signs and symptoms depending on the site of rupture and hemorrhage. We report a case of an aortic aneurysm with an aorto-esophageal fistula, which showed slow gastrointestinal bleeding for days before death. A 79-year-old male was brought to a hospital emergency unit, with a history of melena for about 3 days, and recent hematemesis. He collapsed immediately after endoscopy and died. A forensic autopsy which was performed due to possible medical malpractice demonstrated a large saccular aneurysm of the descending thoracic aorta with a fistula into the esophagus. A significant finding was a lid or valve shaped thrombus covering the aortic orifice of the fistula, which may have partly contributed to slow bleeding, and which may have been dislodged by endoscopy. This case suggests that very careful management of aorto-esophageal fistula is needed in patients with clinical signs of possible thoracic aortic aneurysm with slow hemorrhage.

Aortoesophageal fistula: A case misdiagnosed as esophageal polyp

Aortoesophageal fistula (AEF) is a rare and fatal disorder. It is also a life-threatening cause of massive upper gastrointestinal hemorrhage. Thoracic aortic aneurysm is the most common cause of AEF. Management of a patient with this disorder requires rapid diagnosis and immediate intervention, which is considered the best way to save the patient’s life. We report a case of AEF misdiagnosed as esophageal polyp.

Outcomes of thoracic endovascular aortic repair for aortobronchial and aortoesophageal fistulas

PURPOSE

To identify in-hospital and follow-up outcomes of thoracic endovascular aortic repair (TEVAR) for aortobronchial fistula (ABF) and aortoesophageal fistula (AEF).

METHODS

The authors reviewed all published cases of ABF and AEF undergoing TEVAR indexed in the MEDLINE, Cochrane Library CENTRAL, and EMBASE databases. After removal of duplicates, 850 articles were scrutinized for relevance and validity. Exclusion criteria included: (1) no clear description of the organs involved with the fistula, (2) no description of outcomes after TEVAR for ABF or AEF, or (3) no original data presented in the article. In this manner, 66 relevant articles were identified that included original data on 114 patients (76 men; mean age 63+/-1.5 years) with ABF (n = 71) or AEF (n = 43). Meta-analyses were performed to investigate outcomes of TEVAR for ABF and AEF.

RESULTS

Patients with AEF presented more frequently with hypovolemic shock (33% versus 13%, p = 0.012) and systemic infection (36% versus 9%, p<0.001) compared to patients with ABF. In-hospital mortality was 3% (n = 2) after TEVAR for ABF and 19% (n = 8) after TEVAR for AEF (p = 0.004). Additional thoracic surgery in the first 30 days after TEVAR was performed in 3% (n = 2) of ABF patients and in 37% (n = 16) of AEF patients (p<0.001); 12 AEF patients who had received esophageal surgery in the first month after TEVAR showed lower fistula-related mortality during 6 months of follow-up compared to patients who did not receive additional esophageal surgery (p = 0.018).

CONCLUSION

TEVAR is associated with superior outcomes in patients with ABF. Endovascular management of AEF is associated with poor results and should not be considered definitive treatment. TEVAR could serve as a bridge to surgery for emergency cases of AEF only, with definitive open surgical correction of the fistula undertaken as soon as possible.

Percutaneous removal of a metallic foreign body from the wall of the thoracic aorta

This report details the percutaneous removal of a metallic foreign body from the wall of the thoracic aorta. The foreign body was presumably swallowed and migrated from the esophagus into the aortic lumen progressively during a period of 10 months. The patient had no adverse consequences from the procedure immediately or in the subsequent 18 months of follow-up.

Aortoesophageal fistula following nasogastric tube placement

A 78-year-old woman was admitted to our hospital because of fresh cerebral infarction. She had been diagnosed as having rheumatoid arthritis, but had not been treated for 50 years. She could not take in sufficient food. Upper gastrointestinal endoscopy revealed no esophageal or gastric lesions, but the procedure was difficult because of her stiff neck from severe rheumatoid degenerative changes of the cervical spine. A nasogastric (NG) tube was placed, and enteral nutrition was initiated. On the 15th day from initiation of enteral nutrition, she presented hematemesis, and suddenly went into a state of shock and died. An autopsy revealed two esophageal ulcers, one of which penetrated into the descending thoracic aorta. The patient was diagnosed with hemorrhagic shock due to aortoesophageal fistula. We suspect that the NG tube compressed the esophageal wall, and ischemia caused the ulcers.

Successful management of an aortoesophageal fistula caused by a fish bone--case report and review of literature

We report a case of aortoesophageal fistula (AEF) caused by a fish bone that had a successful outcome. Aortoesophageal fistula is a rare complication of foreign body ingestion from which few patients survive. Over one hundred cases of AEF secondary to foreign body ingestion have been documented but only seven, including our case, have survived over 12 months. Treatment involved stabilising the patient with a Sengstaken-Blakemore tube and insertion of a thoracic aortic endovascular stent-graft. Unfortunately the stent became infected and definitive open surgical repair involved removing the stent, replacing the aorta with a homograft and coverage with a left trapezius flap while under deep hypothermic arrest.

Aortoesophageal fistula with a history of graft treatment for thoracic aortic aneurysm

Aortoesophageal fistula (AEF) is a rare but fatal cause of gastrointestinal hemorrhage, being most commonly associated with thoracic aortic aneurysm. We present a rare case of secondary AEF post graft treatment for mycotic aneurysm of thoracic aorta 4 years previously. Massive upper gastrointestinal hemorrhage resulted in difficult diagnosis by gastrointestinal endoscopy. Computed tomography angiography (CTA) showed contrast extravasation from the descending aorta into the mid-third esophagus. CTA is a useful diagnostic tool in patients suspected of having AEF. Rapid identification of AEF is important for definitive treatment and increases the likelihood of survival.

Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts

OBJECTIVE

The surgical treatment of aortoesophageal fistulae (AEF) has a high morbidity and mortality rate. We report our experience with the sequential use of endovascular thoracic stentgrafts and cryopreserved aortic homografts for in situ repair of the descending thoracic aorta.

METHODS

In a 7-year period, 6 patients with AEF were treated at our center. After primary endovascular repair in all cases, 4 patients subsequently underwent in situ repair of the descending thoracic aorta with cryopreserved homografts. Long-term antibiotic therapy was given in all cases. Recent clinical status and radiologic findings on follow-up studies of each patient were analyzed. The mean follow-up time was 35 months (range, 2-76).

RESULTS

Endovascular stentgraft repair was technically successful in all cases. Two patients were not candidates for open surgical repair because of their medical condition; they both died within 8 weeks after discharge from the hospital, 1 from recurrent septic episodes, and the other from upper gastrointestinal bleeding. One of 4 patients who had undergone open surgical repair died 1 year later from upper gastrointestinal bleeding that occurred presumably due to an infectious degeneration of the homograft after secondary infection with a methacillin-resistant Staphyloccocus aureus. In 1 case persistent paraplegia and in another case persistent renal failure occurred.

CONCLUSION

The use of cryopreserved homografts is a valuable alternative to in situ repair with prosthetic vascular grafts or extra-anatomic reconstructions in the surgical treatment of AEF. Endovascular stentgraft placement plays a role as a bridging procedure in emergency situations.

Diagnosis and management of primary aortoenteric fistulas--experience learned from eighteen patients

OBJECTIVE

Misdiagnosis of primary aortoenteric fistula (PAEF) frequently occurs in clinical practice owing to the rarity of this condition. Herein we present the experience of diagnosis and management for PAEF.

METHODS

Eighteen patients with PAEF at 2 medical centers in China were reviewed. The clinical data, diagnostic procedures, treatment options, and patient outcomes were evaluated.

RESULTS

The fistulas were located at esophagus (5), duodenum (8), jejunum (3), ileum (1), and transverse colon (1). The etiologies include atherosclerotic aneurysms and foreign body. Typical abdominal triad (pain, upper GI bleeding, and abdominal pulsating mass) was found in 27.8% of patients, and Chiari's triad (mid-thoracic pain, sentinel hemorrhage, and massive bleeding after a symptom-free interval) was present in 3 of 5 cases with thoracic aortoesophageal fistulas. All patients had an average of 3.6 (1-9) episodes of gastrointestinal bleeding. The interval between the first sentinel hemorrhage and ultimate exsanguination ranged from 5 hours to 5 months (median, 4 days). Six patients (33.3%) were diagnosed or suggested by diagnostic tools including endoscopy, computerized tomography, and arteriography. Others were diagnosed by surgical exploration (7) and autopsy (5). One to 5 rounds (mean 1.8) of misdiagnosis occurred in 15 patients. Six patients recovered from surgery and remained well during a 36-month follow-up. The surgical options used included in situ replacement with vascular graft (3), aneurysmorraphy and closure of fistula (1), and endovascular stenting (2).

CONCLUSIONS

A high index of suspicion is necessary for correct diagnosis and prompt management of PAEF, especially in patients with aortoiliac aneurysms presenting with gastrointestinal bleeding. In situ graft replacement and endovascular stent-graft may be the preferred therapeutic options.

Intramural hematoma of the esophagus: a pictorial essay

Intramural hematoma of the esophagus (IHE) is a rare but well-documented condition that is part of the spectrum of esophageal injuries which includes the more common Mallory-Weiss tear and Boerhaave's syndrome. Acute retrosternal or epigastric pain is a common clinical feature, which can be accompanied by dysphagia, odynophagia, or hematemesis. An early differentiation from Mallory-Weiss tear, Boerhaave syndrome, ruptured aortic aneurysm, aortic dissection, acute myocardial infarction, or pulmonary pathology can be difficult. Computed tomography (CT) is the imaging modality of choice and characteristically reveals a concentric or eccentric thickening of the esophageal wall with well-defined borders and variable degree of obliteration of the lumen. Measurement of the attenuation values within the lesion will reveal blood density which varies according to the age of the hematoma. CT should be considered the preferred diagnostic technique, thereby facilitating proper clinical management. Early diagnosis is crucial as most patients may be treated conservatively with good outcome.

Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature

An aberrant right subclavian artery (ARSA) is a common aortic arch abnormality. A case of a 57-year-old man presenting with melena and hypotension secondary to an ARSA-esophageal fistula is reported. The current report is unique because it is the first reported case of ARSA-esophageal fistula associated with prior esophagectomy and gastric pull-up. A MedLine search was performed for ARSA-esophageal fistula cases, which were then compared with the present case. Because this patient had no vascular conduits, nasogastric or endotracheal tubes, the fistula likely occurred secondary to the previous surgery. This case is unusual because the patient survived the original hemorrhage associated with the ARSA-esophageal fistula. An ARSA-esophageal fistula is a rare, but potentially fatal cause of upper gastrointestinal bleeding. A high index of suspicion is needed to make the diagnosis. This condition should be considered in patients with risk factors combined with hemodynamically significant gastrointestinal bleeding.

Esophageal foreign body as a cause of upper gastrointestinal hemorrhage: case report and review of the literature

Foreign body ingestion is a common complaint in the emergency department. Severe upper gastrointestinal (GI) hemorrhage is a rare complication of foreign body ingestion and is always considered to signal aortoesophageal fistula (AEF). We report a rare case of a 65-year-old man with upper GI hemorrhage caused by an ingested duck bone 10 days previously. Instead of AEF, massive erosion and edema were found in the esophagus, highlighting the potentially complex pathology of foreign body ingestion. A literature review of the recognized clinical features of esophageal foreign body is described. Some practical points and pitfalls in the management of esophageal foreign body are presented. For patients with a history of esophageal foreign body ingestion, the clinician must maintain a high index of suspicion and must endeavor to obtain a full history.

Role of interventional repair in the thoracic aorta

Endovascular treatment of chronic aneurysmatic diseases of the descending thoracic aorta has demonstrated encouraging peri-interventional mortality and morbidity and is accepted as a preferred strategy in experienced centers. The emergence of endovascular strategies for acute thoracic aortic pathologies is an even more exciting new territory for nonsurgical interventions considering the sobering results of open surgery. Although it is apparent that patients at high risk for open surgery will benefit from endovascular strategies, the exact role of stent-graft placement remains to be defined, as the community awaits solid long-term data and as devices and techniques continue to improve. While some indications and scenarios, such as acute type B dissection with associated malperfusion syndrome or imminent aortic rupture, have been shown to benefit from stent-graft treatment, others are less settled. The current paper discusses both the established and emerging indications, as well as technical and anatomical aspects of this fascinating therapeutic option.

Fístula aorto-esofágica secundária a fratura de endoprótese torácica: relato de caso

O tratamento endovascular dos aneurismas aórticos torácicos tem se desenvolvido consideravelmente nos últimos anos. No entanto, complicações tardias desta nova modalidade terapêutica apenas agora estão sendo observadas e analisadas. Fístulas aorto-esofágicas são complicações raras do tratamento endovascular dos aneurismas aórticos, sendo encontrados poucos relatos na literatura. O presente caso reporta um paciente com aneurisma aórtico torácico tratado há 4 anos e complicado com fratura da endoprótese. Após nova intervenção endovascular, foi observada extrusão da antiga endoprótese através do esôfago com formação de fístula. Apesar do tratamento realizado, o paciente evoluiu a óbito 9 dias após por hemorragia digestiva maciça. Aspectos técnicos e revisão de literatura são discutidos.

Intra-aortic stent graft in oesophageal carcinoma invading the aorta. Prophylaxis for fatal haemorrhage

In patients with advanced oesophageal carcinoma with aortic invasion, any therapy potentially causes fatal haemorrhage. We describe here the successful application of intra-aortic stent graft to prevent haemorrhage before radical oesophagectomy for advanced oesophageal cancer. Four patients with advanced oesophageal cancer complicated by invasion of the aorta. Under general anaesthesia, aortic invasion is evaluated by an intravascular sonography. The stent graft is passed through the right femoral artery into the descending aorta. Subsequently, the stent graft is released to expand in the thoracic aorta during an artificial cardiac arrest. Aortography is performed to check for any stent migration or endoleakage. This procedure was successful in all four patients without any complications. All patients underwent radical oesophagectomy following aortic stent-grafting. One patient survived more than 2 years after stent grafting and operation. This procedure is safe and applicable for the patient with aortic invasion before radiochemotherapy or operation.

Successful surgical treatment of a 4-month infant after exsanguination for aortoesophageal fistula

We report on the case of a 4-month infant in hypovolemic shock for severe digestive hemorrhage 38 days after surgical treatment of a double aortic arch who underwent a successful emergency thoracotomy for suspicion of an aortoesophageal fistula.

Aortobronchial fistula resulting from a mycotic pseudoaneurysm after treatment of an aortoesophageal fistula due to a thoracic aortic aneurysm

A 58-year-old man was admitted for an aortoesophageal fistula (AEF) resulting from a thoracic aortic aneurysm. He underwent immediate in-situ prosthetic graft replacement, primary esophageal repair and wrapping of the aneurysm. Postoperative upper gastrointestinal endoscopy and computerized tomography (CT) findings were unremarkable. He was discharged on postoperative day (POD) 25. Three months after surgery, he was readmitted with complaints of worsening cough and hemoptysis. CT showed a thrombosed aneurysm adjacent to the left bronchus. Aortobronchial fistula due to mycotic pseudoaneurysm was suspected. The patient underwent immediate resection of the infected graft and prosthetic graft replacement positioned to avoid the infected area. The graft was wrapped with omentum. On POD 7, pleural empyema developed, and esophagography revealed a residual leak. Staged reconstruction of the esophagus was performed successfully. We conclude that even if the fistulous opening is small, simultaneous esophageal resection should be performed during the initial treatment of AEF.

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months' follow-up).

Aortoesophageal fistula--an unusual complication of esophagitis caused by Dieffenbachia ingestion

Aortoesophageal fistula (AEF) is a rare and mostly lethal cause of upper gastrointestinal bleeding in children. We report a successful outcome of surgical treatment after resuscitation of a girl aged 12 1/2 years with AEF as a complication of esophagitis caused by Dieffenbachia ingestion. The girl ate a leaf of Dieffenbachia picta in a suicidal attempt. After 5 weeks of medical treatment of esophagitis, small blood-stained vomitus and melena appeared. Within a few hours, it was followed by a massive gastrointestinal bleeding leading to exsanguination. The girl survived despite the pitfalls in clinical presentation and errors in diagnostic approach and treatment. Emergency exploration of cervical esophagus, followed by laparotomy and thoracotomy, was performed in attempt to find the source of bleeding and to control it. Aortoesophageal fistula was located between the ascending aorta near the origin of the brachiocephalic trunk and thoracic esophagus. Resection of the fistula led to prompt circulatory stabilization. The common houseplant, Dieffenbachia picta, causes edematous swelling of mucus membranes when chewed. Dieffenbachia-caused esophagitis is very rare and this etiology of AEF has not been reported in children.

Aortoesophageal fistula as a complication of Montgomery salivary bypass tube

The authors describe a 2-year-old girl with a right-sided aortic arch who developed a sudden, fatal aortoesophageal fistula after prolonged placement of Montgomery salivary bypass tubes in the distal esophagus.

Emergency Endovascular Repair of an Aortoesophageal Fistula Caused by a Foreign Body

PURPOSE

To report stent-graft treatment of an aortoesophageal fistula caused by a foreign body.

CASE REPORT

A 32-year-old man was admitted with massive upper gastrointestinal bleeding 10 days after swallowing a fish bone. Computed tomography demonstrated a fistula from the proximal descending thoracic aorta to the mid esophagus. The bleeding was initially controlled by inflating a Sengstaken-Blakemore tube. A 28-mm x 16-cm Talent stent-graft was delivered transfemorally to repair the aortic defect; the esophageal injury was repaired primarily using a pedicled intercostal muscle flap via a right thoracotomy. Chest radiography at 12 months showed no migration of the stent-graft. Blood parameters of infection were normal; the patient remains well 18 months after stent-graft implantation.

CONCLUSIONS

This case illustrates stent-graft treatment of a life-threatening hemorrhage from an aortoesophageal fistula.

Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta

PURPOSE

To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta.

METHODS

A retrospective review was conducted of patients treated at our facility between July 1999 and June 2003. During this interval, 60 patients (46 men; average age 66+/-10 years) underwent thoracic aortic stent-graft placement for a variety of pathologies.

RESULTS

AEF occurred in 3 (5%) patients. One 62-year-old man presented with recurrent back pain and fever and died suddenly due to fatal exsanguination; the AEF was revealed at necropsy. The other 2 patients (both women) presented with hematemesis after endovascular repair of thoracic aortic aneurysms. AEF was detected by esophagogastroduodenoscopy. Both patients were treated conservatively, as open surgical repair was refused because of their general condition. Both patients developed severe mediastinitis and died after 5 weeks and 10 months, respectively.

CONCLUSIONS

Aortoesophageal fistula is, in our experience, a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Outcome under conservative management is, however, almost invariably fatal.

Evaluation of an aortic stent graft for use in surgery on esophageal cancer involving the thoracic aorta

OBJECTIVE

The purpose of this experimental study was to investigate whether aortic stent grafting can be applied to the treatment of an esophageal cancer involving the thoracic aorta.

METHODS

The canine thoracic aorta was partially resected without aorta being clamped after emplacement of an endovascular stent graft. Study I; The aortic whole layer of 1 cm in length and 1/4 of the circumference was resected and was covered by a free fascia patch of the abdominal rectal muscle immediately after stent graft placement. Study II; The aortic adventitia and the outer half of the media of the same size was resected on day 3, 7, 14, 21, and on day 28, after the stent graft placement. The resected portion was covered by the free fascia patch in half experimental dogs, and was uncovered in the others. Study III; The aortic adventitia and the outer half of the media of 1 cm in length and 1/2 of the circumference was resected and was uncovered on day 7 after stent graft placement. Histological examinations were performed on day 28 and at one year after aortic resection.

RESULTS

The aortic wall could be resected in all cases with no complication, except in resection of 1/2 the circumference where the aorta had become narrow. There was no difference in healing of the resected portion of the aorta between with and without fascia covering.

CONCLUSION

An aortic endovascular stent graft could be applied to surgery for an esophageal cancer involving the aorta.

Aortoesophageal fistula of uncommon origin: perforation of a Barrett's ulcer

Aortoesophageal fistulas are life-threatening conditions of which over half are secondary to thoracic aortic aneurysms. Four cases related to perforation of a Barrett's ulcer have been described so far, accounting for less than 1% of published aortoesophageal fistulas. We report a fifth case, which presented with severe hypotension, anemia and hematemesis. The patient underwent emergency esophagectomy and aortic closure but postoperatively required aortic endoprosthesis for residual bleeding. This case highlights the great diagnostic and therapeutic challenge associated with perforated Barrett's ulcer.