Management of aorto-esophageal fistula secondary after thoracic endovascular aortic repair: a review of literature

Abstract

Aorto-esophageal fistula (AEF) is a rare and lethal entity, and the difficulty of making diagnosis of AEF is well-known. As promising results in the short-term effectiveness of thoracic endovascular aortic repair (TEVAR) promote its usage, the occurrence of AEF after TEVAR (post-TEVAR AEF) increases as one of the major complications. Therefore, we provide a review concerning the management strategy of post-TEVAR AEF. Although its representative symptom was reported as the triad of mid-thoracic pain and sentinel hematemesis followed by massive hematemesis, the symptom-free interval between sentinel hemorrhage and massive exsanguination is unpredictable. However, the physiological condition represents a surgical contraindication. Accordingly, early diagnosis is important, but either CT or esophago-gastroduodenoscopy rarely depicts a typical image. The formation of post-TEVAR AEF might be associated with the infection of micro-organisms, which is uncontrollable with anti-biotic administration. The current first-line strategy is combination therapy as follows, (1) to control bleeding by TEVAR in the urgent phase, and (2) radical debridement and aortic/esophageal re-construction in the semi-urgent phase. In view of the high mortality and morbidity rate, it is proposed that the choice in treatment strategies might be affected by patient's condition, size of the wall defects and the etiology of AEF. Practically, we should keep in mind the importance of making an early diagnosis and, once a suspicious symptom has occurred in a patient with a history of TEVAR, the existence of post-TEVAR AEF should be suspected. A prospective registry together with more developed technologies will be needed to establish a future strategy.Keywords Aorto-esophageal fistula Á Thoracic endovascular aortic repair Á Thoracic aortic aneurysm Á Endoscopy Á Surgery Abbreviations

Hemorrhagic Shock Secondary to Aortoesophageal Fistula as a Complication of Esophageal Cancer

“…Temporary measures, such as the insertion of the Sengstaken-Blakemore tube and embolization with isobutyl-2-cyanoacrylate, were used to stop the bleeding until surgery [9]. Endovascular techniques have shown favorable short-term outcomes [3,[10][11]. Thoracic endovascular aortic repair (TEVAR), proposed by Dake et al, had a success rate of 87% and a mortality rate of 19%.…”

“…Still, there is also evidence suggesting that the conservative approach utilizing TEVAR alone is associated with fatal outcomes due to the risk of recurrent hemorrhage and sepsis. Therefore, current recommendations support the use of TEVAR as a bridge strategy, facilitating hemodynamic stabilization before the definite surgical procedure [3,14]. Primary repair of the esophageal defect could result in positive progression, particularly in small lesions detected early [15].…”

“…The need for diagnostic and management strategies is imperative. A multidisciplinary approach to mitigate the injury and offer therapeutic solutions could reduce the high mortality [3][4]. We report a patient with hemorrhagic shock secondary to an aortoesophageal fistula as a complication of esophageal cancer, radiotherapy, and esophageal stent placement.…”

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

“…Aortoesophageal fistula (AEF) usually results in fatal gastrointestinal bleeding and is associated with a high mortality rate, despite the use of advanced surgical and endovascular techniques [ 1 ]. Previous studies reported that nearly 60% of patients with AEF died within 6 months; the 1-year survival rate was only 28% [ 2 , 3 ]. Since the 1990s, thoracic endovascular aortic repair (TEVAR) has been increasingly used as a less invasive treatment for aortic aneurysm and aortic dissection [ 4 ]; however, post-TEVAR AEF has been frequently observed as a fatal complication [ 5 ].…”

“…Since the 1990s, thoracic endovascular aortic repair (TEVAR) has been increasingly used as a less invasive treatment for aortic aneurysm and aortic dissection [ 4 ]; however, post-TEVAR AEF has been frequently observed as a fatal complication [ 5 ]. Due to the rarity of AEF, few studies have investigated its risk factors for mortality, or the long-term prognosis [ 2 ]. Therefore, we systematically reviewed the literature on AEF related to aortic lesions, including aortic aneurysm and dissection.…”