An Aortoesophageal Fistula in Patient with Lung Cancer after Chemo-Irradiation and Subsequent Esophageal Stent Implantation

Abstract

An aortoesophageal fistula (AEF) is uncommon but is frequently fatal. Most cases are attributable to a thoracic aortic aneurysm. Other common causes include malignant intrathoracic neoplasm, foreign body ingestion, endovascular stent graft repair for thoracic aortic disease, and esophageal surgery. We report a case of an AEF that developed after chemo-irradiation and subsequent esophageal stent implantation in patient with non-small cell lung cancer. The patient underwent self expanding metallic esophageal stent implantation for an esophageal stricture after chemotherapy and radiotherapy. However, 1 month later, he presented with hematemesis. Chest computed tomography and aortography revealed a fistula from the descending thoracic aorta to the stented esophagus. The patient expired 36 hours after initial hematemesis. To our knowledge, this is the first confirmed report of an AEF in patient with a nonesophageal malignancy that had undergone chemo-irradiation and subsequent esophageal stent implantation. We recommend that special caution be exercised when performing esophageal stent implantation in patients who have received prior radiotherapy to the thorax including the esophagus.

Aortoesophageal Fistula Secondary to Placement of an Esophageal Stent: Emergent Treatment with Cyanoacrylate and Endovascular Stent Graft

“…Four reports described perforation or erosion of the proximal end of the stent into the aorta at autopsy or emergent thoracotomy. [1][2][3][4][5] To the best of our knowledge, this is the first report of successful NBCA embolization and subsequent endovascular stent graft placement for treatment of an AEF secondary to placement of an esophageal stent.…”

“…AEF caused by an esophageal stent is extremely rare; only a few cases have been reported. [1][2][3][4][5] To the best of our knowledge, this is the first report of the successful treatment of AEF secondary to esophageal stent placement with N-butyl 2-cyanoacrylate (NBCA) embolization and subsequent endovascular stent graft placement.…”

Emergency repair of a radiation-induced aortoesophageal fistula with endograft: Report of a case

“…The majority of patients present with a herald bleed, with catastrophic exsanguination delayed by hours to even months. 6,11 Other accompanying signs and symptoms include chest pain (75%), sepsis (53%), and back pain (18%). 4,17,18 Dysphagia and syncope occur less frequently.…”

“…Most involve treatment for esophageal malignancy, with reports of lung cancer being rare. 10,11 Radiation can cause damage to the aorta and other great vessels. [12][13][14][15] Poon et al demonstrated the radiation induced histological changes in a ruptured aorta in 1968, noting endothelial proliferation, intimal thickening, and vasa vasorum thrombosis leading to hyaline necrosis.…”

Refractory recurrent bleeding as a late mortal complication of chest wall irradiation

“…[2] Aortoesophageal fistula has been previously described as a cause of mortality in irradiated subjects. [3] However, to the best of our knowledge, arteriovenous fistulae don′t represent a frequent vascular-related cause of mortality among patients who had received thoracic radiation therapy. Modern postmastectomy radiotherapy protocols are associated with a lower rate of thoracic complications without an increased locoregional recurrence risk.…”