Successful management of life-threatening aortoesophageal fistula: A case report and review of the literature

Abstract

BACKGROUND Aortoesophageal fistula (AEF) is a rare but life-threatening cause of upper gastrointestinal bleeding. Only a handful of cases of successful management of AEF caused by esophageal cancer have been reported. The purpose of this study is to report a case of AEF managed by endovascular aortic repair and review the relevant literature. CASE SUMMARY A 66-year-old man with upper gastroenterology bleeding presented at the Emergency Department of our hospital complaining of chest pain, fever and hematemesis for 6 h. He had vomited 400 mL of bright-red blood and experienced severe chest pain 6 h prior. He had a past medical history of advanced esophageal cancer. He received chemoradiotherapy but stopped 8 mo prior because of intolerance. A chest contrast computed tomographic scan revealed communication between the esophagus and the descending aorta as well as a descending aortic pseudoaneurysm. According to the symptoms and imaging findings, AEF was our primary consideration. The patient underwent aortic angiography, which indicated AEF and descending aortic pseudoaneurysm. Emergency percutaneous thoracic endovascular aortic repair (TEVAR) of the descending aorta was performed, and bleeding was controlled after TEVAR. He received antibiotics and was discharged after treatment. However, he died 2 mo after the TEVAR due to cancer progression. CONCLUSION Although AEF is a lethal condition, timely diagnosis and TEVAR may successfully control bleeding.

pTEVAR of an aorto-esophageal fistula in esophageal cancer: Case report and review of the literature

“…AEF is a rare condition that causes upper gastrointestinal bleeding. In the literature there are just few cases of AEF due to esophageal cancer treated by TEVAR [4] . Historically therapy of this condition consisted of surgical repair of the aorta and the esophagus.…”

“…However, the mortality of an open surgical approach ranges from 45.4% to 55% [6] . TEVAR in comparison is a rapid, less invasive and more cost-effective intervention which has a high technical success rate (87.3%) and a more favorable 30-day mortality rate (19.7%) in patients with AEF [4 , [6] , [7] , [8] ]. TEVAR can extend the survival time by an average of 4 months in the context of AEF due to esophageal cancer [4] .…”

“…TEVAR in comparison is a rapid, less invasive and more cost-effective intervention which has a high technical success rate (87.3%) and a more favorable 30-day mortality rate (19.7%) in patients with AEF [4 , [6] , [7] , [8] ]. TEVAR can extend the survival time by an average of 4 months in the context of AEF due to esophageal cancer [4] . In case of ruptured fistula, open thoracic surgery may therefore be offered to patients with AEF who are in relatively good physical condition.…”

“…In case of ruptured fistula, open thoracic surgery may therefore be offered to patients with AEF who are in relatively good physical condition. TEVAR should be considered the treatment of choice for patients with an AEF in an emergency setting or who are in a poor condition as it causes less tissue damage, requires no aortic clipping, and is associated with less cerebral ischemic damage while providing excellent hemostasis [4] .…”

“…Advanced esophageal cancer with aortic invasion is the third common cause of AEF, after thoracic aortic aneurysm and foreign body ingestion [1] , [2] , [3] . Regardless of cause, the ideal management of the fistula remains unclear and up to now there are no generally accepted treatment guidelines [4 , 5] . Current literature has focused on the role of endovascular techniques and open thoracic surgery for dealing with AEF.…”