Management of a traumatic aortoesophageal fistula in a patient with a right-sided aortic arch

Abstract

Clinical Summary A 23-year-old woman was involved in a high-speed car accident and transferred to an outside hospital. Injuries at admission included fractures of the left pelvic ring, right humerus, multiple ribs, and lumbar vertebra. In addition, lung contusions and various skin lesions were present. Acute surgical therapy consisted of the stabilization of the pelvic fracture by external fixation and an intramedullary nailing of the humeral fracture. Three weeks after an uneventful postoperative course, an acute hematemesis developed in the patient. Upper endoscopy failed to detect the localization of the gastrointestinal bleeding because of the persistence of the severe hematemesis. A laparotomy with gastrostomy was performed, revealing massive esophageal bleeding. A Linton–Nachlas balloon tube was placed, which stopped the bleeding. The patient was transferred to an outside cardiothoracic department for surgical treatment of the suspected aortic arch dissection with traumatic aortoesophageal fistula. A sternotomy showed an unexpected right-sided aortic arch obscuring the region of interest. The fistula, 25 cm distal from the incisors, was identified through a right thoracotomy. Both the esophagus and the aorta were oversewn, which stopped the bleeding so the balloon tube could be removed. The patient was transferred back to the primary hospital, where another episode of acute hematemesis occurred 11 days after the closure of the fistula. A Sengstaken–Blakemore tube was inserted, which temporarily stopped the bleeding so the patient could be transferred to our department. Thoracic and abdominal computed tomograms could not localize the bleeding site. Controlled release of the tube under endoscopic visualization resulted in massive esophageal bleeding. We suspected that a relapse of the aortoesophageal fistula was causing the recurrent gastrointestinal bleeding. An endovascular stent-graft (Talent Thoracic Endoprosthesis, 22 22 116 mm; Medtronic AVE, Santa Rosa, Calif) was placed distal to the left common carotid artery through a right-sided transverse arteriotomy of the common femoral artery (Figure 1). Because of a type II endoleak, the left subclavian artery was interventionally coiled (Figure 2). The patient was in stable cardiopulmonary condition postoperatively. Extubation was possible 11 days after stent-grafting, and the patient was transferred to a peripheral ward. Follow-ups with endoscopy and computed tomography demonstrated a local esophageal necrosis in the region of the former fistula, which was treated conservatively. The patient was discharged from the hospital after 67 days on a full oral diet. Thirteen months later, the patient was urgently admitted to the regional hospital because of recurrent upper gastrointestinal bleeding. A laparotomy with gastrostomy was performed that revealed another massive esophageal bleeding. The bleeding was stopped by a Sengstaken–Blakemore tube, and the patient was transferred to our department. A relapse of the aortoesophageal fistula was described, and under circulatory arrest the stent-graft was removed and a resection of the aortic segment adherent to the fistula with an interposition aortic allograft was performed. In addition, a subtotal esophagectomy with cervical esophagostomy and placement of a jejunal feeding tube were performed. Postoperatively, anastomotic leakages of the homograft occurred and were covered by a stentgraft (Gore TAG Thoracic Endoprosthesis, 26 100 mm; WL Gore & Associates, Flagstaff, Ariz). The postoperative course was uneventful, and the patient was discharged with enteral feeding via the jejunal tube. Successful reconstruction of the gastrointestinal tract continuity was performed with colonic interposition 17 months later.