Successful management of aorto esophageal fistula due to rupture thoracic aortic aneurysm in an elderly patient

Aorto-esophageal fistula due to ruptured thoracic aortic aneurysm is very rare but is associated with extremely high mortality. An 81-year-old woman was admitted due to repeated hematemesis. Endoscopic examination revealed ulceration with blood clot on the mid-esophagus and compression of an extra-esophageal mass. The thoracic CT scan revealed an aortoesophageal fistula due to a ruptured descending thoracic aortic aneurysm. Surgery was performed on April 3, 1996. We report an aorto-esophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. The esophagus was reconstructed using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft. The postoperative course was uneventful and theere have been no signs of mediastinal sepsis, graft infection or pyothorax 12 months postoperatively. We suggest that the resection of both the aneurysm and the esophagus as well as the immediate reconstruction of the esophagus by orthotopic gastric interposition to obliterate the retrosternal space are important technique in the management of intrathoracic infections.     

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months' follow-up).     

Successful one-stage operation of aortoesophageal fistula from thoracic aneurysm using a rifampicin-soaked synthetic graft

Aortoesophageal fistula secondary to thoracic aneurysm is rare, but is usually lethal, and few survivors have been reported. We report successful surgery for aortoesophageal fistula in a one-stage operation. Repair involved in situ replacement of the thoracic aneurysm using a rifampicin-soaked graft, primary repair of the esophagus, omental wrap and tube jejunostomy. This is the original report of the surgical repair of aortoesophageal fistula using a rifampicin-soaked graft.     

Bronchoesophageal fistula after endovascular repair of ruptured aneurysm of the descending thoracic aorta

Aortoesophageal fistula secondary to thoracic aneurysm is rare and is usually fatal without prompt surgical intervention. A 79-year-old man with significant comorbidities and previous cancer surgery was admitted on an emergency basis because of the suspicion of a ruptured thoracic aortic aneurysm. Computed tomographic scan followed by angiography demonstrated a ruptured thoracic aneurysm with aortoesophageal fistula. An endovascular stent graft repair was performed with successful exclusion of both aneurysm and fistula. On postoperative day 6, dyspnea and an isolated episode of hemoptysis occurred. Endoscopy revealed the presence of a bronchoesophageal fistula, which necessitated double exclusion of the esophagus and feeding jejunostomy. At 6 months, clinical, bronchoscopic, and computed tomographic scan follow-up showed complete sealing of the aneurysm and resolution of the bronchoesophageal fistula. At 9 months, the patient was still alive but refused to undergo substernal gastric bypass in an attempt to restore oral feeding. Endovascular repair seems promising as an emergent and palliative treatment of aortoesophageal fistula. To the best of our knowledge, this is the first case in which a bronchoesophageal fistula developed after successful endovascular repair of aortoesophageal fistula. The pathogenesis of this complications remains unclear.     

Aortobronchial fistula resulting from a mycotic pseudoaneurysm after treatment of an aortoesophageal fistula due to a thoracic aortic aneurysm

A 58-year-old man was admitted for an aortoesophageal fistula (AEF) resulting from a thoracic aortic aneurysm. He underwent immediate in-situ prosthetic graft replacement, primary esophageal repair and wrapping of the aneurysm. Postoperative upper gastrointestinal endoscopy and computerized tomography (CT) findings were unremarkable. He was discharged on postoperative day (POD) 25. Three months after surgery, he was readmitted with complaints of worsening cough and hemoptysis. CT showed a thrombosed aneurysm adjacent to the left bronchus. Aortobronchial fistula due to mycotic pseudoaneurysm was suspected. The patient underwent immediate resection of the infected graft and prosthetic graft replacement positioned to avoid the infected area. The graft was wrapped with omentum. On POD 7, pleural empyema developed, and esophagography revealed a residual leak. Staged reconstruction of the esophagus was performed successfully. We conclude that even if the fistulous opening is small, simultaneous esophageal resection should be performed during the initial treatment of AEF.     

Combined resection of the thoracic esophagus and thoracic descending aorta.

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.     

Endoscopic Diagnosis of a Clinically Silent Aortoesophageal Fistula: Case Report and Review of the Literature

We report a rare case of a secondary aortoesophageal fistula discovered incidentally during elective upper endoscopy. The patient had previously undergone repair of a descending thoracic aortic aneurysm with a Dacron interposition graft. Esophagoscopy 2 months after the aneurysm repair demonstrated a large mid-esophageal erosion with visualization of the aortic graft at the base. The aortoesophageal fistula had been clinically silent to this point. During preparation for surgery the patient developed large-volume esophageal hemorrhage and died following attempted endovascular repair of the fistula. A review of the literature on the diagnosis and surgical management of aortoesophageal fistula is presented.Presented at the 30th Annual Meeting of the Military Society for Vascular Surgery, Bethesda, MD, December 5, 2002.     

Combined resection of the thoracic esophagus and thoracic descending aorta

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.     

Surgical management of primary aortoesophageal fistula secondary to thoracic aneurysm

Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal fistula, secondary to thoracic aortic aneurysm, but techniques used have varied. We report a successful repair of primary aortoesophageal fistula, secondary to descending thoracic aortic aneurysm, and review the evolution of management since the three previously reported successful repairs at our institution.     

Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft

A 65-year-old woman sought treatment for sentinel upper gastrointestinal hemorrhage. Three years previously she had undergone graft replacement of her ascending aorta for aneurysm. In the interim she was followed for chronic dissection of her remaining aorta, and 6 months before this admission she had undergone graft replacement of a large abdominal aortic aneurysm. Arteriography and CT scanning of the thorax revealed an 8 cm aneurysm of the descending thoracic aorta. Operation was undertaken at which time an aortoesophageal fistula, as a result of erosion of the aneurysm into the esophagus, was identified. The descending thoracic aortic aneurysm was replaced with a Dacron tube graft, the esophageal defect was repaired primarily, and a viable pedicle flap of omentum was used to reinforce the esophageal repair and cover the aortic graft. Her postoperative recovery was free of infection but complicated by rapid expansion of the upper abdominal aorta at the visceral arterial level. Eight weeks after initial operation she underwent graft replacement of her remaining thoracoabdominal aorta with direct reattachment of her celiac axis, superior mesenteric artery, and both renal arteries. Recovery after her second procedure was uneventful, and she continues to do well at 13 months after operation. Development of a primary aortoesophageal fistula caused by aneurysms of the aorta is a rare but lethal complication. We present a technique for treatment of primary aortoesophageal fistula using omentum and preservation of gastrointestinal continuity as a one-stage operation. It is possible in selected cases to manage the esophageal perforation with primary closure and omental coverage to achieve healing free of infection without temporary or permanent discontinuity of the gastrointestinal tract.     

Successful management of an aortoesophageal fistula resulting from an aneurysm of the thoracic aorta with a covered stent.

Aortoesophageal fistula (AEF) is a relatively rare but life-threatening cause of upper gastrointestinal bleeding. There have been only a few survivors previously reported. There are controversies particularly regarding the treatment of the esophagus and postoperative infections. We report a case of an elderly man with an aortoesophageal fistula resulting from a thoracic aortic aneurysm. We managed the replacement of the aorta using a prosthetic graft, and an omentopexy for the fistula of the esophagus. For the treatment of leakage of the esophageal fistula, we successfully used a covered stent. This is the first report of the management of AEF using a covered stent.     

Rupture of a dissecting thoracic aortic aneurysm into the pulmonary artery: successful surgical repair

A rare complication of dissecting thoracic aortic aneurysms is rupture into a cardiac chamber or great vessel with fistula formation. A case of congestive heart failure caused by a chronic DeBakey type I dissecting aortic aneurysm that ruptured into the pulmonary artery is reported. Surgical repair involved closure of the fistula followed by graft replacement of the ascending aorta and transverse aortic arch. A review of the literature revealed no previous reports describing successful repair of this lesion. A clinical picture consistent with concomitant aortic dissection and biventricular heart failure, especially when a continuous cardiac murmur is present, suggests the diagnosis of an aortopulmonary arterial fistula caused by a ruptured dissecting thoracic aortic aneurysm. Various imaging studies confirm the diagnosis.     

Extra-anatomic bypass grafting for aortoesophageal fistula: a logical operation

Aortoesophageal fistula (AEF) is an uncommon cause of upper gastrointestinal hemorrhage. Usually, but not always, patients present with a small sentinel bleed followed by a variable interval of apparent resolution, and then they experience a massive exsanguinating hemorrhage. The variable interval of time after the sentinel bleed is the period in which most AEFs resulting from thoracic aortic aneurysm have been successfully treated. Although only a few successful cases have been reported in the literature, most describe an in situ repair. We describe treatment of a late-presenting AEF due to a thoracic aneurysm with an extra-anatomic bypass graft for the aortic repair.     

Esophageal perforation of aortic arch aneurysm treated free of mediastinitis without manipulating esophagus

Esophageal perforations of thoracic aortic aneurysms are most likely to be fatal. Patients with aorto-esophageal fistula require urgent operation on both the esophageal perforation site and the aortic lesion to avoid terminal exsanguination and uncontrollable mediastinitis. We present a case of 71-year-old woman suffering esophageal perforation of aortic arch aneurysm with sentinel arterial hemorrhage, who has not developed patent aortoesophageal fistula. Computed tomography verified rupture of aortic arch aneurysm that had eroded the esophagus. She underwent successful graft replacement and remains well without signs of mediastinitis over one year after the event. It is possible, in selected cases of esophageal perforation of thoracic aortic aneurysm, to manage the esophageal lesion without any surgical intervention, such as primary closure, omental coverage and surgical discontinuity to achieve esophageal healing free of infection.     

Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection

Secondary aortoesophageal fistula (AEF) is a rare but catastrophic complication that occurs after thoracic aortic reconstruction. Recently endoluminal stent grafts have been used in selected patients with a thoracic aortic aneurysm, dissection, or traumatic aortic transection. A 24-year-old woman had massive upper gastrointestinal tract bleeding 15 months after endoluminal stent graft placement because of traumatic descending thoracic aortic transection. Evaluation demonstrated an AEF from the mid-esophagus to the endoluminal stent graft. The endoluminal graft was explanted, with primary repair of the thoracic aortic defect and simultaneous primary repair of the esophageal injury. The patient is well 15 months after open repair of the AEF.     

Endovascular management of a descending thoracic mycotic aneurysm: mid-term follow-up.

Open surgical repair of mycotic aneurysm is associated with a high surgical morbidity and mortality. Endovascualr graft management of thoracic aortic aneurysm has been associated with a less surgical risk. The role of endovascular graft repair of mycotic aneurysm remains controversial since graft material remains in contact with possible infected tissue. We report the marked thrombosis and marked regression of a thoracic mycotic aneurysm with an endovascular graft at mid-term follow-up.     

Management of aortobronchial fistula with graft replacement and omentopexy

Massive hemoptysis due to a recurrent aortobronchial fistula after repair of a thoracic aortic aneurysm developed in a 64-year-old woman. The infected aortic tissue was resected and replaced with an in situ Dacron graft covered by omentum. The patient is alive and well 15 months later.     

Aortoesophageal fistula caused by aneurysm of the thoracic aorta: successful surgical treatment, case report, and literature review

Aortoesophageal fistula induced by atherosclerotic thoracic aortic aneurysm is rare, but is usually a fatal disorder, with few survivors reported. We report the case of a 72-year-old man with aortoesophageal fistula successfully treated in a two-stage operation. In the first stage, we performed resection and replacement of the aortic aneurysm with a prosthetic graft in situ, esophagectomy, cervical esophagostomy, and jejunostomy. After the patient recovered well postoperatively, a transmediastinal retrosternal interposition of the stomach was performed, with esophagogastroanastomosis in the cervical area, to re-establish the gastrointestinal tract. We include a discussion of the causes, diagnostic approach, management of the aorta and esophagus, and review of the literature.     

Aortoduodenal fistula and associated rupture of abdominal aortic aneurysm after endoluminal stent graft repair

The main complications of endovascular repair of abdominal aortic aneurysms are vascular leaks and rupture, although infection and aortoduodenal fistulas have also been reported rarely. We report a case of aortoduodenal fistula with separate retroperitoneal rupture of an abdominal aortic aneurysm after endovascular stent graft repair. The initial implantation was uneventful, without any leaks at 1 month. The patient underwent open repair and did well. To our knowledge, this is the first case report of aortoduodenal fistula and associated retroperitoneal rupture of the aneurysm after endovascular stent graft repair of an abdominal aortic aneurysm.     

Successful surgical treatment for an aortoesophageal fistula due to a descending aortic aneurysm.

The patient was a 68-year-old man who consulted another hospital with a chief complaint of dysphagia, and was referred to our hospital based on a suspicion of esophageal submucosal tumor. However, the patient was emergently admitted due to hematemesis and hypotension, which occurred immediately after the acquisition of computed tomographic (CT) images for further examinations at the outpatient clinic. Contrast-enhanced chest CT demonstrated a thoracic aortic aneurysm measuring 45 mm in maximal diameter, in addition to pneumatization adhering to mural thrombus, which appeared to be the esophagus. Upper gastrointestinal endoscopy also demonstrated ulcerative lesions accompanied by coagulations in the middle thoracic esophagus. Therefore, emergency surgery was performed based on a diagnosis of an aortoesophageal fistula due to a descending aortic aneurysm. Graft replacement was performed under partial extracorporeal circulation, followed by total thoracic esophagectomy, esophagostomy, and gastrostomy after weaning from extracorporeal circulation. This study reports the course of a patient with an aortoesophageal fistula due to a thoracic aortic aneurysm whose life was successfully saved by emergency surgery, together with literature.