Aberrant right subclavian artery-esophageal fistula: massive upper gastrointestinal hemorrhage secondary to prolonged intubation

Abstract

Aberrant right subclavian artery-esophageal fistula is a rare but potentially fatal complication. It may be associated with procedures, such as tracheostomy and tracheal or esophageal intubation, and yields massive upper gastrointestinal bleeding difficult to identify and to control. A high index of suspicion is essential for early diagnosis and better prognosis. We report a rare case of a patient who survived after emergent surgical procedure for massive upper gastrointestinal bleeding secondary to aberrant right subclavian artery-esophageal fistula after prolonged intubation.

An extremely dangerous case of acute massive upper gastrointestinal bleeding: a case report

“…Based on medical history, physiological signs, examination and treatment, this case of delayed but high-risk massive upper GI bleeding was the result of a fish bone piercing the esophagus, causing the mediastinal abscess that corroded the LSA. Fistulas between the subclavian artery and esophagus are rare but can rapidly become life-threatening [ 12 , 13 ]. Clinically, among arterial-esophageal fistulas caused by esophageal foreign bodies, the proportion of LSA esophageal fistulas is only 2% [ 3 ].…”

Upper Gastrointestinal Bleeding From Aberrant Right Subclavian Artery-Esophageal Fistula

“…The most common etiology for development of ARSA-esophageal fistula appeared to be secondary to compression, friction, or pressure necrosis from recent instrumentation with an endotracheal tube, nasogastric tube, or tracheostomy tube, seen in 14 of the 33 summarized cases. 14,15,17,19,21,22,24,27,29,31,[38][39][40][41] Fistula development from prior placement of esophageal stent was noted in 5 cases. 34,36,42,43 Other reported causes for fistula formation included placement of a salivary bypass tube and a possible consequence of gastric pull-up surgery.…”

“…Of the 33 summarized cases, thirteen cases survived all episodes of bleeding (39%). 21,22,24,27,28,30,31,33,34,[36][37][38]43 The severity of bleeding, in the setting of several comorbid conditions, likely contributed to the high mortality rate.…”

“…33 A more recent approach (2000) is placement of an endovascular stent, but success with this approach is questionable because of the rates of infection that may result in the need for further surgery. 44 Reported cases in adults involved treatment with surgery alone in 5 cases, 11,16,26,30,38 endovascular repair alone in 2 cases, 41,42 and a combination of endovascular and surgical intervention in 6 cases. 28,29,31,35,36,43 Balloon tamponade was performed in 16 cases, 1,14,15,21,22,24,25,27-29,31-33,35-37 with 3 of those 16 performed solely with endovascular repair.…”

“…28,29,31,35,36,43 Balloon tamponade was performed in 16 cases, 1,14,15,21,22,24,25,27-29,31-33,35-37 with 3 of those 16 performed solely with endovascular repair. 1,27,32 Six of the 11 patients who underwent either surgery alone or surgery with endovascular repair survived (55%), 28,30,31,36,38,43 whereas only 1 of the 5 cases of endovascular repair with or without balloon tamponade survived (20%). 27 Although the higher percentage of survival among patients who had surgery with or without endovascular repair compared to the 5 patients who underwent endovascular repair without surgery might suggest a better outcome with surgery, this discrepancy is likely confounded by patient factors and comorbidities for which surgical intervention is usually deferred, as well as the relatively low number of patient cases reported to have been treated with endovascular repair without surgery.…”