Aortoesophageal Fistula

Abstract

Introduction: A 83-year-old man with past medical history significant for non-small cell lung cancer in remission status post-surgical resection 9 years ago presented with hematemesis. Aortoenteric fistula is an uncommon etiology of gastrointestinal bleeding. Considering the most common site for aortoenteric fistulas is the third or fourth portion of the duodenum, aortoesophageal fistulas are rarer, representing less than 10% of aortoenteric fistula cases. In the U.S., the most frequent clinical setting where primary aortoesophageal fistulas are observed is the expansion of thoracic aortic aneurysms. Secondary causes include aortic graft complications (51% cases), ingested foreign bodies (19% cases), infiltrating esophageal neoplasms, esophageal ulcerations, trauma, and mediastinal radiation therapy. First described by Chiari in 1914, characteristic symptoms include mid thoracic pain, sentinel upper arterial hemorrhage, and rapid exsanguination. CT scanning is often an adequate diagnostic modality revealing aortic fistulas, phlegmons and active extravasation (Figure 2). Endoscopy may reveal a graft, an ulcer with adherent clot, or an extrinsic pulsatile mass (Figure 1). A recent case review recommended urgent management of the aortic tear with endovascular aortic repair (EVAR) and subtotal esophageal resection followed by gastroesophageal reconstruction. Previous literature has suggested a mortality rate of approximately 40% with surgical intervention and a mortality rate approaching 100% without intervention. Though rarely seen, it is important to consider aortoesophageal fistulas in cases of gastrointestinal bleeding, particularly in the presence of aortic aneurysms.Figure 2Figure 1