Aortoesophageal fistula: Report of a successfully managed case and review of the literature

Abstract

Aortoesophageal fistula is a rare, frequently fatal cause of upper gastrointestinal bleeding. Although several causes have been described, it appears that the most common cause is rupture of a thoracic aortic aneurysm into the esophagus, occurring in approximately 12% of thoracic aneurysm ruptures. Although the entity was originally described in 1818, the diagnosis has rarely been made before death, and until 1983 no one survived surgery for aneurysm-associated aortoesophageal fistulas. Since that report of two cases, only two other survivors, including this patient, have been reported. Included herein is the report of a successfully managed case, along with a discussion of the causes, clinical features, and diagnostic approach to the disease, as well as the management of both the aortic and esophageal components of the fistula.

Aortoesophageal Fistula: Report of an Unusual Case

“…When an AEF has resulted from an atherosclerotic aneurysm, it must be replaced with a prosthetic graft. 1 Although esophageal perforation in patients with an AEF has sometimes been managed by wide resection with staged restoration of gastrointestinal continuity, 2 our successful result suggests the effectiveness of primary repair for both the aorta and the esophagus when the defects are limited. Debridement of the tissue surrounding the fistula is necessary for control of infection.…”

“…The diagnosis of AEF requires a high degree of suspicion and aggressive evaluation. 1 The present case report suggests that AEF must be considered in any patient with midthoracic pain or hematemesis, even without a history suggestive of atherosclerotic aneurysm, foreign body ingestion, or esophageal disease.…”

“…8 Although the first case of AEF was documented as early as 1818, 9 the number of reports on successful treatment is still limited. 10 Some authors 1,8 have stressed the importance of early diagnosis by careful evaluation of CT scans and arteriograms 1 following urgent surgical investigation, intiated soon after the initial bleeding. The diagnosis of AEF requires a high degree of suspicion and aggressive evaluation.…”

“…1 We describe herein the case of a patient with an AEF who was successfully managed by primary repair of the aorta and the esophagus, even though the etiology remained indefinite.…”

Successful Endovascular Stent-Graft Treatment for an Aortoesophageal Fistula Caused by a Descending Thoracic Aortic Aneurysm: Report of a Case

“…17 Conventional surgical management involves excision or exclusion of the aneurysm combined with extra-anatomic bypass or in situ aneurysm repair. 18 However, the former technique is associated with a high operative mortality rate ranging from 25% to 90%, while the average perioperative mortality rate for the latter technique is still 27%-30%. 6 The effectiveness of an endovascular stent-graft technique in the treatment of primary AEF has not been established.…”