Successful Endovascular Management of a Case of Aorto-oesophageal Fistula Presenting as Life Threatening Upper Gastrointestinal Bleed

Abstract

IntroductionAorto-oesophageal fistula is a rare but life threatening cause of upper gastrointestinal haemorrhage. Severity of presentation and complexity of subsequent management depends on the size of the defect on both the aortic side and oesophagus.ReportThe patient was a 67 year old Chinese man, who presented initially with a Stanford type A dissection with caudal extension to the right common iliac artery. The patient underwent replacement of the ascending aorta and proximal arch with debranching of the right innominate artery and aortic valve replacement. A follow up computed tomography (CT) aortogram done in the post-operative period showed a stable appearance of the caudal extension of the aortic dissection. The patient was discharged with a plan for future stenting of the thoracic aorta. Three weeks later the patient re-presented with an upper gastrointestinal bleed from an aorto-oesophageal fistula. The patient underwent endovascular stenting of the descending aorta for management of the fistula. Repeat oesophagogastroduodenoscopy showed a small erosion 35 cm from the incisors where the previous bleeding site had been. No further bleeding was seen.DiscussionThe patient recovered uneventfully after the procedure. Follow up CT aortogram done at 6 weeks demonstrated thrombosis of the false lumen of the descending thoracic aorta. Aorto-oesophageal fistula related to chronic type B aortic dissection is an extremely rare clinical entity and presents a challenge to the treating surgeon. This case demonstrates that selected cases can be judiciously managed by thoracic endovascular aneurysm repair alone.

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

“…Surgery for AEF is performed to repair the fistula and control bleeding and infection [ 20 , 21 ]. The approaches include extra-anatomical bypass or in situ replacement with grafts, as well as repair or resection of esophageal fistula with primary or secondary reconstruction [ 1 , 22 , 23 ]. In our study, the overall survival rate of patients with AEF who underwent surgery either for aortic or esophageal lesions was significantly higher compared to that of nonsurgical patients with AEF ( P < 0.001).…”