Aortoesophageal Fistulas Research Articles

Technical details with the use of cryopreserved arterial allografts for aortic infection: Influence on early and midterm mortality

Purpose: In situ repair with cryopreserved vascular allografts improves the results in the surgical treatment of aortic infection. This study evaluated the technical pitfalls with the use of allografts that influence early and midterm mortality. Methods: Between 1990 and 1999, 49 patients, 21 (43%) with a mycotic aneurysm and 28 (57%) with a prosthetic graft infection of the thoracic and abdominal aorta including pelvic and groin vessels, underwent in situ repair with cryopreserved arterial allografts. Seventeen patients (35%) had aortobronchial, aortoesophageal, or aortoenteric fistulas Results: Allograft-related technical problems occurred in eight patients (16%) in this series, and they included: intraoperative rupture caused by allograft friability; allograftenteric fistula from ligated allograft side branches rupturing 8, 18, and 48 months after implantation; anastomotic failure caused by inappropriate mechanical stress; anastomotic stricture after partial replacement of infected prosthetic grafts; allograft failure caused by inappropriate wound drainage; and recurrence of infection after inappropriate duration of antifungal treatment. Seven of the eight technical problems (87%) occurred in the first 10 patients (80%) in this series. There was one technical failure in the remaining 39 patients (2.6%; P =.0002) because of various technical adaptations, such as critical selection of allografts, use of allograft strips supporting large anastomoses, sealing with antibiotic-impregnated fibrin glue, and change in technique of allograft side-branch ligature. The 30-day mortality rate was 6% for the whole series; however, it was 2.6% for last 39 patients, with no recurrence of infection or allograft-related late death Conclusions: In situ repair with cryopreserved arterial allografts achieves excellent early and late results in the treatment of aortic infection. However, distinct allograft-related technical problems had to be overcome to improve the outcome of patients with major vascular infections. (J Vasc Surg 2002;35:80-6.)

Successful Repair of Primary Concomitant Aortobronchial and Aortoesophageal Fistulas

Combined aortobronchial and aortoesophageal fistulas de veloped after a rupture of a thoracoabdominal aneurysm in a 73-year-old man and were successfully repaired in a one-stage procedure. This case demonstrates that operation can be successful even in this desperate situation.(Ann Thorac Surg 1997;63:1779–81)

Primary Aortoesophageal Fistula Caused by an Atherosclerotic Thoracoabdominal Aortic Aneurysm: A Case Report and Review of the Literature

A 55-year-old woman suffered an episode of massive hematemesis caused by an aortoesophageal fistula from an atherosclerotic thoracoabdominal aortic aneurysm. In situ grafting of the thoracic portion of the aneurysm was followed by sepsis and a sinus tract between the mid-esophagus and the aortic prosthesis. Graft removal, aortic closure, esophageal closure and axillobifemoral bypass allowed clearing of the sepsis and recovery. Severe hypertension followed aortic closure and extra-anatomic bypass and resulted in the eventual death of the patient 16 months later from dissection of the ascending aorta with pericardial tamponade. There are very few treated cases of aortoesophageal fistulas caused by atherosclerotic aneurysms reported in the literature. Furthermore, there are no reported cases where the aorta was closed at the level of the subclavian artery with extra-anatomic bypass to restore blood flow to the lower half of the body.

Primary aortoesophageal fistula caused by an atherosclerotic thoracoabdominal aortic aneurysm: a case report and review of the literature

A 55-year-old woman suffered an episode of massive hematemesis caused by an aortoesophageal fistula from an atherosclerotic thoracoabdominal aortic aneurysm. In situ grafting of the thoracic portion of the aneurysm was followed by sepsis and a sinus tract between the mid-esophagus and the aortic prosthesis. Graft removal, aortic closure, esophageal closure and axillobifemoral bypass allowed clearing of the sepsis and recovery. Severe hypertension followed aortic closure and extra-anatomic bypass and resulted in the eventual death of the patient 16 months later from dissection of the ascending aorta with pericardial tamponade. There are very few treated cases of aortoesophageal fistulas caused by atherosclerotic aneurysms reported in the literature. Furthermore, there are no reported cases where the aorta was closed at the level of the subclavian artery with extra-anatomic bypass to restore blood flow to the lower half of the body.

Staged repair using omentum for posttraumatic aortoesophageal fistula

Aortoesophageal fistulas from traumatic thoracic aortic pseudoaneurysms are almost uniformly fatal. We report a case of a young woman who nearly exsanguinated soon after diagnosis. Immediate operative intervention consisted of prosthetic graft replacement of the pseudoaneurysm and pleural patch coverage. Definitive treatment of the esophageal perforation was necessary later for mediastinal sepsis. Primary repair of the esophagus accompanied by mobilization of the omentum into the space between the esophageal closure and the prosthetic graft led to a successful outcome.

Aortoenteric fistulas.

During an 11-year period ending in December 1991, 36 patients with aortoenteric fistulas were assessed and treated. Twenty-five patients (69%) had previously undergone aortic reconstruction with Dacron grafts, and 11 (31%) had spontaneous aortoenteric fistulas. Of the 25 patients with secondary fistulas, 14 (56%) had undergone aortic aneurysmal rupture or multiple aortic vascular reconstructions. Preoperative diagnosis was established in only 13 (36%) of 36 patients. Remote bypass preceding removal of the infected arterial prosthesis had the least morbidity and mortality. Three primary fistulas were found in unusual locations: aortocolonic, aortobronchial, and aortoesophageal. The patient with the aortoesophageal fistulas was the fifth survivor described in the literature. The overall mortality was 56%. A positive preoperative blood culture predicted a poor outcome. There were four amputations, there due to infection of the extra-anatomical bypass. Prompt directed assessment to ensure appropriately staged operative intervention should improve survival.

Aortoesophageal fistula: Report of a successfully managed case and review of the literature

Aortoesophageal fistula is a rare, frequently fatal cause of upper gastrointestinal bleeding. Although several causes have been described, it appears that the most common cause is rupture of a thoracic aortic aneurysm into the esophagus, occurring in approximately 12% of thoracic aneurysm ruptures. Although the entity was originally described in 1818, the diagnosis has rarely been made before death, and until 1983 no one survived surgery for aneurysm-associated aortoesophageal fistulas. Since that report of two cases, only two other survivors, including this patient, have been reported. Included herein is the report of a successfully managed case, along with a discussion of the causes, clinical features, and diagnostic approach to the disease, as well as the management of both the aortic and esophageal components of the fistula.

Successful management of aortoesophageal fistula due to thoracic aortic aneurysm

Aortoesophageal fistulas due to atherosclerotic thoracic aneurysms are usually fatal, with few reported survivors. We report an aortoesophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. Immediate esophageal reconstruction was attained using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft.

Clinical and radiographic manifestations of aortoesophageal fistulas.

Aneurysms of the thoracic aorta simulated primary esophageal disease both clinically and radiographically in 5 patients. Four had an aortoesophageal fistula at the time of presentation; endoscopic biopsy of a presumed esophageal tumor precipitated hematemesis in the fifth patient. In retrospect, the fistulas were demonstrated by barium esophagography in 3 patients. In 3, arteriography showed the aortic aneurysm but failed to reveal the fistula. The literature confirms a similar presentation for most other aortoesophageal fistulas, with premonitory esophageal bleeding followed hours to days later by massive hemorrhage. Of the reported cases of rupture of aneurysms of the thoracic aorta, 12% bled into the esophagus. While clinical and radiographic distinction between primary esophageal disease and esophageal manifestations of an aortic aneurysm is occasionally difficult, it is crucial for proper management.

AORTOESOPHAGEAL FISTULA COMPLICATING CARCINOMA INVOLVING THE ESOPHAGUS. REPORT OF 3 CASES.

Three patients manifesting an unusual complication of cancer in the esophagus have been presented. Cases 1 and 2 were instances of primary carcinoma of the esophagus, while Case 3 represents metastases in the esophageal wall from a primary focus in the cervix. All had massive hematemesis associated with perforation of the aorta secondary to local spread of the tumor. The diagnosis in the first 2 patients was unsuspected antemortem, but an aortoesophageal fistula was considered as a source of bleeding at the time of esophagoscopic examination in the third patient. Hemorrhage from the aorta into the esophagus was the cause of death in all 3 patients. The literature pertaining to aortoesophageal fistulas was briefly reviewed.