Atypical Aortoesophageal Fistula with Atypical and Delayed Presentation and Negative Imaging Studies

Abstract

A 59-year-old man with past medical history of thoracic aortic aneurysm treated with thoracic endovascular aortic repair presented with melena for 2 weeks. Initial EGD did not reveal the source of bleeding and showed normal esophagus; abdominal arteriogram did not reveal a fistulous communication and initial CTA showed normal position of the aortic graft stent without endoleak. The sixth EGD revealed a submucosal tumor-like projection in the upper esophagus and stigmata of recent bleeding. Another thoracic endovascular aortic repair with stent was placed over the old graft for presumed aortoesophageal fistula. Poststent upper gastrointestinal series with contrast showed extravasation of the contrast from the esophagus and CTA showed fistulous tract between aorta and esophagus. The patient refused definitive surgical repair despite having infected aortic graft; jejunostomy tube was placed and life-long suppressive antibiotic treatment was given and the patient is doing well at 2-year follow-up.

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

“…Although a better prognosis was observed in patients with AEF treated with TEVAR compared to those treated with conservative therapy ( P < 0.001), no correlation was found between TEVAR and mortality in Cox regression ( P > 0.05). TEVAR can be recommended only as an emergency bridging therapy before surgery [ 37 , 38 ]. Radical surgery should be performed as soon as possible once the condition is stable because TEVAR can control bleeding but cannot debride infection [ 39 , 40 ].…”

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

“…High-resolution CT (HR-CT) provides a higher accuracy rate for AEF with its clear view of the mediastinum components, and, further, it can help to assess the condition of a pseudo-aneurysm or mediastinitis together with the extent of soft tissue involvement, so as to enable planning for aspiration or drainage of the inflamed components [44]. CT angiography (CTA) can also directly depict extravasation of the contrast material outside the aorta [31,[45][46][47]. Accordingly, CT is usually used for the initial investigation in cases suspicious for AEF, though such typical findings may be rarely seen.…”

“…There was a case report in which the diagnosis was confirmed retrospectively after the second session of the TEVAR procedure, despite the fact that the initial examination of UGIS and CTA missed the presence of post-TEVAR AEF due to the lack of typical findings [47]. Therefore, for early diagnosis prior to the occurrence of lethal complications, it is important to keep in mind that once suspicious symptoms have occurred in any patient with a history of TEVAR, we should not rule out the possibilities of AEF, in spite of its rare occurrence as well as occult findings in several pre-operative examinations.…”

“…Accordingly, TEVAR and/or esophageal stenting followed by anti-biotic treatment and/or percutaneous drainage could be an option for a palliative strategy for a substantial period [47]. Further developments of endoscopic technologies can be expected to contribute to the improving the outcome of palliative strategies.…”

“…However, previous studies demonstrated that the rate of mortality after surgery for secondary AEF (78%) was higher than that for primary AEF (61%) [21]. Therefore, some investigators proposed that the appropriate choice in treatment strategies might be depend on the patient's condition, size of the wall defects and the etiology of AEF [47,79]. …”