Case Report: Successful Repair of Primary Aortoesophageal Fistula With an Endovascular Stent Graft and an Esophageal Stent

Abstract

Aortoesophageal fistula (AEF), secondary to thoracic pseudoaneurysm as a result of upper gastrointestinal bleeding, is a rare condition and will be undoubtedly lethal without prompt surgical intervention. The estimated annual incidence of primary AEFs and secondary AEFs is about 0.0015% and 0.6%–2%, respectively. The challenges of the therapy posed by AEF are control of the hemorrhage, arterial reconstruction in an infection field, control of sepsis, and re-establishment of the alimentary tract. We present a case of a 58-year-old man who suffered from chest pain and hematemesis and was finally diagnosed with pAEF caused by descending thoracic pseudoaneurysm. Our team successfully deployed an endovascular stent graft and esophageal stent to seal ruptured thoracic aorta and esophageal defects, which provided a new surgical strategy for aortoesophageal fistula in the endovascular era.

Combined Endovascular and Endoscopic Management of a Secondary Aortoesophageal Fistula after Open Surgical Aortic Repair in a Giant Descending Thoracic Aortic Pseudoaneurysm: Case Report and Review of Literature

“…AEF are classified as primary (0.0015%) and secondary (0.6–2%) [ 2 , 3 ]. Primary AEF is mostly caused by thoracic aortic aneurysms (51%), while other causes include penetrating aortic ulcer, esophageal cancer, ingestion of foreign bodies, Barrett’s ulcer, trauma, or prolonged nasogastric tube intubation [ 4 , 5 ].…”

“…Aortoesophageal syndrome in AEF was first described by Chiari in 1914 as a sequence of dysphagia or mid-thoracic pain, sentinel minor bleeding expressed as minor hemoptysis or hematemesis, followed by a symptom-free period before a major bleeding event with exsanguination. (1,3,10) However, in a review of the literature consisting of more than 500 cases, only 45% of the patients presented with classical Chiari's triad, while herald bleeding was found in 65% of the cases, mid-thoracic pain in 59%, and dysphagia in 45% of the cases [5]. Another study identified hematemesis as the most common symptom of AEF [1].…”

“…Aortoesophageal fistula (AEF) is a rare entity of gastrointestinal hemorrhage associated with high mortality rates of over 77% with treatment and is fatal without any intervention [ 1 , 2 ]. It is defined as communication between the aorta and the esophagus, and it is classified as primary AEF and secondary AEF with an annual estimated incidence of 0.0015% and 0.6–2%, respectively [ 2 , 3 ]. Secondary AEF occurs after aortic disease treatment or esophageal procedures [ 4 , 5 ].…”

“…AEF has a short clinical course and requires prompt diagnosis and emergency intervention [ 9 ]. The aortoesophageal syndrome in AEF was first described by Chiari as a sequence of dysphagia or mid-thoracic pain and sentinel minor bleeding expressed as minor hemoptysis or hematemesis, followed by a symptom-free period before a major bleeding event with exsanguination [ 3 ].…”

“…There is no consensus in the literature regarding the best treatment strategy for AEF, with multiple options available, including open surgery or endovascular aortic repair combined with management of the esophageal lesion (surgical or endoscopic) and extensive antibiotic therapy [ 1 , 3 , 7 ]. In this study, we present our approach for a complex case involving a high-risk and fragile patient.…”