Tracheo-Bronchial Obstruction and Esophageal Perforation after TEVAR for Thoracic Aortic Rupture

A rare case of posttraumatic aortic rupture, treated with an endovascular stent graft implantation and complicated with esophageal rupture

BACKGROUND

Esophageal necrosis and perforation after thoracic endovascular aortic repair (TEVAR) for ruptured traumatic aortic aneurysm is extremely rare. It is difficult to manage, and patients rarely survive without treatment. Although, there is no certain consensus in relation with the optimal treatment we present a subsequent successful management of both life-threatening conditions.

CASE PRESENTATION

A 52-year-old man experienced a blunt chest trauma after motor vehicle collision with mild symptoms of pain and fractured ribs. On the 12th day he had severe chest pain and computed tomography (CT) revealed a ruptured traumatic thoracic aortic aneurysm with massive mediastinal hematoma. An emergency thoracic endovascular aortic repair (TEVAR) was performed. Several days later the patient developed a fever. CT suspected a pneumomediastinum, a sign of esophageal rupture, but no confirmation from esophagography and esophagoscopy was achieved. Because of deteriorated septic condition, patient was referred for exploratory thoracotomy. The rupture was found and esophagectomy was performed, with an esophagostomy and gastrostomy to enable enteral nutrition. Almost one year after the esophagectomy, gastric conduit reconstruction through the retrosternal route was performed. The patient was still alive and symptom-free more than 1 year after the reconstruction and no infection of the stent graft was observed.

CONCLUSION

We successfully managed a rare case of esophageal necrosis after TEVAR for ruptured traumatic thoracic aortic aneurysm. It is essential to diagnose the esophageal necrosis at an early stage and provide appropriate treatment to increase survival.

A Case of Acute Esophageal Necrosis from Unruptured Thoracic Aortic Aneurysm

Acute esophageal necrosis (AEN), also known as black esophagus due to its appearance on endoscopy, classically involves the distal esophagus (97% of cases). AEN affecting the midesophagus with sparing of the distal esophagus is rare and usually occurs in patients with thoracic aortic aneurysmal (TAA) rupture or aortic dissection. Herein, we report a unique case of AEN in the midesophagus in a patient with an unruptured and undissected TAA.

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.

Oesophageal necrosis after thoracic endovascular aortic repair: a minimally invasive endovascular approach-a dramatic complication

There are few cases in the literature reporting dysphagia caused by oesophageal compression by the aorta due to acute or chronic aortic pathology. This type of dysphagia is called dysphagia aortica. Thoracic endovascular aortic repair is nowadays the treatment of choice for anatomically suitable patients experiencing complicated Type B aortic dissection. Oesophageal necrosis is a rare but fatal complication following thoracic endovascular aortic repair. Extrinsic oesophageal compression by the thrombosed aneurysmal sac, a mediastinal haematoma or extensive thrombosis in the false lumen of a dissected aorta and acute vascular occlusion of the oesophageal supply are possible mechanisms. When oesophageal necrosis is suspected, endoscopic examination and computed tomography imaging should be performed repeatedly. Oesophagoscopy will confirm the diagnosis revealing a black, diffusely necrotic and ulcerated oesophageal mucosa. It is critical to intervene before full-thickness oesophageal wall necrosis and mediastinitis occur. Guidelines are absent because of the rarity of this complication. Moreover, lack of a large series does not permit the establishment of guidelines either. However, oesophagectomy of the impaired oesophagus is the only chance for survival. Unfortunately, survival rates are disappointing. Prevention and awareness is the cornerstone of success. Early endoscopic examination when oesophageal necrosis is suspected due to even minimal symptoms will detect this fatal menace on time.

Seven esophageal perforation cases after aortic replacement/stenting for thoracic aortic dissection or aneurysm

Background

Esophageal perforation after aortic replacement/stenting for aortic dissection or aneurysm is a rare but severe complication. However, its cause, standard treatment, and prognosis are unclear. We analyzed the treatment and outcome retrospectively from seven cases experienced at our hospital.

Case presentation

The median age of the patients was 70 years (range, 41–86), and six of the seven cases were male. As the first treatment, aortic replacement techniques were performed in five, and thoracic endovascular aortic repair (TEVAR) procedure was performed in two. We evaluated the treatment of the perforation, the cause of death, and the median survival time after reparative surgery (esophagectomy).

Initial treatment of the perforation was esophagectomy without reconstruction in six and esophagogastric bypass (later, esophagectomy was performed) in one. Three of seven cases could be discharged from hospital or moved to another hospital, but two of these three cases died of major bleeding on postoperative days 320 and 645. The other four esophagectomy cases died in hospital because of sepsis on postoperative days 14, 30, and 41 and major bleeding on postoperative day 54. The one surviving case was a 65-year-old man who underwent reconstruction, and was still alive without signs of infection at 424 days postoperatively.

Conclusion

The prognosis of esophageal perforation cases after aortic replacement/stenting for thoracic aortic dissection or aneurysm is poor, though there were some cases with relatively long survival. Therefore, the indication for invasive esophagectomy should be decided carefully. Control of infection including regional infection is essential for successful treatment.

The bronchial obstruction as a complication of endovascular repair of aortic pseudoaneurysm in Behçet's disease

Behçet's disease (BD) is an autoimmune disorder affecting multiple organs. Aortic pseudoaneurysm is the most catastrophic lesion in BD. This lesion type is considered as a complicated and challenging pathology by surgeons because of the technical operative difficulties and frequent recurrence. So, the endovascular repair of inflammatory aortic pseudoaneurysm has been used as an alternative to open surgical repair. It is particularly important in patients who are high-risk surgical candidates because of comorbidities. In this report, we present a case and treatment of bronchial obstruction, which caused progressive dyspnea after endovascular repair of aortic rupture, in patient with known history of BD.

Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic Aneurysm

Free esophageal perforation following a hybrid visceral debranching and distal endograft extension to repair a ruptured thoracoabdominal aortic aneurysm (TAAA) is a rare complication. The authors report a 56-year-old male who underwent elective thoracic endovascular aortic repair of a thoracic aneurysm. Four and a half years later, he presented with a new aneurysm extending from the distal end of the thoracic stent graft to the aortic bifurcation involving all the visceral arterial branches. The TAAA ruptured while he was awaiting an elective repair, and as a result, he underwent an emergency hybrid procedure. This involved debranching the visceral arterial branches including autotransplantation of the left kidney and distal endograft extension. Postoperatively, he developed free esophageal perforation secondary to ischemic necrosis requiring esophageal resection and gastric pull-up. The patient was well 6 months after the gastrointestinal restorative procedure. Thus, esophageal perforation following an emergency hybrid repair of ruptured TAAA is a rare complication, and a successful outcome depends on early recognition and surgical exclusion of the ruptured viscus.

Importance of early detection of oesophageal complications after aortic stent graft repair

Oesophageal complications after endovascular aortic stent repair are rare, but may lead to catastrophic consequences. Early detection is mandatory, but is sometimes difficult because of a lack of specific signs in the early stages. We report 2 cases with opposing results of oesophageal complications after aortic stent graft repair, and discuss the early signs of this disastrous complication and potential methods for early detection.