Radiation therapy-induced aortoesophageal fistula: a case report and review of literature

Abstract

Aortoesophageal fistula (AEF) is a rare cause of massive upper gastrointestinal hemorrhage. Thoracic aortic aneurysm, esophageal foreign body, esophageal cancer and post-surgical complications are common causes of AEF; however, AEF induced by radiation therapy is a rare phenomenon and seldom described in the literature. It is a catastrophic condition which requires rapid implementation of resuscitative measures, broad-spectrum antibiotics and surgical or endovascular intervention. Transthoracic endovascular aortic repair (TEVAR) is a newer and less invasive technique, which helps to achieve rapid hemostasis in patients with severe hemodynamic instability and offers advantages over conventional repair of the aorta in emergency situations. However initial TEVAR should be followed up with a more definitive surgical repair of the aorta and the esophagus, to lower the mortality rate and achieve better outcomes. We describe here a case of a seventy-year-old male who presented with massive upper gastrointestinal bleeding due to AEF induced by radiation therapy, and his subsequent successful initial management with TEVAR.

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“…24 The fistula formation mechanism might be related to the following two factors: development of fibrosis in the submucosa, and thrombosis of the vasa vasorum due to the radiation therapy, resulting in large vessel perforation. [25][26][27] These factors might have contributed to the development of aorto-esophageal fistulas. The metal stent that we placed in the third section of the duodenum was similar to the one placed in the esophagus and close to the aorta.…”

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“…While the bigger vessels are not directly compromised, the small arteries and arterioles suffer defacement of endothelial cells, fibrosis of the intima, thrombosis, and subsequent occlusion of the downstream circulation. The small capillaries supplying nutrients to the wall of major vessels can become thrombosed and result in necrosis and perforation of the subjacent main vessel, prompting the formation of the fistula [7].…”

Massive hemorrhage following definitive esophageal chemoradiation: teaching case of a fatal aortoesophageal fistula and lessons learned

“…The three most common etiologies of AEF include thoracic aortic aneurysm (51.2%), foreign body ingestion (18.6%), and esophageal malignancy (17.0%) . Alarmingly, a growing number of cases have been published demonstrating formation of AEF independent of direct tumor involvement, mostly indicating external‐beam radiation therapy as the causative agent, perhaps resulting from radiation‐related damage to the vasa vasorum of the aorta .…”

“…Sumiyoshi and colleagues have previously reported on their experience of 22 patients undergoing SEMS placement after CRT, with 6 of 8 patients with clinical T4 disease and evidence of invasion into the aorta dying of massive hemorrhage . Additional toxicity may be attributable to alterations of dose distribution resulting from SEMS presence in field , while some reports suggest the causative role of radiotherapy itself .…”