Repair of aortoesophageal fistula after total aortic arch grafting

Abstract

This case report describes the repair of an aortoesophageal fistula caused by a previously placed aortic arch graft. A 62-year-old man underwent total aortic arch graft replacement one year ago. He was readmitted with hematemesis and a high fever. Examination by endoscopy revealed a perforation and two swollen lesions in the mid-esophagus. With the diagnosis of aortoesophageal fistula, the patient underwent esophagectomy, cervical esophagostomy, and gastrostomy with plans for esophageal continuity. Twenty days later, the patient had the graft replacement. Left thoracotomy was performed at the fourth intercostal space and the incision was extended to a sternal transection. The old aortic arch graft was replaced with a rifampicin-bonded gelatin-sealed Dacron graft. After successful esophageal reconstruction (a cervical esophagogastrostomy with the stomach in the substernal position), he fully recovered from surgery. Aortoesophageal fistula is rare and always fatal if surgical intervention is not attempted. When homografts are unavailable, an alternative therapeutic approach is in situ replacement with a rifampicin-bonded gelatin-sealed Dacron graft.

Therapeutic strategy for treating aortoesophageal fistulas

“…If the AEF patient can physically tolerate open surgery of the esophagus, aggressive surgery to repair the esophagus in addition to aortic repair is still recommended. If, therefore, the patient's condition is not too deteriorated as to preclude the use of thoracotomy, performing esophagectomy before [24] or after or with aortic repair may be an acceptable strategy for the management of AEF. In our series, the number of survivors at more than 6 and 18 months who underwent esophagectomy was 22 of 25 patients (88 %) and all 14 patients (100 %), respectively, and the use of esophagectomy significantly improved the late prognosis (at 6 and 18 months).…”

Management of secondary aortoesophageal fistula without graft extraction

“…If the patient can physically tolerate an open aortic repair or has any sign of aortic graft infection, aggressive surgery to repair both the esophagus and the aortic graft is therefore still recommended. If, however, the patient's condition is so deteriorated as to preclude open aortic repair or there is no evidence of infection or hemorrhage, an esophagectomy before aortic repair 4 or an esophagectomy alone may be acceptable for the management of EPPF. FIGURE 2.…”

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

“…The most common EGD finding of AEF is a sub-mucosal tumor-like protrusion with/without clots/debris due to extrinsic compression on the esophageal wall. Other reported EGD findings included ulcerative lesions, oozing from a pin-hole erosion or a pulsating protrusion with fistula, which might be related to graft exposure [35,49,50]. Interestingly, AEF is usually observed between the posterior to left lateral wall of the upper/middle-esophagus in the endoscopic findings.…”