Thoracic endovascular aortic repair in management of aortoesophageal fistulas

Combined Endovascular and Endoscopic Management of a Secondary Aortoesophageal Fistula after Open Surgical Aortic Repair in a Giant Descending Thoracic Aortic Pseudoaneurysm: Case Report and Review of Literature

Secondary aortoesophageal fistula (AEF) is defined as a communication between the aorta and the esophagus, occurring after aortic disease treatment or esophageal procedures, associating very high mortality rates with treatment and being fatal without it. Several treatment strategies have been described in the literature, combining open surgery or endovascular aortic repair with surgical or endoscopic management of the esophageal lesion. We present the case of a 53-year-old patient with a history of open aortic surgery for a giant descending thoracic aortic pseudoaneurysm complicated with secondary AEF, successfully managed using emergency transiliac TEVAR (thoracic endovascular aortic repair), extensive antibiotic therapy associated with nutritional replenishment, and rehabilitation therapy. Novel endovascular and endoscopic devices have been developed, offering less invasive treatment strategies with improved outcomes, especially for high risk surgical patients. This case highlights the importance of a multidisciplinary approach to personalized medicine to manage such complex situations.

Aortoesophageal fistula due to esophageal cancer: a case report of successful management

BACKGROUND

Aortoesophageal fistula (AEF) is a rare but potentially life-threatening condition. The best treatment for the AEF due to esophageal carcinoma is still unresolved. Here, we report a rare case of AEF caused by esophageal cancer, that was successfully treated with emergency thoracic endovascular aortic repair (TEVAR), followed by esophagectomy and gastric tube reconstruction.

CASE PRESENTATION

A 64-year-old man presented with loss of consciousness and hypotension during chemoradiotherapy for advanced esophageal cancer. Enhanced computed tomography showed extravasation from the descending aorta into the esophagus at the tumor site. We performed emergency TEVAR for the AEF, which stabilized the hemodynamics. We then performed thoracoscopic subtotal esophagectomy on day 4 after TEVAR to prevent graft infection, followed by gastric tube reconstruction on day 30 after TEVAR. At 9 months after the onset of AEF, the patient continues to receive outpatient chemotherapy and leads a normal daily life.

CONCLUSION

TEVAR is a useful hemostatic procedure for AEF. If the patient is in good condition and can continue treatment for esophageal cancer, esophagectomy and reconstruction after TEVAR should be performed to prevent graft infection and maintain quality of life.

Successful management following combined thoracic endovascular aortic repair and minimally invasive esophagectomy for primary aortoesophageal fistula: A case report

Aortoesophageal fistula (AEF) is a rare but life-threatening pathology. We report a case of a primary AEF that was successfully managed with temporary thoracic endovascular aortic repair (TEVAR) and esophagectomy with video-assisted thoracoscopic surgery. A 73-year-old man was transferred to the emergency department with a complaint of hematemesis. A computed tomography scan identified an AEF due to aortic aneurysm. We placed a stent using TEVAR for the purpose of hemodynamic stasis, and the operation was performed 23 h after admission. Right video-assisted thoracoscopic esophagectomy (VATS-E) was chosen, and a cervical esophagostomy and a feeding gastrostomy tube was constructed. Infection had been effectively controlled postoperatively. Four months after the first operation, we performed esophageal reconstruction. At the 70-month follow-up examination, the patient had no signs of mediastinitis. VATS-E immediately after hemostabilization by TEVAR is useful management for primary AEF.

Staged Repair of Primary Aortoesophageal Fistula

Primary aortoenteric fistulas are rare with an incidence reported up to .07% at autopsy. Literature review yields few reported cases, and rarer still is a fistula between a normal thoracic aorta and the esophagus. Rather, 83% of cases are associated with an aneurysmal aorta and 54% involve the duodenum. Patients with aortoesophageal fistula (AEF) usually present with a triad of chest pain, dysphasia, and a herald bleed. Without treatment, AEFs will result in exsanguination and are universally fatal; even with traditional open surgical treatment, mortality is reported over 55%. The complex pathology of AEFs makes repair more challenging, given an infected field, friable tissue, and patients who are often hemodynamically unstable. Staged repair using endografts as initial treatment with the primary goal of controlling bleeding and preventing fatal exsanguination has been reported. We present a case where a descending thoracic aorta to esophageal fistula was repaired, and this strategy was utilized.

Secondary Endovascular Conversions for Failed Open Repair

Late aortic and graft-related complications after open aortic repair are not infrequent and a significant number of them are missed, diagnosed at a very late stage, or present as urgent complications such as aortic rupture or aorto-enteric fistula. Once a late complication is diagnosed and reintervention is necessary, both open and endovascular strategies are possible. Open reintervention is complex and usually associated with very high rates of morbidity and mortality. Endovascular techniques may offer several solutions for these cases, which may be tailored to the patient and specific complication. In this review, we aim to summarize current indications, options, and strategies for endovascular salvage after failed or complicated open surgical repair.

A fatal aorto-oesophageal fistula due to a mutton bone: A case report

INTRODUCTION AND IMPORTANCE OF THE CASE

Aorto-oesophageal fistula (AEF) following foreign body ingestion is rare and conservative management is always fatal. The delayed presentation further confounds poor outcomes.

PRESENTATION OF CASE

A 46-year-old South-Asian woman presented with pain and difficulty in swallowing following ingestion of a mutton-containing meal. The patient refused urgent upper GI endoscopy and was initially managed conservatively on the basis of the resolution of symptoms and hemodynamic stability and was discharged home. On review a week later, the patient did not consent to a UGIE. She presented the next day with a severe upper GI bleed. Due to profuse haemorrhage, a bleeding point could not be identified, and she suffered a cardiac arrest. Attempts at resuscitation were unsuccessful. The autopsy revealed an AEF caused by a sharp mutton bone lodged in the lower oesophagus.

CLINICAL DISCUSSION

High-risk food bolus impactions such as the ones caused by sharp objects need urgent endoscopy to confirm the position and extraction if safe. AEF occurs with time and could result in massive haemorrhage and mediastinitis. Endoscopic stenting, thoracoscopic surgery, and open repair are methods of emergent and definite management that still carry significant mortality.

CONCLUSION

Management of AEF requires early diagnosis with a high index of suspicion, endoscopic and CT-based angiography studies, and surgical interventions tailored to patients based on the available expertise. High-risk patients should be similarly educated on the probable complications and the symptomatology.

Aortoesophageal fistula complicated by mycotic aneurysm secondary to endoscopic procedures: A case report

Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal bleeding that often receives little attention in the emergency department. The classic presentation includes the Chiari triad of central chest pain, sentinel arterial bleeding, and subsequent evacuation after an asymptomatic period. For patients suspected of having AEF, a CT scan with IV contrast is the preferred diagnostic modality. In our patient, the presence of an aortic wall outpouching, ectopic gas, periaortic fat stranding, and leukocytosis, even in the absence of fever and positive blood culture, suggested mycotic aneurysm with AEF. The unique aspect of this case report is the occurrence of AEF as a rare complication of endoscopic procedures, which should be considered. Treatment options for AEF include surgery and thoracic endovascular aortic repair (TEVAR). TEVAR is a good option for stabilizing the patient's condition and reducing mortality in the short term. Once the patient's condition is suitable for AEF repair surgery, surgical intervention can be performed.

Single-Center Retrospective Subgroup Analysis of "Primary Aortic" (Aneurysm, Aortic Dissection, PAU) and "Secondary Aortic" (Iatrogenic, Trauma, Aortoesophageal Fistula) Indications for Emergency TEVAR

BACKGROUND

The aim of this study was to analyze the outcome of emergency thoracic endovascular aortic repair (TEVAR) in the treatment of "primary aortic" (aneurysm, aortic dissection, penetrating aortic ulcer (PAU)) and "secondary aortic" (iatrogenic, trauma, and aortoesophageal fistula) pathologies.

METHODS

Retrospective review of a cohort of patients treated at a single tertiary referral center from 2015 to 2021. The primary end point was postoperative in-hospital mortality. Secondary end points were the duration of the procedure, duration of postoperative intensive care treatment, length of hospital stay, and the nature and severity of postoperative complications according to the Dindo-Clavien classification.

RESULTS

A total of 34 patients underwent TEVAR for emergency indications. Twenty-two patients were treated for primary and twelve patients for secondary aortic pathologies. Concerning in-hospital mortality, no statistically significant difference could be observed between the primary and secondary aortic groups (27.3% vs. 33.3%, p = 0.711). Patients with an aortoesophageal fistula had a mortality rate of 66.7%. Postoperative morbidity (Dindo-Clavien > 3) was also not statistically significantly different between the primary and secondary aortic groups (36.4% vs. 33.3%, p = 0.86). Preoperative hemoglobin level (p < 0.001 for mortality, p = 0.002 for morbidity), hemoglobin level difference (p = 0.022, p = 0.032), postoperative creatinine level (p = 0.009, p = 0.035), and pre- and postoperative lactate levels (p < 0.001 for both mortality and morbidity) were found to be independent factors associated with postoperative mortality and morbidity (Dindo-Clavien > 3), respectively. The preoperative creatinine level was found to be associated with mortality (p = 0.024) but not morbidity.

CONCLUSIONS

Morbidity and in-hospital mortality are still considerable after emergency TEVAR for both primary and secondary aortic indications. Pre- and postoperative levels of hemoglobin, creatinine, and lactate may be valuable to predict patient outcomes.

Case report: Aortoesophageal fistula-an extremely rare but life-threatening cardiovascular cause of hematemesis

Aortoesophageal fistula (AEF) is an extremely rare cardiovascular etiology of hematemesis and upper gastrointestinal bleeding. As such, its recognition and diagnosis are challenging and may be delayed when such patients present to the emergency department (ED). Without timely surgical intervention, AEF is almost always fatal. Awareness of AEF as a possible diagnosis and consequently early identification of these patients presenting to the ED are therefore crucial in optimizing clinical outcomes. We report a 45-year-old male presenting to the ED with the classical triad of an AEF (Chiari's triad)-midthoracic pain or dysphagia, a sentinel episode of minor hematemesis, then massive hematemesis with risk of exsanguination. The case report highlights the importance of considering the differential diagnosis of AEF when evaluating patients presenting to the ED with hematemesis, especially if they have predisposing risk factors such as prior aortic or esophageal surgeries, aortic aneurysms, or thoracic malignancies. Patients suspected of having AEF should be prioritized for early computed tomography angiography to expedite diagnosis and treatment.

A Catastrophic Complication of Thoracic Endovascular Aortic Repair: Aortoesophageal Fistula

A 62-year-old man was admitted to the hospital due to sepsis secondary to a hemodialysis catheter-related infection that, upon diagnostic evaluation, demonstrated to be caused by P. aeruginosa and was treated with meropenem. Eradication of the infectious episode was confirmed by blood workup, including cultures. One month after the initial episode, the patient was readmitted due to a symptomatic penetrating aortic ulcer, which was classified as a cardiovascular emergency. The patient underwent an aortic stent-graft placement. Four weeks later, he presented to the emergency department with a 2-hour onset of thoracic pain and massive hematemesis. The esophagus and aortic segment with aortic stent graft were resected en bloc after an aortoesophageal fistula was diagnosed.

Salvaged, Staged, and Safer Management of Aortoesophageal Fistula and Mediastinitis After Removing a Pork Bone: A Case Report

Aortoesophageal fistula (AEF) caused by esophageal foreign body (EFB) ingestion is a life-threatening condition with a very low survival rate. However, the optimal management strategy remains undetermined. Here, we describe our successful management of a patient with AEF and mediastinitis. A 36-year-old man developed persistent chest and back pain and vomited fresh blood three days after removal of a pork bone in the esophagus under endoscopy in a local hospital. Computed tomography (CT) confirmed bilateral pulmonary infections, mediastinitis, and fistula of the aortic arch. After a multidiscipline discussion, a comprehensive staged strategy was made including salvaged thoracic endovascular aortic repair (TEVAR) to control fatal bleeding, adequate mediastinal debridement, drainage with cervical incision, and video-assisted thoracoscopic surgery, as well as jejunostomy to prevent nasal or gastrostomy reflux from aggravating the mediastinal infection. Furthermore, systematic personalized nutrition support and antibiotics were provided. The patient recovered well and has survived for 50 months until now. Careful assessment should be made with CT to ascertain the risk of AEF before and after the removal of EFB. A salvaged staged strategy of TEVAR with adequate mediastinal debridement and drainage in a less invasive approach may be a safer alternative for AEF patients with infections caused by EFB.

Total endoluminal repair of aorto-oesophageal fistula

A woman in her 50s presented to the Emergency Department, following massive haematemesis, having swallowed a single tooth denture 3 years previously. Endoscopy initially revealed profuse bleeding at 20cm from the incisors, initially treated with an oesophageal covered stent. Following ongoing haematemesis, a thoracic and abdominal CT angiogram demonstrated an aorto-oesophageal fistula, which was successfully treated with a thoracic endograft and left tube thoracostomy. The patient remains well to 1 year. This is the first case to demonstrate successful use of covered stents in both the aorta to stop exsanguination, as well as the oesophagus to prevent mediastinitis and avoid the need for thoracotomy and hypothermic circulatory arrest in a critically ill patient.

Endovascular stent-graft treatment for aortoesophageal fistula induced by an esophageal fishbone: Two cases report

BACKGROUND

Aortoesophageal fistula (AEF) induced by esophageal fishbones is a rare complication of esophageal foreign bodies and is very difficult to treat. Although the current view suggests that endovascular stent-graft treatment is useful for AEF, whether a subsequent thoracic operation is necessary remains controversial. The purpose of this report is to describe our experience using endovascular stent-graft treatment without combined thoracic operations for the treatment of AEF in two specific cases.

CASE SUMMARY

We presented two cases of patients complaining of retrosternal discomfort treated in our department for an aortoesophageal fistula caused by the accidental ingestion of a fishbone. The two patients were effectively managed with combined means of endoscopic, medical (broad-spectrum antibiotic therapy, fasting, gastrointestinal decompression, etc.) and endovascular stent-graft treatment. The main difference in treatment was that the first patient presented with hematemesis after endoscopic removal of the fishbone. Subsequently, the patient underwent endovascular stent-graft treatment. The second case was managed with endoscopic removal of the fishbone with simultaneous endovascular stent-graft treatment, without any signs of hematemesis or melena. Both patients had successful postoperative management and were discharged home. Long-term follow-up is ongoing.

CONCLUSION

The treatment decision-making process should depend on the patients’ specific situations. Our practice indicates that endovascular stent-graft treatment without combined thoracic operations could be a valuable alternative in selected patients.

Primary aortoesophageal fistula from metallic bristle ingestion

Although many patients are treated for the removal of ingested foreign objects each year, ingestions that perforate the esophagus and lead to intra-abdominal complications are rare. Aortoesophageal fistulas and aortic pseudoaneurysms are deadly complications of esophageal foreign body impaction. However, the surgical approach to aortic repair from foreign object damage has not been standardized. We have described the diagnostic, open surgical, and therapeutic approach to treating a man who had accidentally ingested a 3-cm metallic bristle that lodged in his aortic wall. The patient recovered after excision of the aortic pseudoaneurysm with CryoGraft (CryoLife, Inc, Kennesaw, Ga) replacement, drainage of abscesses, and antibiotic treatment for multiple infections.

Thoracic Endovascular Aortic Repair for a Ruptured Mycotic Aortic Pseudoaneurysm Secondary to Esophageal Carcinoma

A 47-year-old female presented to the emergency department with new episodes of hematemesis. She had a background of unresectable T4b + N1 + M0 esophageal squamous cell carcinoma. Contrast CT thoracic aorta diagnosed a ruptured mycotic aortic pseudoaneurysm of the descending aorta, forming a life threating aorto-esophageal fistula secondary to neoplasm. Due to the high risk of fatal haemorrhage, she underwent successful emergency thoracic endovascular aortic repair (TEVAR). Mycotic aortic pseudoaneurysms are a rare and often fatal complication of esophageal carcinomas. They represent a small subsection of aorto-esophageal fistulas. Early diagnosis with cross sectional imaging and vascular control of the sentinel bleed is essential for survival. TEVAR may be used as a bridge to palliative treatment in the case of unresectable esophageal carcinoma.

Secondary aortoesophageal fistula initially presented with empyema after thoracic aortic stent grafting: A case report

BACKGROUND

Massive upper gastrointestinal (GI) bleeding is usually urgent and severe, and is mostly caused by GI diseases. Aortoesophageal fistula (AEF) after thoracic aortic stent grafting is a rare cause of this condition, and has a poor prognosis with a high mortality rate. The clinical symptoms of AEF are usually nonspecific, and the diagnosis is often difficult, especially when upper GI bleeding is absent. Early identification, early diagnosis, and early treatment are very important for improving prognosis.

CASE SUMMARY

A 74-year-old man was admitted to the infectious disease department with > 10-d fever and 10-mo prior history of thoracic aortic stent grafting for thoracic aortic penetrating ulcers. Blood tests revealed elevated inflammatory indicators and anemia. Chest computed tomography (CT) showed postoperative changes of the aorta after endovascular stent graft implantation, pulmonary infection and pleural effusion. Pleural effusion tests showed empyema. After 1 wk of anti-infective treatment, temperature returned to normal and chest CT indicated improvement in pulmonary infection and reduction of pleural effusion. Esophageal endoscopy was performed because of epigastric discomfort, and showed a large ulcer with blood clot in the middle esophagus. However, on day 11, hematemesis and melena developed suddenly. Bleeding stopped temporarily after hemostatic treatment and bedside endoscopic hemostasis. Thoracic and abdominal aortic CT angiography confirmed AEF. Later that day, he suffered massive hemorrhage and hemorrhagic shock. Eventually, his family elected to discontinue treatment.

CONCLUSION

AEF should be strongly considered in patients with a history of aortic intervention who present with fever, especially with empyema.

Results of cryopreserved arterial allograft replacement for thoracic and thoracoabdominal aortic infections

BACKGROUND

Primary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts.

METHODS

Between January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity.

RESULTS

Thirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved. Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days. During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively.

CONCLUSIONS

Although rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications.

Aortoesophageal fistula treated with emergent thoracic stent grafting

Aortoesophageal fistula (AEF) is a rare pathology with a poor prognosis. Historically, open repair approaches were undertaken. With the advent of endovascular techniques, alternative methods such as thoracic endovascular aortic repair (TEVAR) have emerged. This case describes a patient who presented with severe hematemesis and, upon imaging, an AEF was discovered. Urgent TEVAR was indicated with a graft oversized to the native aorta by 10% to 15%, along with coil embolization of the intercostal artery. We report here on the successful management of AEF via TEVAR.

Management of life-threatening aortoesophageal fistula: experiences learned from eight patients

BACKGROUND

Aortoesophageal fistula (AEF) is a rare but fatal condition causing massive upper gastrointestinal bleeding.

PURPOSE

To report our experiences in the management of life-threatening AEF.

MATERIAL AND METHODS

A total of eight patients (seven men, one woman; mean age = 59.4 years; age range = 43‒76 years) presenting with AEF between 2005 and 2018 were recruited from three different Korean hospitals. The medical records of these patients were reviewed for patient demographics, clinical features, diagnostic and therapeutic modalities, and outcomes.

RESULTS

Two patients died as a result of massive hemorrhage before endovascular or surgical treatment could be undertaken. Of the six patients who were treated, five underwent endovascular interventions: embolization of the fistula using n-butyl cyanoacrylate (NBCA) and subsequent thoracic endovascular aortic repair (TEVAR) in two patients; TEVAR alone in two patients; and NBCA embolization alone in one patient. Among them, three patients who received TEVAR with or without NBCA embolization in a timely fashion recovered and were discharged. One patient who received delayed TEVAR died of disseminated intravascular coagulation, and one who received NBCA embolization alone died of hemorrhagic shock, both dying within three days of treatment. The remaining patient who underwent surgical aortic repair is alive after 13 years.

CONCLUSION

Rapid identification and surgical treatment are necessary to increase the likelihood of survival, if emergency surgery is feasible. TEVAR in a timely fashion facilitates hemodynamic stabilization by rapidly controlling hemorrhage and saves the patient's life.

A date pit induced aorto-oesophageal fistula: a case report and concise literature review

Aorto-oesophageal fistula (AEF) is rare and fatal without intervention. Having consumed a date pit 2 weeks prior, the patient in this case presented with the ‘Chiari’ triad of chest pain, sentinel arterial upper gastro-intestinal haemorrhage and exsanguination after an asymptomatic interval. Following resuscitation, the patient was managed with a Blakemore tube with both oesophageal and gastric balloons inflated to systemic pressures. An aortic stent graft was planned but the patient died on the operating table.

AEFs can be treated surgically with either open or endovascular repair. Open repair is highly risky and involves combined replacement/bypass of the thoracic aorta along with resection/repair of the involved oesophagus. Endovascular repair can prevent fatal exsanguination and increase the likelihood of survival but is associated with a significant rate of secondary infection, recurrence of fistula, mediastinitis and sepsis. Further studies are required to inform on management.

Multidisciplinary Management of an Aorto-esophageal Injury Caused by Foreign Body Ingestion

A 37-year-old incarcerated male ingested a complex "X-shaped" foreign body that resulted in a penetrating aorto-esophageal injury. A primary esophagotomy with retrieval of the foreign body and muscle flap closure was performed simultaneously with thoracic endovascular aortic repair. This multidisciplinary surgical approach controls for both immediate exsanguination and postoperative complications to improve patient outcome.

Thoracic endovascular aortic repair in management of aorto-oesophageal fistulas: a case series

Background 

Aorto-oesophageal fistula (AOF) is a rare, catastrophic disease with an extremely poor prognosis. A ruptured thoracic aortic aneurysm is a common aetiology for AOF. The clinical presentation is usually massive haematemesis and collapse. Timely diagnosis and appropriate treatment are crucial in managing AOF.

Case summary 

We hereby report two cases of AOF, who underwent successful emergency thoracic endovascular aortic repair (TEVAR) to control active bleed and exsanguination. Case 1, an elderly lady with atherosclerotic aneurysm had TEVAR followed by open surgery for oesophageal rent and necrosed left main bronchus. Case 2 had mycotic tubercular aneurysm who later had infected graft-stent following TEVAR.

Discussion 

Open surgery is the conventional treatment for AOF; however, TEVAR can be an alternative and less invasive approach in selected high-risk patients. Various management issues related to TEVAR with AOF have been discussed in the article.

Risk Factors for Mortality in Patients with Aortoesophageal Fistula Related to Aortic Lesions

Objective

Aortoesophageal fistula (AEF) related to aortic aneurysm and dissection is an uncommon but life-threatening condition. We performed a systematic review of risk factors for mortality and factors associated with the prognosis of AEF.

Methods

A systematic search of the PubMed, Embase, and Cochrane Library databases was performed. Clinical characteristics, diagnostic methods, and treatments were assessed in terms of their ability to predict mortality.

Results

The systematic review identified 184 eligible articles including 219 patients with AEF. Multivariable Cox regression revealed positive correlations of hemorrhagic shock (hazard ratio (HR): 1.824, 95% CI: 1.217-2.735, P = 0.004), sepsis (HR: 1.714, 95% CI: 1.112-2.641, P = 0.015), multiorgan failure (HR: 3.060, 95% CI: 1.470-6.368, P = 0.003), and conservative treatment (HR: 5.257, 95% CI: 3.405-8.116, P < 0.001) with mortality and a negative correlation between combination therapy (aortic graft replacement and esophagectomy) and mortality (HR: 0.319, 95% CI: 0.125-0.813, P = 0.017). Kaplan–Meier survival analysis showed that the 1-year cumulative survival rate was 42.5 ± 3.8%. The overall fistula-related mortality rate was 47.0% (103/219). The most common causes of death were bleeding (54.9%) and infection (29.2%).

Conclusions

We found that hemorrhagic shock, sepsis, and multiorgan failure were risk factors for death in patients with AEF. Additionally, conservative treatment was associated with a higher rate of mortality, while combined aortic graft replacement and esophagectomy improved the prognosis.

Surgical treatment for secondary aortoesophageal fistula

Background

Aortoesophageal fistula (AEF) is a relatively rare condition that is often life-threatening. Secondary AEF is a complication of previous surgery, which can be more critical and challenging than primary AEF. The number of secondary AEF is increasing due to increase in the number of thoracic endovascular aortic repair (TEVAR). Although TEVAR has become a successful alternative surgical strategy for thoracic aortic aneurysms, secondary AEF after TEVAR might be critical than other secondary AEF because of severe adhesion between the esophagus and residual thoracic aortic wall.

Methods

This study analyzed six patients with secondary AEF who were treated at Tokyo Medical University Hospital between 2011 and 2016. These participants included four patients who had undergone TEVAR and two who had undergone total arch replacement.

Results

Although they were subsequently hospitalized for a long period, open surgical repair was completed in two patients who had undergone total arch replacement. TEVAR alone was performed in two patients who had undergone TEVAR and they were discharged without major complications shortly. Combined repair of TEVAR as a bridge to open surgery was planned for two patients who had undergone TEVAR. However, reconstruction of the aorta and esophagus could not be completed in these patients due to severe adhesions, and they died during hospitalization.

Conclusions

Definitive open repair was successfully performed in patients with secondary AEF after total arch replacement. However, in the patients with secondary AEF after TEVAR, severe adhesion between the aorta and esophagus led to difficulty in performing a successful definitive open repair. The strategy for secondary AEF should, therefore, be decided considering the etiology of secondary AEF. In secondary AEF after TEVAR, definitive open repair is difficult to complete because of catastrophic complication, and palliative treatment using TEVAR without reconstruction of aorta and esophagus can be an alternative.

Surgical treatment for secondary aortoesophageal fistula after prosthetic aortic replacement: A report of four cases

•

Secondary aortoesophageal fistula (AEF) after aortic prosthetic replacement is rare, so there have been few reports assembling multiple cases.

•

AEF is difficult to diagnose early if there is little experience, and hence is associated with high mortality and morbidity rates.

•

The strategy involving stepwise surgery in coordination with infection control and general health improvement was attempted in our facility.

•

From our observations, this approach appears to be a valid strategy for secondary AEF after aortic prosthetic replacement.

Introduction

With the increase of thoracic aortic aneurysm surgery and thoracic endovascular aortic repair, secondary aortoesophageal fistula (AEF) has been reported. However, the treatment strategy for AEF remains controversial.

Presentation of cases

Four patients who had undergone prosthetic aortic replacement for thoracic aortic aneurysm 4–36 months previously, were hospitalized with sepsis-like symptoms. They were diagnosed with aortic prosthetic graft infection after computed tomography revealed ectopic gas around the prosthesis. After that, esophagogastroduodenoscopy revealed an esophageal perforation, so we diagnosed AEF. They received medication and stepwise surgery; 1 patient was discharged, 2 remain hospitalized, and 1 died.

Discussion

Some reports have suggested that combined surgery provides better outcomes for AEF. Infection may be controlled by esophagectomy and antibiotic treatment, so prosthesis replacement is not always necessary. However, we should note that infection between a prosthetic graft and the native aorta brings a danger of pseudoaneurysm of the anastomosis.

Conclusion

Based on our experience we conclude that surgery performed stepwise along with infection control and general health improvement is a valid treatment strategy for secondary AEF after prosthetic aortic replacement.

Delayed presentation of a traumatic descending thoracic aorta aneurysm as an aorto-oesophageal fistula

Aorto-oesophageal fistula is a rarely described but life-threatening complication presenting with upper gastrointestinal haemorrhage. We present a case of a 58-year-old gentleman who presented to a peripheral hospital with a short duration of haematemesis and melaena and recent onset symptoms of dysphagia. This gentleman had a past medical history of alcohol excess and a history of trauma following a road traffic accident 38 years ago. Initial computer tomography scan demonstrated a large saccular aneurysm arising from the descending thoracic aorta adjacent to the oesophagus. The patient underwent radiological stenting of the large aneurysm with thoracic endovascular aortic replacement procedure. Follow-up computerized tomography (CT) angiography demonstrated satisfactory appearances of the thoracic aortic stent graft with no evidence of endo-leak. The triad of dysphagia, occult gastrointestinal blood loss and CT findings of a large aneurysm should prompt diagnosis or aorto-oesophageal fistula until proven otherwise.

Aortoesophageal fistula treated with staged aortic stent graft and subsequent homograft interposition

Aortoesophageal fistula (AEF) is a rare complication of esophageal interventions. We present a 49-year-old woman who underwent Roux-en-Y gastric bypass with a recurrent gastrojejunal anastomotic leak requiring covered esophageal stent placement. She presented 1 month later with abdominal pain, leukocytosis, and hematemesis. A computed tomography scan demonstrated migration of the esophageal stent with aortic erosion concerning for AEF. She underwent emergent endovascular exclusion of an AEF to the descending thoracic aorta with subsequent esophageal resection and diversion and aortic endograft explant, resection, and homograft repair on postoperative day 6 allowing for staged removal of prosthetic material and maintenance of inline flow.

Repair of aortoesophageal fistula with homograft aortic replacement and primary esophageal closure

OBJECTIVES

The presence of a fistula between the thoracic aorta and the esophagus is a rare and highly fatal condition. This study aimed to evaluate the outcomes of the surgical treatment of an aortoesophageal fistula (AEF).

METHODS

We retrospectively reviewed patients with AEF who underwent surgery at our institution.

RESULTS

Between 2007 and 2018, a total of 10 patients who underwent surgery for AEF. The mean age was 63 ± 12 years, and 6 patients were men. Four patients had primary AEFs and 6 patients had secondary AEFs (3 graft replacements and 3 thoracic endovascular aortic repairs). The timing of AEF since graft replacement or thoracic endovascular aortic repairs was 21.6 ± 27 days. We performed aortic replacement with a prosthetic graft (4 patients) or a homograft (5 patients) and extra-anatomical bypass due to a previous aortic graft infection (1 patient). As a treatment of the esophagus, we conducted primary repair in 7 of 10 patients. The median lengths of hospital and intensive care unit stay were 59 days (range, 9-225 days) and 6.3 days (range, 1-87 days), respectively. Seven patients achieved oral feeding after a median 10.3 postoperative days (range, 7-78 postoperative days). Two of the 10 patients died of sepsis at 9 and 74 days postoperatively.

CONCLUSIONS

The strategy for patients with AEF should be individualized. Our surgical strategy for AEF, which includes simultaneous aortic graft replacement and primary repair of esophagus in the same operative field, is feasible and promising.

Aortic injury caused by esophageal foreign body-case reports of 3 patients and literature review

OBJECTIVES

Ingestion of a foreign body can cause different degrees of damage to esophagus, and several complications are potentially life-threatening if not properly handled. The aortic injury caused by a perforating esophageal foreign body is rare but lethal. The optimal management still remains controversial. The purpose of this report is to describe our experience in the management of the aortic injury caused by esophageal foreign body ingestion.

METHODS

Between January 2015 and December 2015, we retrospectively enrolled cases of esophageal perforation involving the aorta by foreign body. The general parameters, esophageal foreign body, types of aortic injury, treatment, and outcome were analyzed. Additionally, we reviewed the literature of the management of esophageal perforation involving the aorta caused by foreign bodies. The study was approved by the ethics committee of the First Affiliated Hospital, College of Medicine, Zhejiang University, and the need for informed consent was waived (Quick review 2019, No. 609).

RESULTS

Three cases of esophageal perforation involving the aorta by foreign body was selected in the study. Two male and 1 female patients (range, 51-58 years old) with the aorta involvement caused by a perforating foreign body in the esophagus in 3 forms were identified, including 1 patient with mycotic aortic pseudoaneurysm, 1 patient with aortoesophageal fistula and 1 patient with the aortic intramural hematoma. One patient died of the rupture of the pseudoaneurysm during the preparation of the surgery. The other 2 patients were cured with a multidisciplinary approach, which is an urgent thoracic endovascular aortic repair followed by mediastinal debridement/drainage or endoscopic retrieval. Two of 3 patients were survived until now.

CONCLUSION

The management of the aortic injury caused by esophageal foreign body injury is challenging. Early diagnosis and multidisciplinary management is crucial.

Challenges and experience of setting up an aortic service

Aortic surgery is a complex procedure posing high risks in comparison to other adult cardiac surgeries. Novel surgical approaches including minimally invasive procedures, sutureless aortic valve replacement, and transcatheter aortic valve implantation have been found to be acceptable alternatives to conventional surgeries. In addition, novel endovascular repair techniques and hybrid procedures have been introduced for the management of patients with thoracoabdominal aortic pathologies. However, these modalities are not readily available in every center, and such novel procedures impose a learning curve for surgeons and high costs for affected patients. In this review, we discuss the challenges of setting up an aortic service, having regard to the Iranian experience.

Successful management of aortoesophageal fistula caused by esophageal cancer using thoracic endovascular aortic repair

Aortoesophageal fistula (AEF) is a highly life-threatening condition, even when treated promptly. However, little is known about the treatment for AEF in patients with advanced esophageal cancer. We report the case of a 69-year-old man diagnosed with esophageal squamous cell carcinoma (ESCC) that was admitted to our hospital for ESCC treatment. On diagnosis of unresectable ESCC invading the thoracic aorta, chemotherapy was administered. The response to treatment after two courses was evaluated as stable disease. We performed radiation therapy followed by bypass operation for esophageal stenosis. After radiation therapy, AEF was detected. His condition improved after hemostasis using thoracic endovascular aortic repair (TEVAR). He was discharged from our care after treatment with antibiotics; he died due to cancer progression 7 months after TEVAR. AEF with ESCC is a lethal condition that may occur during cancer treatment; however, TEVAR might help improve the patient's condition.

[Endoscopic Diagnosis of Aortoesophageal Fistula Not Presenting Hematemesis]

Aortoesophageal fistula (AEF) is an extremely rare but lethal cause of massive gastrointestinal hemorrhage. Characteristic symptoms are mid-thoracic pain, sentinel minor hemorrhage, and massive hemorrhage after a symptom-free interval. Prompt diagnosis and immediate treatments are necessary to reduce mortality. However, AEF is difficult to diagnose because it is uncommon and often leads to death with massive bleeding before proper evaluation. We report a case of endoscopic diagnosis of AEF that did not present with hematemesis; it was treated with thoracic endovascular aortic repair (TEVAR) and surgery. A 71-year-old female presented to the emergency department with epigastric discomfort. Endoscopy demonstrated a submucosal tumor-like protrusion and pulsating mass with blood clots. Contrast-enhanced chest CT confirmed AEF due to descending thoracic aortic aneurysm. The patient immediately underwent TEVAR to prevent massive bleeding and subsequently underwent surgery. Endoscopists should consider AEF if they see a submucosal tumor-like mass with a central ulcerative lesion or a pulsating protrusion covered with blood clots in mid-esophagus during an endoscopy.

Thoracic Endovascular Aortic Repair of Esophageal Cancer-Associated Aortoesophageal Fistula: A Case Report and Literature Review

Background

Thoracic endovascular aortic repair of an aortoesophageal fistula is an effective emergency treatment for patients with T4-esophageal cancer, as it prevents sudden death, and is a bridge to surgery. However, the course of unresectable malignant aortoesophageal fistula treated with thoracic endovascular aortic repair alone is not well-known.

Case Presentation

We report a 67-year-old Japanese man with T4-esophageal cancer who experienced a chemoradiation-induced aortoesophageal fistula and was rescued with thoracic endovascular aortic repair. He recovered after the procedure and survived for 4 additional months with management of a mycotic aneurysm and secondary aortoesophageal fistula with the exposure of the stent graft into the esophagus. Thoracic endovascular aortic repair of aortoesophageal fistula with T4-esophageal cancer extended life for nearly an average of 4 months in the reported cases. As a postoperative complication, the exposure of the stent graft into the esophagus is rare but life-threatening; the esophageal stent insertion was effective.

Conclusions

With postoperative management advances, thoracic endovascular aortic repair can improve survival and increase the quality of life of patients with T4-esophageal cancer.

Aortoesophageal Fistula: A Fatal Complication of Thoracic Endovascular Aortic Stent-Graft Placement

Patient: Female, 80

Final Diagnosis: Aortoesophageal fistula

Symptoms: Hematemesis

Medication: —

Clinical Procedure: Thoracic endovascular aortic repair

Specialty: General and Internal Medicine

Aortoesophageal Fistula Causing Massive Gastrointestinal Bleeding and Death in a Patient with Dermatomyositis: A Case Report

Patient: Female, 46

Final Diagnosis: Aortoesophageal fistula

Symptoms: Gastrointestinal bleeding • hypotension

Medication: —

Clinical Procedure: Angiography • esophagogastroduodenoscopy

Specialty: Pulmonology

Treatment of post-thoracic endovascular aortic repair aorto-esophageal fistula-only radical surgery can be effective: techniques and sequence of treatment

Aorto-esophageal fistulas (AEFs) are rare after thoracic endovascular aortic repair (TEVAR), being associated with the presence of mediastinal hematoma and the need for emergency TEVAR. Left untreated, AEFs are always lethal. "Redo"-stent-grafting can serve as a "bridging" procedure in hemodynamically unstable patients, but is not a durable therapy. Radical surgery is shown to be the most durable and effective treatment. This includes esophagectomy, stent-graft removal and aortic replacement followed by esophageal reconstruction, e.g., gastric pull-up operation. Aortic reconstruction can be performed by the use of self-made bovine pericardial tubes. A bilateral anterior ("clam-shell") thoracotomy can be chosen for surgical exposure in revision cases after previous sternotomy, in which the ascending aorta, aortic arch and proximal descending aorta require reconstruction.