2013 Thoracic Aortic Erosion Into the Esophagus With Aortoesophageal Fistula

Abstract

INTRODUCTION: Aortoesophageal fistula is a rare but well described life-threatening cause of upper gastrointestinal bleeding. Primary aortoesophageal fistula is predominately caused by descending thoracic aortic aneurysms (52.4%), followed by foreign body ingestion and esophageal carcinoma.1–3 Secondary aortoesophageal fistula is an increasingly recognized complication of thoracic endovascular aortic repair (TEVAR), occurring in 1.7-1.9% of cases.4,5 CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of known 6cm thoracic aortic aneurysm was transferred to our facility for one day of hematemesis and hematochezia to undergo upper endoscopy. On arrival the patient had an emergent esophagogastroduodenoscopy which revealed a visible thoracic aorta through a large transmural defect adjacent to an aortoesophageal fistula in the middle esophagus (Figure 1). After the procedure, the patient underwent emergent CTA of the aorta, which revealed corresponding images to the endoscopic findings with an aortoesophageal fistula directly superior to an area of thoracic aorta protruding into the esophagus (Figure 2). The patient then had an emergent endovascular repair of the aortoesophageal fistula and thoracic aortic aneurysm with fluoroscopic images demonstrating successful graft deployment and fistula closure (Figure 3). DISCUSSION: Aortoesophageal fistula is a life-threatening condition that must be on a gastroenterologist’s differential for upper GI bleeding, in particular in patients with a known aortic aneurysm. Proper and rapid identification of the diagnosis is essential to allow for emergent vascular intervention and hemostatic control. Additionally, literature review highlights a paucity of evidence on the options for endoscopic intervention with esophageal stents. In this particular case, there was fortunately no active gastrointestinal bleeding at time of endoscopy and the patient had successful endovascular grafting; however, there are a number of case reports suggesting that esophageal stenting may be another therapeutic option if there is active esophageal hemorrhage, albeit more of a temporizing measure and one associated with a number of complications.3,6,7