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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 36-37

Aortoesophageal fistula postthoracic endovascular aortic repair


Department of Vascular, Aseer Central Hospital, King Khalid University, Abha, Saudi Arabia

Date of Web Publication14-Mar-2019

Correspondence Address:
Dr. Abdullah Alhaizaey
Aseer Central Hospital, P. O. Box 34, Abha 61321
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_35_18

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  Abstract 

Thoracic endovascular aortic repair (TEVAR) is one of the choices for management of thoracic aortic aneurysms.[1] However, the complications of this procedure remain undetermined.[1] We present a 91 years male with a fatal post TEVAR aortoesophageal pseudoaneurysm leak and fistula to draw attention for such complication and its primary symptoms that may provide immediate treatment.

Keywords: Aortic endovascular repair, aortoesophageal, fistula


How to cite this article:
Hassan A, Alhaizaey A, Alghamdi M. Aortoesophageal fistula postthoracic endovascular aortic repair. Saudi Surg J 2019;7:36-7

How to cite this URL:
Hassan A, Alhaizaey A, Alghamdi M. Aortoesophageal fistula postthoracic endovascular aortic repair. Saudi Surg J [serial online] 2019 [cited 2019 Jun 18];7:36-7. Available from: http://www.saudisurgj.org/text.asp?2019/7/1/36/254111


  Introduction Top


Thoracic endovascular aortic repair (TEVAR) is one of the choices for the management of thoracic aortic aneurysms.[1] However, the complications of this procedure remain undetermined.[1] We present the case of a fatal clinical finding, which can be a complication of TEVAR.


  Case Report Top


A 91-year-old male patient was referred to our vascular unit through the otorhinolaryngology department with horsiness of voice and dysphagia for 6 months. Arterial-phase contrast-induced computed tomography showed a descending thoracic aortic saacular aneurysm (diameter: 6 cm) located just distal to the left subclavian artery [Figure 1]a. He underwent uneventful TEVAR (GORE, C-TAG, 31 mm X 150 mm) as shown in [Figure 1]b. He was discharged in a stable condition with regular clinical and radiological follow-up 1 month and then 3 months postoperation without significant clinical complaint or radiological abnormalities as shown in [Figure 1]c. Four months later, he presented with hematemesis and was admitted again.
Figure 1: (a) Descending thoracic aortic secular aneurysm. Arrow marked the anatomical site of aneurysm that may explain the clinical sign of left recurrent laryngeal nerve compression that leads to voice disappearance. (b) Intraoperative completion angiography showed complete sealing of aneurysm and normal stent deployment with proper proximal and distal landing zones. (c) Computed tomography follow-up with arterial phase contrast 3 months postaortic stent deployment that appeared normal position for stent and complete aneurysmal resolve

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Upper gastrointestinal endoscopy showed a mid-esophageal ulcer with a blood clot and an aortoesophageal fistula. The patient was admitted urgently as his vital signs were unstable: blood pressure – 60/30 mmHg; heart rate – 140/min; and Glasgow coma scale – 6. He was resuscitated and received six units of blood. He underwent urgent intraoperative conventional aortic angiography that showed proximal migration for the aortic stent with possibility for distal aorta disruption at the distal part of previous aortic aneurysm and aortoesophageal fistula [Figure 2]a. Distal new stent graft extension (GORE, TAG 37mm X 150mm) with 50 mm overlap with distal extension stent graft.
Figure 2: (a) Conventional angiography for descending thoracic aortic postsecular aneurysm repair using stent graft that showed aorta disruption with pseudoaneurysm leak and aortoesophageal fistula formation distal to the previous aortic stent graft as marked by arrow. (b) Completion angiography postaorta stent-graft deployment that showed complete exclusion for the leaked pseudoaneurysm and fistula as marked by arrow

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Angiography shows complete exclusion of the leaked aneurysm and fistula [Figure 2]b. Fifteen hours later, he experienced another attack of massive hematemesis, arrested, and did not survive.


  Discussion Top


Aortoesophageal fistula is a rare clinical finding. This case shows a fatal complication of TEVAR. The first case was reported in 1998 by Norgren et al.[1],[2]

To understand how this complication may occur, several hypotheses have been made.

Coverage of the aortic side branches that feed the esophagus by the stent graft leads to ischemic esophageal necrosis.[3] The oversizing of the device by 10%–20% increases the aortic diameter and may lead to esophageal compression and a decrease in its lumen. The passage of the bolus in the compressed esophagus and mycotic aortic aneurysms may lead to injuries in this organ also.[4],[5] Last hypothesis, which we intend to support with this case, is the presence of endoleak into the residual aneurysm with subsequent esophageal pressure.[6]

Although different therapies for aortoesophageal fistula, such as surgical aortic repair and esophageal fistula resection via a left posterolateral thoracotomy,[7],[8] have been reported, aortoesophageal fistulas still have a high mortality rate. In this report, we aim to highlight this clinical finding, which is a complication of TEVAR.


  Conclusion Top


Aortoesophageal fistula is an uncommon but fatal complication after TEVAR. Therefore, all surgeons should be aware of this complication and its primary symptoms, and this may provide immediate treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Norgren L, Jernby B, Engellau L. Aortoenteric fistula caused by a ruptured stent-graft: A case report. J Endovasc Surg 1998;5:269-72.  Back to cited text no. 1
    
2.
Azabou N, Chaouch N, Saaidi A, Romdhane NB, Aouini F. Aortoesophageal Fistula after Thoracic Endovascular Aortic Repair. J Vasc Med Surg 2016;4:287.  Back to cited text no. 2
    
3.
Eggebrecht H, Mehta RH, Dechene A, Tsagakis K, Kühl H, Huptas S, et al. Aortoesophageal fistula after thoracic aortic stent-graft placement: A rare but catastrophic complication of a novel emerging technique. JACC Cardiovasc Interv 2009;2:570-6.  Back to cited text no. 3
    
4.
Tehrani HY, Peterson BG, Katariya K, Morasch MD, Stevens R, DiLuozzo G, et al. Endovascular repair of thoracic aortic tears. Ann Thorac Surg 2006;82:873-7.  Back to cited text no. 4
    
5.
Gavens E, Zaidi Z, Al-Jundi W, Kumar P. Aortoesophageal fistula after endovascular aortic aneurysm repair of a mycotic thoracic aneurysm. Int J Vasc Med 2011;2011:649592.  Back to cited text no. 5
    
6.
Albors J, Bahamonde JÁ, Sanchis JM, Boix R, Palmero J. Aortoesophageal fistula after thoracic stent grafting. Asian Cardiovasc Thorac Ann 2011;19:352-6.  Back to cited text no. 6
    
7.
Chiesa R, Melissano G, Marone EM, Marrocco-Trischitta MM, Kahlberg A. Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: A national survey. Eur J Vasc Endovasc Surg 2010;39:273-9.  Back to cited text no. 7
    
8.
Kouritas VK, Dedeilias P, Sotiriou K, Klimopoulos S. Delayed presentation of aortoesophageal fistula after endovascular repair. Asian Cardiovasc Thorac Ann 2016;24:51-3.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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