Endovascular Repair of Thoracic Aortoenteric Fistulas

Aortoesophageal Fistula Occurring during Lung Cancer Treatment: A Case Treated by Thoracic Endovascular Aortic Repair

A 63-year-old man had received chemoradiotherapy 7 years ago for stage IIIA pulmonary adenocarcinoma of the left lower lobe and stereotactic irradiation 3 years ago for stage IA pulmonary squamous cell carcinoma of the left upper lobe. An esophageal stent was placed because of esophageal narrowing caused by tumor invasion. Five months later, he was diagnosed with an aortoesophageal fistula. Because invasive surgery posed challenges, thoracic endovascular aortic repair (TEVAR) was performed. We report this rare case of aortoesophageal fistula treated using TEVAR. However, the therapeutic effect was temporary. Further studies investigating the indications for TEVAR are warranted.

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.

Combined thoracic endovascular aortic repair and neurosurgical intervention for injury due to posterior spine surgery

Aortic injuries represent a rare but life-threatening complication of spinal surgery. Perforation of the aorta due to pedicle screw penetration or misplacement can lead to immediate bleeding with hemodynamic instability or to pseudoaneurysm development with delayed risk of rupture, which can occur weeks to months later. Recently, thoracic endovascular aortic repair (TEVAR) in aortic trauma has contributed to a reduction of both mortality and morbidity. The literature on this subject is reviewed.