Acute Management of Aortoesophageal Fistula and Tracheoesophageal Fistula Treated by Thoracic Endovascular Aortic Repair and Esophageal Endoprosthesis: A Case Misdiagnosed as Esophageal Cancer

Complications of thoracic endovascular aneurysm repair (TEVAR): A pictorial review

Thoracic endovascular aneurysm repair (TEVAR) has replaced open surgical repair as the treatment of choice for several aortic conditions. Despite its lower morbidity and mortality, several TEVAR-related complications can occur and some of which may necessitate surgical or endovascular re-intervention. The current article reviews common and rare complications of TEVAR procedure with emphasis on complications identifiable on cross-sectional imaging and potential pitfalls of pre-procedural planning.

Aortoesophageal fistula: review of trends in the last decade

We reviewed articles on aortoesophageal fistula (AEF) published between January, 2009 and December, 2018. Postoperative aortic disease was the most common cause of AEF, followed by primary aortic aneurysm, bone ingestion, and thoracic cancer. Thoracic endovascular aortic repair (TEVAR) was the most common initial therapy for primary aortic disease, rather than graft replacement. Secondary AEF developed between 1 and 268 months, and between 1 and 11 months after the initial therapy for aortic disease and thoracic cancer, respectively. TEVAR trended to be preferred over surgery for aortic lesions because of its minimal invasiveness and certified hemostasis. In contrast, esophagectomy was preferred for esophageal lesions to remove the infectious source. A combination of surgery for the aorta (TEVAR, graft replacement or repair) and esophagus (esophagectomy, esophageal stent or repair) was usually adopted. Each graft replacement or esophagectomy was associated with a favorable prognosis for aortic or esophageal surgery, and the combination of graft replacement and esophagectomy generally improved the prognosis remarkably. Antibiotic therapy was given to 65 patients, with 20 receiving multiple antibiotics aimed at strong effects and the type of antibiotic described as broad-spectrum in 29 patients. Meropenem, vancomycin, and fluconazole were the most popular antibiotics used to prevent graft or stent infection. In conclusion, graft replacement and esophagectomy can achieve a favorable prognosis for patients with AEF, but strong, broad-spectrum antibiotic therapy might be required to prevent sepsis after surgery.

Revised Endografting for a Giant Descending Thoracic Aorta Aneurysm due to Synchronous Type III/Ib Endoleak, Causing Dysphagia

BACKGROUND

Although surgical resection and graft replacement therapy for thoracic aortic aneurysms has advanced greatly over the last 20 years, significant perioperative morbidity and mortality still occur, particularly in patients considered high risk due to significant coexisting medical illness or previous operations performed for the treatment of intrathoracic disease.

METHODS

The case described is that of a patient with a giant (13.8 cm) symptomatic descending thoracic aorta aneurysm (DTAA), previously treated endovascularly 15 years ago. The expanding aneurysm was due to undiagnosed synchronous type III/Ib endoleak resulting in chronic malnutrition and eventually dysphagia and dyspnea due to compressive symptoms of the esophagus. Besides the risk of rupture, dyspnea and dysphagia with progressive weight loss were significant indications necessitating repair. Regarding his major comorbidities, the patient was identified as high risk for open surgical repair, therefore an endovascular option was offered. Two valiant tube endografts were inserted and deployed successfully without complications.

RESULTS

Postoperatively, upper gastrointestinal endoscopy imaging that was performed to the patient revealed marked persistent stenosis of the esophagus despite aneurysm pressure relief. However, at the multidisciplinary team meeting, an esophageal stenting was ruled out due to the risk of stent fracture and esophageal perforation with its devastating complications. Therefore, a conservative management was deemed appropriate for the patient taking into consideration the risks of prolonged hospitalization and malnourishment coupled with an unpredictable clinical course regarding the remission of the symptoms. Despite the slight gradual clinical improvement in the immediate postoperative period, the patient passed away at the 40th postoperative day due to hospital acquired pneumonia.

CONCLUSIONS

Following endovascular repair of giant DTAA compressing the esophagus, significant symptomatic improvement should not be always expected due to the large residual thrombotic aneurysm sac. Although compression symptoms can be managed conservatively in patients deemed at high risk for esophageal perforation, postoperative course and management is of paramount importance and should be treated on an individual basis.

Complications and Perioperative Management of Patients Undergoing Thoracic Endovascular Aortic Repair

Endovascular treatments have become increasingly common for patients with a variety of thoracic aortic pathologies. Although considered less invasive than traditional open surgical approaches, they are nonetheless complex procedures. Patients undergo manipulation of an often calcified aorta near the origin of the carotid and subclavian vessels and have stents placed in a curved vessel adjacent to a perpetually beating heart. These stents can obstruct blood flow to the spinal cord, induce an inflammatory response, and in rare cases erode into the adjacent trachea or esophagus. Renal complications range from contrast-induced nephropathy to hypotension and ischemia to dissection. Emboli can lead to strokes and mesenteric ischemia. These patients have complex medical histories, and skilled perioperative management is critical to achieving the best clinical outcomes. Here, we review the medical management of the most common complications in these patients including stroke, spinal cord ischemia, renal injury, retrograde dissections, aortoesophageal and aortobronchial fistulas, postimplantation syndrome, mesenteric ischemia, and endograft failure.

Thoracic endovascular aortic repair in management of aortoesophageal fistulas

OBJECTIVE

To provide a systematic review of the outcomes of thoracic endovascular aortic repair (TEVAR) for aortoesophageal fistula (AEF) and to identify prognostic factors associated with poor outcomes.

METHODS

Literature searches of the Embase, Medline, and Cochrane databases identified relevant articles reporting results of TEVAR for AEF. The main outcome measure was the composite of aortic mortality, recurrence of the AEF, and stent graft explantation. The secondary outcome measure was aortic-related mortality.

RESULTS

Fifty-five articles were integrated after a literature search identified 72 patients treated by TEVAR for AEFs. The technical success rate of TEVAR was 87.3%. The overall 30-day mortality was 19.4%. Prolonged antibiotics (>4 weeks) were administered in 80% of patients. Concomitant or staged resection or repair of the esophagus was performed in 44.4% of patients. Stent graft explantation was performed within the first month after TEVAR as a planned treatment in 11.1%. After a mean follow-up of 7.4 months (range, 1-33 months), the all-cause mortality was 40.2%, and the aortic-related mortality was 33.3. Prolonged antibiotic treatment (P = .001) and repair of AEFs due to a foreign body (P = .038) were associated with a significant lower aortic mortality. On univariate analysis, TEVAR and concomitant or staged adjunctive procedures (resection, repair of the esophagus, or a planned stent graft explantation) were associated with a significantly lower incidence of aortic-related mortality (P = .0121). When entered into a binary logistic regression analysis, prolonged antibiotic treatment was the only factor associated with a significant lower incidence of the endpoint (P = .003).

CONCLUSIONS

Late infection or recurrence of the AEF and associated mortality rates are high when TEVAR is used as a sole therapeutic strategy. Prolonged antibiotic treatment has a strong negative association with mortality. A strategy of a temporizing endovascular procedure to stabilize the patient in extremis, and upon recovery, an open surgical esophageal repair with or without stent graft explantation is advocated.