Is Endovascular Stenting as Benign as Proposed?

Abstract

Introduction: Aortoesophageal fistula (AEF) is a potentially fatal complication that seldom ensues after endovascular repair of a thoracic aortic aneurysm. The initial symptoms can be very subtle. Early recognition can limit disastrous complications. A 70-year-old male with hypertension and, recent thoracic endovascular aortic repair (TEVAR) 15 days prior, was admitted with worsening of recent dysphagia. He denied any hematochezia, hematemesis, hemoptysis or melena. A CT chest done two months prior revealed an 8.8 cm saccular lower thoracic aortic aneurysm, following which he underwent a TEVAR. A repeat CT chest during the current admission displayed the stent with in the thoracic aorta without residual aneurysm or contrast leak. The esophagus exhibited apparent distal mucosal thickening with irregularity and an air fluid level. An endoscopy revealed a large ulcerated defect without any bleeding in the lower third of the esophagus, through which the outside wall of TEVAR graft could be visualized protruding into the esophageal lumen. The patient underwent staged resection and repair of thoracic aorta with axillo-femoral bypass. On day-1, he underwent a laparoscopic J-tube insertion with defunctionalization of esophagus and cervical esophagostomy. This was followed by extra anatomic arterial bypass (right axillary to right iliac-left iliac bypass) on day 2 and, removal of thoracic aorta and distal esophagectomy on day-3. His post-operative course was complicated by anuric renal failure, quadriplegia due to spinal cord ischemia post aortic resection and, sepsis with hafnia alvei (Gram-negative rod, which is a commensal in the human gastrointestinal tract). He is currently dialysis dependent, undergoing rehab in a special care unit. Aortoesophageal fistula (AEF) is a rare but serious complication of TEVAR with a reported incidence rate of 0.5- 1.7% in the literature. Suggested mechanisms of AEF in TEVAR includes direct perforation of the aorta and esophagus by the stent, ischemic esophageal necrosis, pseudo aneurysm formation or endoleak into the aneurysm with subsequent esophageal pressure and finally, infection of the prosthesis (5% of the reported cases). The Chiari’s triad comprising midthoracic chest pain, sentinel arterial hemorrhage and, subsequent massive hemorrhage is the most common presentation of AEF. The presentation with dysphagia alone as in our patient is extremely rare. Definitive treatment of AEF is resection or repair of the fistula with repair of the esophageal, aortic walls and stent removal. Depending on the extent of lesion the surgery can have devastating effects as in our patient.