Successful Endovascular Stenting of Aortoesophageal Fistula

Abstract

Introduction Aortoesophageal fistula (AEF) is rare and caries high mortality. Esophageal cancer, foreign body ingestion, esophageal stent, thoracic aortic aneurysm are among common causes. Treatment is challenging, and early recognition is the key. We present a case of successful endovascular stent treatment of AEF presented with massive upper gastrointestinal bleeding. Case Presentation A 69 year-old man with history of GERD, Barrett's esophagus, who was found to have a high-grade signet ring adenocarcinoma on a surveillance endoscopy. Soon thereafter, he had dysphagia and significant weight loss. An endoscopic metal stent was placed. He had persistent symptoms and inability to swallow. A jejunal tube was placed for nutrition. He presented to the ER with sudden onset of hematemesis and drop in hemoglobin from 13 to 6.9 in 12 hours. CT scan of the chest was performed which showed suspicion for AEF (Figure 1). He immediately had an angiogram, which confirmed AEF. (Figure 2,3) An endovascular stent graft was placed above the celiac axis. The angiogram showed good apposition of the graft without any continued bleeding. Discussion AEF is rare case that carries high incidence of morbidity and mortality. Commonly presented with hematemesis, dysphagia and/or chest pain. Early diagnosis and intervention is a key for treatment. The goals for therapy in AEF include - Prevention of immediate exsanguination, treatment of the primary fistula and prevention of complications. Treatment options include endoscopic, surgical and interventional radiology. Endovascular stent placement is a quick procedure where a covered stent is used to block the vascular defect. Primary open surgical closure has a high mortality rate. There is an approximate 15 % risk of re bleed and graft infection after endovascular repair alone. Therefore, additional surgical repair of the fistula, which may include debridement of the thoracic cavity, may be required. Antibiotics are one of the strongest factors shown to lower the mortality in a multivariate analysis. Antibiotic duration has not been studied prospectively, however a 4-8 week duration has been suggested to prevent immediate mortality in retrospective analysis. Conclusion AEF is a rare and fatal complication of esophageal disorders. Early recognition is important. High index of suspicion need to be maintained in the right patient cohort. Immediate vascular stenting is key to prevention of exsanguinating and severe bleeding.Figure 1Figure 2Figure 3