The role of TEVAR in the management of a recurrent aorto-gastric fistula

Abstract

An aorto-gastric fistula is a catastrophic and rare cause of an upper gastrointestinal bleed. The diagnosis requires a high index of suspicion and expedient management as any delay in each of these component, will be to the detriment of the patient. We report a case of a patient with two episodes of this rare event, with haemodynamic compromise, 15 years after having had a trans-hiatal oesophagectomy for an adenocarcinoma of the oesophagus who presented on both occasions. He had thoracic endo-vascular aortic repair (TEVAR) on both presentations and survived. This case exemplifies the fact that while TEVAR is a good bridging therapy for the management of an aorto-enteric fistula. It however should not be considered as the definitive management for patients who are operable or patients who do not have prohibitive surgical risk.

Successful management of aorto-conduit fistula after esophagectomy: Tips and tricks to avoid catastrophe

“…Placement of endovascular stents in the setting of an ACF also requires suppressive antibiotic therapy, and reintervention is often necessary. 4 As in this patient's case, placement of an occlusive aortic balloon under angiographic guidance can buy time to resuscitate and reach an operating room. Repositioning of the aortic balloon to above or below the fistula can provide proximal or distal control intraoperatively, minimizing dissection and hemorrhage.…”

First Result of a Tailored Progressive Multistep Approach for the Treatment of Aorto-esophageal Fistulae

“…As recent publications have suggested, aggressive surgical resection of the esophagus and the aorta is the most promising approach toward long-term survival after AEF. [8][9][10]15,16 There is no long-term survival with conservative treatment only. 6 Recently, a trend toward the control of the acute stage by TEVAR or even "redo" TEVAR is noticeable, 8 but the standard of care for definite treatment is still open surgery.…”

“…6 Recently, a trend toward the control of the acute stage by TEVAR or even "redo" TEVAR is noticeable, 8 but the standard of care for definite treatment is still open surgery. 16 Especially, the introduction of a stent graft in a contaminated surgical field as a permanent solution can lead to continuous morbidity and the requirement of a long-term or even lifelong antibiotic regimen. 17 Good long-term survival after TEVAR has not been reported 5 and patients initially treated by TEVAR require open surgery at the end.…”