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

Clinical Characteristics and Early Surgical Outcomes of Aortoesophageal Fistula

BACKGROUND

The incidence and prognosis of aortoesophageal fistula (AEF) has not been clarified. The clinical characteristics and surgical outcomes of AEF were investigated.

METHODS

The clinical data of patients who underwent surgical treatment of AEF from January 2020 to December 2021 that were registered in the Japan Cardiovascular Surgery Database (JCVSD) were analyzed.

RESULTS

During the period, 123 patients (aged 71.0 years [interquartile range, 61.0-78.0 years]; 76.4% men) underwent surgical treatment of AEF. The prevalence of secondary AEF was 61%. Secondary AEF after aortic grafting was the most frequent (n = 40 [32.5%]), followed by AEF after thoracic endovascular aortic repair (TEVAR; n = 30 [24.4%]). Operative mortality occurred in 23 patients (18.7%). TEVAR for AEF (P = .019). Univariable logistic regression analyses showed postoperative bleeding (P = .047), stroke (P = .004), renal failure (P < .001), newly required hemodialysis (P = .023), pneumonia (P = .003), multisystem failure (P < .001), and dyslipidemia (P = .02) were associated with risk factors of operative mortality after surgical treatment of AEF.

CONCLUSIONS

This nationwide study on the surgical treatment of AEF demonstrated a higher incidence of secondary AEF than primary AEF. Open surgical repair and TEVAR for AEF were both associated with high operative mortality. TEVAR and dyslipidemia were risk factors for operative mortality. Precautions and further improved treatment strategies for AEF are still required.

Rapid formation of aortoesophageal fistula complicated by mycotic thoracic aortic aneurysm secondary to infective endocarditis

A 73-year-old man was admitted with four weeks of intermittent fever. He had a history of total aortic arch replacement for aortic arch aneurysm four years prior. CT scans showed no abnormalities before admission. Repeated blood cultures yielded Streptococcus anginosus and Prevotella melaninogenica, suggesting infective endocarditis (IE). Transesophageal echocardiography revealed a vegetation on the aortic valve, confirming IE. He suddenly presented with massive hematemesis and hypotension. Endoscopy revealed an elevated lesion with a laceration but no active bleeding in the esophagus. CT scans showed a thoracic aneurysm involving the esophagus. A diagnosis of aortoesophageal fistula (AEF) complicated by mycotic thoracic aortic aneurysm (MTAA) was made, and he underwent stent graft interpolation followed by minimally invasive esophagectomy. MTAAs are more prone to rupture than arteriosclerotic aneurysms as they are usually not true but pseudoaneurysms. Antecedent infection, including endocarditis, sepsis, predisposes to MTAA. AEF is a rare but life-threatening cause of gastrointestinal bleeding characterized by Chiari's triad. There have been no reports of such rapid formation of AEF after the graft replacement, as shown here. A recent article reported a rapid formation (16 days) of AEF after thoracic endovascular aortic repair, emphasizing prosthetic infection as the most important risk factor. Our case underscores the importance of suspecting AEF and conducting repeated appropriate examinations even if initial examinations do not reveal any aneurysms.

Timely Endoscopic Recognition of Aortoesophageal Fistula With Successful Treatment

Aortoesophageal fistula (AEF) is a devastating cause of upper gastrointestinal bleeding that occurs because of pathologic communication of the esophagus with the aorta. Bleeding AEF has high mortality even with appropriate interventions. In this study, we present a case of a 52-year-old man who presented with hematemesis, which was found to be due to an actively bleeding AEF. Prompt identification of the fistula led to multiple endoscopic interventions that stabilized the patient and allowed him to undergo emergent endovascular aortic stent placement with successful bleeding control.

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.

Dual-modality emergency management of a rare cause of an aorto-oesophageal fistula: a case report

Aorto-oesophageal fistula (AOF) is a life-threatening condition that usually presents with upper gastro-intestinal haemorrhage. This case report details the emergency presentation and management of a 51-year-old male who presented with hematemesis secondary to an impacted denture (ingested two years previously) in the oesophagus that had led to an AOF. This necessitated urgent thoracic endovascular aortic repair followed by thoracotomy, oesophagotomy, T-tube insertion and oesophagostomy. This is the first documentation in the literature of the dual-modality management for this rare cause of AOF and demonstrates the multidisciplinary approach to successful management of this complex yet rare presentation.