Aortoesophageal fistula: an uncommon complication after stent-graft repair of an aortic thoracic aneurysm

Aorto-esophageal Fistula Management

Aorto-esophageal fistula is a rare but life-threatening source of massive upper gastrointestinal bleeding. Prompt diagnosis and intervention are key for patient survival. Treatments consist of aortic resection, thoracic endovascular aortic repair, esophagectomy with diversion, and primary esophageal repair. The appropriate treatment is dependent on patient hemodynamics and fitness and familiarity with operative approaches by the treating team.

A novel approach to surviving an acute aorto-oesophageal fistula: A case report

INTRODUCTION AND IMPORTANCE

Acute aorto-oesophageal fistula poses a significant mortality risk, requiring immediate and decisive medical intervention. This report highlights the critical need for innovation in emergency surgical responses.

CASE PRESENTATION

A 57-year-old male, with a history of aortic repair, presented with chronic anaemia and dysphagia. He suffered a cardiac arrest from massive hematemesis during surgery for an infected thoracic hematoma. Lacking a Stengsten-Blackmore tube, a 26Fr Foley catheter was used to control the bleeding. This measure stabilized the patient enough for a definitive endovascular repair with aortic stents, which successfully managed the bleeding.

CLINICAL DISCUSSION

The treatment objectives for this condition include initial control of oesophageal bleeding, followed by endovascular management to further control the bleeding, subsequently releasing the oesophageal control, and ultimately preventing infection through the administration of intravenous antibiotics.

CONCLUSION

This case illustrates the importance of adaptability and the use of unconventional methods in emergency situations, demonstrating that innovative solutions can be lifesaving in critical surgical emergencies.

Fatal bleeding due to an aorto-esophageal fistula: A case report and literature review

BACKGROUND

Aorto-esophageal fistula is an extremely rare cause of acute upper gastrointestinal bleeding (UGIB).

CASE SUMMARY

We present a case of an 80-year-old woman with esophageal cancer who was admitted to our department with hemorrhagic shock due to UGIB. During the diagnostic procedure, emergency computed tomography angiography was performed and confirmed aorto-esophageal fistula. Interventional radiologists inserted a stent graft into the aorta, successfully closing the fistula. Unfortunately, the patient later died of heart failure following irreversible hemorrhagic shock. Autopsy confirmed the aorto-esophageal fistula, which formed 1 cm below the distal edge of the stent previously inserted into the esophagus for a malignant stricture.

CONCLUSION

There are very rare causes of UGIB. Although clinical decisions are made during the diagnostic workup of these patients, we must be aware of the limitations of various therapeutic options, even the most contemporary.

[Peculiarities of diagnosis and emergency surgical care in aorto-oesophageal fistula]

An aorto-oesophageal fistula is a rare but life-threatening pathological condition developing on the background of diseases of the aorta and oesophagus, as well as after surgical interventions on the aorta. The article deals with a clinical case report regarding management of a patient presenting with an aorto-oesophageal fistula resulting from a thoracic artery aneurysm. The main clinical manifestations of the diseases included dysphagia (due to oesophageal obstruction caused by thrombotic masses of the aneurysm) and the occurring gastrointestinal haemorrhage. Comprehensive instrumental diagnosis was performed using roentgen examination of the oesophagus, oesophagoscopy, and contrast-enhanced computed tomography of the chest. The obtained findings made it possible to objectively assess the patient's state, to carry out timely treatment in conditions of a surgical hospital, and to avoid severe complications.

Treatment of aortoesophageal fistula developed after thoracic endovascular aortic repair: a questionnaire survey study

BACKGROUND

Aortoesophageal fistula (AEF) is a life-threatening late complication that can occur after thoracic endovascular aortic repair (TEVAR). More data are required to identify the optimal treatment strategy for AEF developed after TEVAR. The aim of this study was to clarify the current status of surgical treatments for AEF developed after TEVAR and the outcomes of these treatments.

METHODS

The Japan Esophageal Society conducted a questionnaire survey targeting authorized or semi-authorized institutes at Authorized Institutes for Board Certified Esophageal Surgeons. Thirty-nine patients with AEF developed after TEVAR were identified from 15 institutes. Data on patient demographics, treatment performed, and survival rate were obtained by the questionnaire. The Kaplan-Meier method was used for survival analysis and differences in the survival rates.

RESULTS

Esophagectomy and aortic replacement were performed in 32 and 22 patients, respectively, and 22 underwent both procedures. Postoperative complications were observed in 24 patients (75.0%). Complications with Clavien-Dindo Grade III or higher were observed in 53.1% of patients. Operative and hospital mortality rates were 3.1% and 18.8%, respectively. The survival rate in patients who underwent esophagectomy was higher than in those who did not (P < 0.0001). The survival of patients who underwent both esophagectomy and aortic replacement was also higher than in those who did not (P < 0.0001).

CONCLUSION

Esophagectomy combined with aortic replacement can offer a long-term treatment strategy with higher survival rates in patients who develop AEF after TEVAR. Because of the high incidence of postoperative morbidity and mortality, these types of surgery should only be performed in centers with both experienced esophageal and cardiovascular surgical teams.

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.

A systematic review of infected descending thoracic aortic grafts and endografts

OBJECTIVE

The objective of this study was to collect and critically analyze the current evidence on the modalities and results of treatment of descending thoracic aortic surgical graft (SG) and endograft (EG) infection, which represents a rare but dramatic complication after both surgical and endovascular aortic repair.

METHODS

A comprehensive electronic health database search (PubMed/MEDLINE, Scopus, Google Scholar, and the Cochrane Library) identified all articles that were published up to October 2017 reporting on thoracic aortic SG or EG infection. Observational studies, multicenter reports, single-center series and case reports, case-control studies, and guidelines were considered eligible if reporting specific results of treatment of descending thoracic aortic SG or EG infection. Comparisons of patients presenting with SG or EG infection and between invasive and conservative treatment were performed. Odds ratio (OR) meta-analyses were run when comparative data were available.

RESULTS

Forty-three studies reporting on 233 patients with infected SG (49) or EG (184) were included. Four were multicenter studies including 107 patients, all with EG infection, associated with a fistula in 91% of cases, with a reported overall survival at 2 years of 16% to 39%. The remaining 39 single-center studies included 49 patients with SG infection and 77 with EG infection. Association with aortoesophageal fistula was significantly more common with EG (60% vs 31%; P = .01). In addition, time interval from index procedure to infection was significantly shorter with EG (17 ± 21 months vs 32 ± 61 months; P = .03). Meta-analysis showed a trend of increased 1-year mortality in patients with SG infection compared with EG infection (pooled OR, 3.6; 95% confidence interval, 0.9-14.7; P = .073). Surgical management with infected graft explantation was associated with a trend toward lower 1-year mortality compared with graft preservation (pooled OR, 0.3; 95% confidence interval, 0.1-1.0; P = .056).

CONCLUSIONS

Thoracic aortic EG infection is likely to occur more frequently in association with aortoesophageal fistulas and in a shorter time compared with SG infection. Survival is poor in both groups, especially in patients with SG infection. Surgical treatment with graft explantation seems to be the preferable choice in fit patients.

Oesophageal mucosal blood flow changes after thoracic endovascular stent graft implantation using a novel sensor probe

OBJECTIVES

Secondary aorto-oesophageal fistula is a rare, lethal complication occurring after thoracic endovascular aneurysmal repair. The cause of secondary aorto-oesophageal fistula is unknown, but a reduction in local oesophageal mucosal blood flow (OMBF) may be a basis for such a devastating sequela. Our study aims to develop a novel blood flow sensor probe to detect changes in OMBF after thoracic stent graft implantation in an experimental swine model.

METHODS

A novel laser Doppler flowmetry sensor probe incorporating an optical fibre sensor within a nasogastric tube was developed using microelectromechanical system technology. OMBF was measured at various levels using this sensor probe, to test its feasibility before and after thoracic endovascular stent graft implantation covering Th4-Th8 vertebral levels in 6 swine.

RESULTS

In the middle oesophagus (Th5-Th7), where the aorta was covered with a stent graft, the measured OMBFs were significantly decreased after thoracic endovascular stent graft implantation than those of baseline (8.6 ± 2.7 vs 18.4 ± 7.9 ml/min/100 g, P < 0.0001), followed by a plateau period for at least 2 h after stent grafting (8.7 ± 3.3 ml/min/100 g, P < 0.0001 vs baseline). OMBFs in the upper (Th1-Th3) and lower (Th9-Th11) oesophagus, where the aorta was not covered with a stent graft, were unaffected by thoracic endovascular stent grafting.

CONCLUSIONS

The novel laser Doppler flowmetry sensor probe was useful to monitor precise changes of OMBF in a swine model, demonstrating a significant reduction in OMBF after thoracic endovascular stent graft implantation.

Management of aorto-esophageal fistula secondary after thoracic endovascular aortic repair: a review of literature

Aorto-esophageal fistula (AEF) is a rare and lethal entity, and the difficulty of making diagnosis of AEF is well-known. As promising results in the short-term effectiveness of thoracic endovascular aortic repair (TEVAR) promote its usage, the occurrence of AEF after TEVAR (post-TEVAR AEF) increases as one of the major complications. Therefore, we provide a review concerning the management strategy of post-TEVAR AEF. Although its representative symptom was reported as the triad of mid-thoracic pain and sentinel hematemesis followed by massive hematemesis, the symptom-free interval between sentinel hemorrhage and massive exsanguination is unpredictable. However, the physiological condition represents a surgical contraindication. Accordingly, early diagnosis is important, but either CT or esophago-gastro-duodenoscopy rarely depicts a typical image. The formation of post-TEVAR AEF might be associated with the infection of micro-organisms, which is uncontrollable with anti-biotic administration. The current first-line strategy is combination therapy as follows, (1) to control bleeding by TEVAR in the urgent phase, and (2) radical debridement and aortic/esophageal re-construction in the semi-urgent phase. In view of the high mortality and morbidity rate, it is proposed that the choice in treatment strategies might be affected by patient`s condition, size of the wall defects and the etiology of AEF. Practically, we should keep in mind the importance of making an early diagnosis and, once a suspicious symptom has occurred in a patient with a history of TEVAR, the existence of post-TEVAR AEF should be suspected. A prospective registry together with more developed technologies will be needed to establish a future strategy.

Imaging of iatrogenic conditions of the thorax

Common medical interventions performed by cardiologists, radiologists, surgeons, dentists, and alternative practitioners can result in complications within the thorax that lead to significant patient morbidity. Prompt radiologic identification of iatrogenic complications of medical procedures in the thorax is essential to guide patient triage and treatment. Understanding the approach to common thoracic interventions and the placement of thoracic medical devices can aid radiologists in the evaluation of iatrogenic complications.

Delayed presentation of aortoesophageal fistula after endovascular repair

The incidence of aortoesophageal fistula after thoracic endovascular aortic repair has increased following an increase in thoracic endovascular aortic procedures. A 68-year-old man was diagnosed with aortoesophageal fistula 6 years after thoracic endovascular aortic repair of a descending aortic aneurysm. Due to massive hematemesis and instability, he underwent a left thoracotomy, graft repair of the aorta with stent removal, gastrostomy, and proximal esophagostomy. Unfortunately, he died 1 week later due to sepsis. Aortoesophageal fistula may present long after thoracic endovascular aortic repair, and clinicians treating such cases should always be aware of this complication.

Surgical strategy for aortoesophageal fistula in the endovascular era

OBJECTIVE

Aortoesophageal fistula (AEF) is relatively rare and usually life-threatening. Lots of strategies have so far been discussed for this entity including the role of endovascular repair. The aim of this study is to review our experiences and reconsider the surgical strategy for aortoesophageal fistula in the endovascular era.

METHODS

This is a retrospective multicenter study. From 1995 to 2011, 10 aortoesophageal fistula cases were identified in four institutions. For all of these cases surgical procedures and results were retrieved from medical records.

RESULTS

Six patients underwent open aortic repair and four patients underwent thoracic endovascular aortic repair (TEVAR) as a primary intervention. Three patients who underwent open aortic repair with esophagectomy and omental coverage in early phase, either as a primary intervention or performed after bridging TEVAR, showed 100 % 1-year survival. On the other hand, three patients with TEVAR alone did not survive more than 1 year without recurrence. One patient with bridging TEVAR underwent concomitant esophageal resection and conventional aortic graft replacement 2 days later, and simultaneous gastric tube reconstruction was performed with intact whole omentum covering the aortic prosthesis. This patient is doing well with no sign of infection at 1-year follow-up.

CONCLUSION

For AEF, TEVAR as a primary approach is quite useful to stabilize the patients' condition. However, definitive aortic repair with omental coverage should be performed as early as possible as a next step. It may be one of the strategies for the treatment of AEF that concomitant esophageal resection and aortic graft replacement is performed with simultaneous gastric tube reconstruction with intact whole omentum after removing the stent graft, so far as the patient's physical condition permits.

A case of secondary aortoesophageal fistula inserted a covered self-expanding esophageal stent to control gastrointestinal bleeding

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.

Aortoesophageal fistula after endovascular repair for aberrant right subclavian artery aneurysm

A 76-year-old woman with malignant rheumatic arthritis developed dysphagia and hoarseness secondary to an aberrant right subclavian artery aneurysm. We performed a hybrid endovascular repair with concomitant surgical treatment for the aberrant right subclavian artery aneurysm. One month after discharge, she was emergently admitted to our hospital because of chest pain and fever. We diagnosed aortoesophageal fistula and stent graft infection based on computed tomography, gallium scintigraphy, and esophagoscopy results. Esophagectomy, elimination of the infected stent graft, and muscle plombage were performed during several surgeries. However, she died of hemorrhagic shock secondary to an aortobronchial fistula.

Lethal aorto-oesophageal fistula - characteristic features and aetiology

Aorto-oesophageal fistula refers to a rarely encountered communication between the aorta and the oesophagus that results in massive and lethal haemorrhage into the upper gastrointestinal tract. Although the time between the initial haemorrhage and the terminal event may be days, a clinical diagnosis may not be established by the time of autopsy. A fistulous tract develops between the aorta and the oesophagus most commonly due to expansion of a thoracic aortic aneurysm or from an ingested foreign body. Less common causes include infiltrating neoplasms, oesophageal ulceration, vascular rings and iatrogenic lesions. Three cases are presented to illustrate the features of such cases due to aortic dissection, bronchial carcinoma and tuberculosis. Cases should be suspected if there has been a history of midthoracic pain or dysphagia, a 'herald' haemorrhage and then massive fatal haematemesis with bright red blood. Careful dissection at autopsy is required to demonstrate the site of the fistulous tract.

Outcome of surgical repair of aorto-eosophageal fistulas with cryopreserved aortic allografts

Aorto-oesophageal fistula (AEF) is a rare but life-threatening disease with an underlying infective aetiology that can cause serious complications. This study investigated the clinical outcomes of patients with AEF who received in situ cryopreserved aortic allograft replacement. From August 2000 to February 2011, 11 patients with AEF received aortic allografts; 5 for primary AEF caused by ruptured aortic aneurysm and 6 for secondary AEF that comprised 4 cases following thoracic endovascular aortic repair (TEVAR) and 2 after open graft replacement of the thoracic aorta. As for results, 2 cases of primary AEF received TEVAR and then allograft replacement, one for graft infection and the other for bleeding. Three primary AEF cases received allografts directly. Six secondary AEF cases received staged (5) or simultaneous (1) oesophagectomy and allograft replacement. There were 3 in-hospital deaths (27%), 2 because of bleeding and one because of multisystem organ failure. Four patients completed oesophageal reconstruction. There were 2 late deaths, one due to aspiration pneumonia and one of unknown cause. In conclusion, surgical results for repair of AEF using cryopreserved aortic allograft were satisfactory considering preoperative critical condition, and this type of allograft appears to be an ideal graft of choice.

Aortoesophageal fistula secondary to thoracic endovascular aortic repair of a descending aortic aneurysm rupture

PURPOSE

We present the case of a patient who developed an aortoesophageal fistula (AEF) 4 years after thoracic endovascular aortic repair (TEVAR) of a descending thoracic aortic aneurysm rupture.

CASE REPORT

A 60-year-old female patient underwent emergency stent graft placement in December 2006 because of rupture of a distal descending aortic aneurysm. The patient was discharged uneventfully. Four years later, the patient was readmitted because of recurrent hematemesis, weight loss, and malaise. A computed tomography scan and an upper gastrointestinal system (GIS) endoscopy examination revealed an AEF located at the midportion of the esophagus and at the caudal end of the stent graft. An emergency stent graft was re-replaced into the previous graft. The patient died from hemorrhagic shock due to massive GIS bleeding while she was being prepared for secondary major esophageal surgery.

CONCLUSION

AEF is a catastrophic complication of TEVAR. Conservative treatment is often associated with fatal results. If possible, these patients should be treated with secondary major surgical procedures.

Unusual complications of endovascular repair of the thoracic aorta: MDCT findings

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.

Successful therapy of brachiocephalic arteriogastric fistula after esophagectomy

We report the case of an 86-year-old man, who had undergone subtotal esophagectomy and reconstruction with a gastric tube through the retrosternal route 7 years ago, who was referred for treatment of a brachiocephalic arteriogastric fistula. An emergency stent-graft placement was performed to prevent massive bleeding from the fistula. After 2 weeks, a follow-up esophagogastroscopy revealed that the gastric tube ulcer had been penetrated, and the stent graft was exposed. Therefore, surgical treatment was indicated. After a carotid-carotid arterial bypass graft was made, the brachiocephalic artery was resected with the stent graft and the gastric wall. The defect between the cervical esophagus and the remnant gastric tube was replaced by a free jejunal graft. The patient tolerated these procedures well and was transferred to the referral hospital 3 months after surgery. Therefore, both an early diagnosis and the administration of multidisciplinary treatment are essential to save patients presenting with an arterioenteric fistula.

Surgical treatment of aortobronchial fistula after thoracic endograft failure

Endovascular stent grafting has been recently considered as a less invasive alternative to either medical therapy or open surgical treatment for many patients with descending thoracic aortic disease. Late complications are rarely described in literature. Herein, we described the occurrence of an aorto-bronchial fistula and a retro-A dissection in a 73-year-old man after stent-grafting for a penetrating atherosclerotic ulcer (PAU) of the descending thoracic aorta and the successful surgical technique adopted in order to remove the stent-graft.

Aortoesophageal fistula after thoracic stent grafting

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.

Percutaneous treatment of an infected aneurysmal sac secondary to aortoesophageal fistula with a history of stent-graft treatment for thoracic aortic aneurysm

A 68-year-old man who was subjected to stent-grafting of a descending thoracic aortic aneurysm (TAA) 4 months previously was admitted to our hospital with constitutional symptoms, including high fever, sweating, nausea, vomiting, weight loss, and backache. An infected aneurysmal sac was suspected based on computed tomography (CT) findings, and an aortoesophageal fistula (AEF) was identified during esophagoscopy. CT-guided aspiration was performed using a 20-G Chiba needle, confirming the presence of infection. For treatment of the infected aneurysmal sac, CT-guided percutaneous catheter drainage in a prone position was performed under general anesthesia with left endobronchial intubation. Drainage catheter insertion was successfully performed using the Seldinger technique, which is not a standard treatment of an infected aneurysmal sac. Improvement in the patient's clinical condition was observed at follow-ups, and CT showed total regression of the collection in the aneurysmal sac.

Conservative treatment of an aortoesophagial fistula after endovascular stent grafting for a thoracic aortic aneurysm

Background

Aortoesophageal fistula (AEF) is an uncommon condition that presents a problem in therapy because of the high rate of morbidity and mortality associated with its surgical management and the uniformly fatal outcome of medical treatment. In this article we describe a case of secondary AEF after endoluminal stent grafting of the thoracic aorta, which was observed by only conservative management and followed up for 14 months with no signs of recurrent hemorrhage or chronic mediastinitis.

Case Report

A 54-year old man with hepatocellular carcinoma (HCC) was admitted to our hospital because of tarry stool. He had a history of traumatic aneurysm, and undergone segmental replacement with a stent graft three years ago. After admission, Esophagogastroduodenoscopy and computed tomography identified AEF. He was treated conservatively, because his stage of HCC was advanced. Oral intake was prohibited, and the patient received proton pump inhibitors, intravenous hyperalimentation and antibiotics. Afterwards, no signs of hemorrhage were observed. Although oral intake was resumed after that, another bleeding event or development of mediastinitis was not observed. Subsequently, He was received chemotherapy for advanced HCC, and we observed downstaging of his advanced HCC.

Conclusions

Although we observed 14 months survival in our case under conservative management of secondary AEF, it seems that the treatment of secondary AEF should do the operative management.

Aorto-oesophageal fistula: an unusual complication of oesophageal biopsies

The authors report a case of an aorto-oesophageal fistula presenting in a patient undergoing investigation for possible oesophageal malignancy who underwent multiple oesophageal biopsies. A 73-year-old gentleman underwent endoscopic biopsy of an oesophageal lesion. Histology showed only inflammatory changes, endoscopy was repeated and again biopsy showed only inflammatory changes. The patient then presented with severe haematemesis, which was shown by CT angiogram to be due to an aorto-oesophageal fistula. This was treated with endovascular stenting, and the patient recovered well. Sequential imaging has shown gradual resolution of the submucosal swelling and lymphadenopathy, excluding the possibility of underlying oesophageal malignancy. This is the first reported case of aorto-oesophageal fistulation as a complication of endoscopic oesophageal biopsies. Aorto-oesophageal fistula is an uncommon but potentially life-threatening cause of haematemesis. It is a potential complication of endoscopic oesophageal biopsy.

Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta

Infection of a vascular prosthesis or endovascular stent-graft is probably the most serious complication that may occur after implantation and dramatically affects the patient's outcome. Surgical treatment is almost always required but even after surgery, morbidity can be significant. Several approaches have been described with some advantages and/or some limitations. Complete resection of the infected foreign material with debridement of the surrounding tissue gives most probably the better results. Orthotopic reconstruction is the best option for all thoracic and thoraco-abdominal pathologies and the use of coated prostheses, homografts or self-made vascular tubes from xenopericardial tissue has to be discussed from case to case. In some exceptional situations, endovascular stent-graft can be performed as bridging to a more complete treatment if general condition of the patient has to be stabilized.