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Donato F, Boskoski I, Vincenzoni C, Montanari F, Tinelli G, Donati T, Tshomba Y. A New Mini-Invasive Approach for a Catastrophic Disease: Staged Endovascular and Endoscopic Treatment of Aorto-Esophageal Fistulas. J Pers Med 2022; 12:1735. [PMID: 36294876 PMCID: PMC9605668 DOI: 10.3390/jpm12101735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/01/2022] [Accepted: 10/18/2022] [Indexed: 08/10/2023] Open
Abstract
Aorto-esophageal fistula (AEF) is an uncommon but usually fatal disorder. Surgery with resection of an aneurysm and esophagus, in situ reconstruction of the descending aorta and omental flap installation offers the gold standard for the reduction of infections, but it is burdened by high intraoperative and perioperative mortality rates. We report our experience with a combined minimally invasive approach for the multi-stage treatment of three cases of aorto-esophageal fistula caused by thoracic aneurysm rupture. In all of the patients, the aneurysm was treated with thoracic endovascular aortic repair and the esophageal lesion was treated with esophageal endoprosthesis placement. According to our experience, the combined strategy of thoracic endovascular aortic repair (TEVAR) and esophageal less invasive endoscopic treatments represents an alternative solution in frail patients with high surgical risk.
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Affiliation(s)
- Federica Donato
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudio Vincenzoni
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Montanari
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giovanni Tinelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Tommaso Donati
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Grossman R, Francis R. The Way to Man's Heart Is through the Stomach. Thorac Cardiovasc Surg 2019; 69:2-7. [PMID: 31756748 DOI: 10.1055/s-0039-1700886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Organ systems do not exist in a vacuum. However, in an era of increasingly specialized medicine, the focus is often on the organ system alone. Many symptoms are associated with differential diagnoses from upper gastrointestinal (GI) and cardiovascular medical and surgical specialties. Furthermore, a large number of rare but deadly conditions cross paths between the upper GI tract and cardiovascular system; a significant proportion of these are iatrogenic injuries from a parallel specialty. These include unusual fistulae, herniae, and embolisms that transcend specialties. This review highlights these conditions and the shared anatomy and embryology of the two organ systems.
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Affiliation(s)
- Rebecca Grossman
- Department of General Surgery, Buckinghamshire Healthcare NHS Trust, Amersham, United Kingdom
| | - Rohin Francis
- The Hatter Cardiovascular Institute, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Sager HB, Wellhöner P, Wermelt JA, Schunkert H, Kurowski V. Lethal hemorrhage caused by aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta. Cardiovasc Intervent Radiol 2015; 34 Suppl 2:S60-3. [PMID: 20390273 DOI: 10.1007/s00270-010-9844-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 03/06/2010] [Indexed: 11/28/2022]
Abstract
Aortoesophageal fistula (AEF) is a rare but life-threatening complication after endovascular or surgical aortic repair. Here we report a patient with AEF secondary to aortic stent-placement 2 years earlier who presented with hematemesis and died from hemorrhagic shock. By means of this case and the literature, we highlight potential bleeding sources in such a scenario because this is of crucial importance for the management strategy.
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Affiliation(s)
- Hendrik B Sager
- Medizinische Klinik II, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany,
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Fatimi SH, Malik AI, Ashfaq A, Murtaza N. Primary pseudoaneurysm of the descending aorta. Indian J Surg 2014; 75:472-4. [PMID: 24426652 DOI: 10.1007/s12262-013-0839-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 01/16/2013] [Indexed: 11/28/2022] Open
Abstract
Aortoesophageal fistula (AEF) is an atypical cause of massive hematemesis proving to be lethal if left untreated. We report a case of a 56-year-old man who presented with chest pain and hematemesis. He was diagnosed with pseudoaneurysm of the descending aorta and underwent open surgery for primary repair.
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Affiliation(s)
- Saulat H Fatimi
- Division of Cardiothoracic Surgery, Department of Surgery, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800 Pakistan
| | - Anum I Malik
- Medical College, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800 Pakistan
| | - Awais Ashfaq
- Medical College, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800 Pakistan
| | - Naquiya Murtaza
- Medical College, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800 Pakistan
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A case of secondary aortoesophageal fistula inserted a covered self-expanding esophageal stent to control gastrointestinal bleeding. Case Rep Gastrointest Med 2013; 2013:857135. [PMID: 23781353 PMCID: PMC3679725 DOI: 10.1155/2013/857135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 05/09/2013] [Indexed: 12/31/2022] Open
Abstract
A 73-year-old man presented with melena. After a thorough workup including esophageal endoscopy, computed tomography scans, and esophagography, the diagnosis of secondary aortoesophageal fistula was made. Two years previously, he had undergone endovascular stent-graft repair for the dissection of his descending thoracic aorta. Because of the generally poor condition of the patient and the high risk of any aggressive surgical intervention, we inserted a covered self-expanding esophageal stent on postadmission day 18. Esophagography after insertion did not show any evidence of a leak of contrast medium. Despite treatment with antibiotics, he developed sepsis and expired on day 52, but rebleeding did not occur in this period. We consider insertion of a covered self-expanding esophageal stent as a feasible option in the management of secondary aortoesophageal fistula in high-risk patients.
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Preventza O, Livesay JJ, Cooley DA, Krajcer Z, Cheong BY, Coselli JS. Coarctation-associated aneurysms: a localized disease or diffuse aortopathy. Ann Thorac Surg 2013; 95:1961-7; discussion 1967. [PMID: 23643549 DOI: 10.1016/j.athoracsur.2013.03.062] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 03/20/2013] [Accepted: 03/22/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND We evaluated the occurrence and treatment of aortic aneurysms in coarctation patients. METHODS During 1962 to 2011, 943 cases of coarctation were repaired. Aortic aneurysms were identified in 55 patients (5.8%). Forty-eight had prior coarctation repair (median 23 years earlier, interquartile range 18 to 26 years). Forty-two aneurysms were found in the descending thoracic aorta (76.4%), 18 in the ascending aorta (32.7%), 8 in the left subclavian artery (14.5%), and 1 each (1.8%) in the abdominal aorta, iliac artery, and innominate artery. Twenty-three patients (41.8%) had multiple aneurysms. Twenty-five patients (45.4%) had a bicuspid aortic valve. RESULTS Fifty-three patients' aneurysms were treated surgically. Thirty-five (66.0%) had descending thoracic aortic repair, of whom 11 had aorto-left subclavian bypass. Aortic cross-clamping alone was used in 23 patients, left heart bypass in 4, and circulatory arrest in 8. Eleven patients underwent endovascular repair (20.8%). Proximal aortic aneurysms were repaired in 7 patients (13.2%); 1 had simultaneous antegrade endostent delivery. Four patients had ascending-to-descending aortic bypass (7.3%). Concomitant valve-sparing root repair was performed in 2 patients, Bentall in 4, aortic valve replacement in 3, and coronary artery bypass in 1. One 30-day death occurred (1.9%). Three patients (5.7%) had transient neurologic deficits, 2 (3.8%) required tracheostomy, and 11 (20.8%) had vocal cord paralysis. CONCLUSIONS Coarctation is a marker for aortic aneurysm formation in adults and merits long-term surveillance. Anatomic complexity and associated conditions can complicate the surgical repair. Various open, extra-anatomic, and endovascular techniques may be used.
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Affiliation(s)
- Ourania Preventza
- Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke's Episcopal Hospital/Baylor College of Medicine, Houston, Texas, USA
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San Norberto EM, Taylor J, Estévez I, Fuente R, Carrera S, Vaquero C. Fístula aortoesofágica secundaria a endoprótesis torácica: a propósito de 3 casos y revisión de la literatura. ANGIOLOGIA 2013. [DOI: 10.1016/j.angio.2013.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Valente T, Rossi G, Lassandro F, Rea G, Marino M, Dialetto G, Muto R, Scaglione M. Unusual complications of endovascular repair of the thoracic aorta: MDCT findings. Radiol Med 2012; 117:831-54. [PMID: 22228128 DOI: 10.1007/s11547-011-0771-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 06/20/2011] [Indexed: 11/26/2022]
Abstract
With the development of minimally invasive surgical techniques, endovascular stent-graft placement has become an accepted and widely used alternative to the traditional surgical repair of aortic disease and is gaining acceptance as the treatment of choice. Many studies show that endovascular stent-graft therapy is safe and effective, although complications related to this treatment are also recognised. Although the incidence of major complication is low, neurological sequelae remain the major concern of endovascular repair. With growing experience, however, the spectrum of mid- and long-term complications has broadened to include potentially disastrous events, other than paraplegia or stroke, that require diligent surveillance. Three-dimensional data sets acquired quickly by multidetector computed tomography (MDCT) allow multiplanar reformations and 3D viewing, as well as quantitative assessment of vessel lumens, walls and surroundings. Although a large portion of radiologists will not be involved in the actual endograft deployment, many will be involved in the interpretation of postprocedural surveillance studies. Accordingly, the goal of this report is to summarise our experience with the presentation, diagnostic approach, management and outcomes of these unusual, but potentially catastrophic, postendovascular aortic repair complications to highlight their significance and increase familiarity with them among the imaging community. Increasing awareness of these complications may facilitate rapid diagnosis and/or triage and treatment.
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Affiliation(s)
- T Valente
- Dipartimento di Diagnostica per Immagini, Servizio di Radiologia, A.O.R.N. Monaldi, 80131, Napoli, Italy
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Albors J, Ángel Bahamonde J, Manuel Sanchis J, Boix R, Palmero J. Aortoesophageal fistula after thoracic stent grafting. Asian Cardiovasc Thorac Ann 2011; 19:352-6. [DOI: 10.1177/0218492311419230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aortoesophageal fistula after thoracic stent grafting is rare and usually fatal. A 66-year-old woman developed an aortoesophageal fistula 1 month after endovascular stent grafting of the thoracic aorta for a complicated type B dissection. She had a fatal episode of massive bleeding before she could be treated. The limited treatment options are discussed.
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Affiliation(s)
- José Albors
- Department of Cardiovascular Surgery, Hospital Clínico Universitario/Clinic University Hospital, Valencia, Spain
| | - José Ángel Bahamonde
- Department of Cardiovascular Surgery, Hospital Clínico Universitario/Clinic University Hospital, Valencia, Spain
| | - Juan Manuel Sanchis
- Department of Cardiovascular Surgery, Hospital Clínico Universitario/Clinic University Hospital, Valencia, Spain
| | - Ricardo Boix
- Department of Cardiovascular Surgery, Hospital Clínico Universitario/Clinic University Hospital, Valencia, Spain
| | - Julio Palmero
- Department of Cardiovascular Surgery, Hospital Clínico Universitario/Clinic University Hospital, Valencia, Spain
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Chiesa R, Melissano G, Marone EM, Kahlberg A, Marrocco-Trischitta MM, Tshomba Y. Endovascular treatment of aortoesophageal and aortobronchial fistulae. J Vasc Surg 2010; 51:1195-202. [PMID: 20304579 DOI: 10.1016/j.jvs.2009.10.130] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 09/28/2009] [Accepted: 10/17/2009] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Roberto Chiesa
- Vascular Surgery, Scientific Institute H. San Raffaele, Vita-Salute University School of Medicine, Milano, Italy
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Aortoesophageal fistula after thoracic aortic stent-graft placement: a rare but catastrophic complication of a novel emerging technique. JACC Cardiovasc Interv 2009; 2:570-6. [PMID: 19539264 DOI: 10.1016/j.jcin.2009.03.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 03/03/2009] [Accepted: 03/04/2009] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Our goal was to report characteristics and outcomes of 6 patients with aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR). BACKGROUND Neurologic events are severe complications of TEVAR. With growing experience of TEVAR, other yet unexpected devastating complications have emerged. METHODS Between July 1999 and August 2008, 268 patients underwent TEVAR for various thoracic aortic diseases at our institution. RESULTS Six of 268 patients (age 49 to 77 years, 50% female patients) developed AEF (incidence 1.9%) within 1 to 16 months after the procedure. Indications for TEVAR were acute aortic dissection (n = 3), chronic aortic dissection (n = 1), and thoracic aortic aneurysm (n = 2). Four patients presented with sudden massive hematemesis whereas 2 patients were readmitted for new-onset fever and elevated markers of inflammation that preceded hematemesis. Esophago-gastro-duodenoscopy identified deep esophageal ulcerations at the level of the implanted aortic stent-graft in 4 patients, but only mild erosive lesions within the proximal esophagus without signs of active bleeding in the remaining 2 patients. Surgical repair was performed in only 1 patient and declined in the remaining because of comorbidities and multiorgan system failure. Despite this, all patients died due to fatal rebleeding (n = 4) or mediastinitis (n = 2). CONCLUSIONS AEF is a rare and unusual complication of TEVAR that occurs relatively early after the procedure and is almost invariably fatal. New-onset fever with elevated inflammatory markers or hematemesis should heighten clinical suspicion of AEF in TEVAR patients and prompt computed tomography or esophago-gastro-duodenoscopy in the hope of detecting, triaging, and treating this early to improve the otherwise dismal outcomes of these patients.
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Christensen JD, Heyneman LE. Case of the season: aortoesophageal fistula complicating thoracic aortic aneurysm stent graft repair. Semin Roentgenol 2009; 44:4-7. [PMID: 19064067 DOI: 10.1053/j.ro.2008.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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