Volume 36, Issue 3 , Pages 297-299, September 2008
Aortic and Esophageal Endografting for Secondary Aortoenteric Fistula
Article Outline
Abstract
The aorto-esophageal fistula is a well-recognized and potentially fatal complication of thoracic aortic surgery. Several strategies regarding its prevention and subsequent management have been described. We report the management of a large midthoracic fistula complicating redo thoraco-abdominal aortic surgery by the placement of covered stents in the aorta and esophagus to successfully exclude the lesion.
While long term durability is uncertain, endografts and long-term antibiotics provide a therapeutic option for palliation in patients unfit for immediate surgery.
Keywords: Aneurysm, Infected, Esophageal fistula, Endograft
Introduction
The aortoesophageal fistula (AEF) is a well-recognized complication of thoracic aortic surgery; it is universally fatal in untreated patients, but operative repair is challenging and fraught with high morbidity and mortality rates.
We describe a novel approach based on endoluminal repair of the mediastinal lesion.
Case Report
A 61-year-old man was referred to our Institution with fever, thoracic pain and several episodes of gastro-intestinal bleeding. Blood tests revealed severe anemia, coagulation impairment and elevated inflammatory markers. The patient had a history of myocardial infarction, COPD and repair of a ruptured descending thoracic aneurysm. Two years later, a type III thoraco-abdominal aortic aneurysm grafting was performed for progression of the disease.
An emergent 64-row multislice CT angiogram revealed a pseudoaneurysm of the proximal anastomosis (mid-thoracic aorta) with perigraft fluid collection and gas bubbles in close proximity to the oesophagus. Collateral findings revealed patency of a large intercostal branch reimplanted during the previous operation and dilatation of the Carrell patch (5
cm) with patency of the renal and splanchnic vessels (Fig. 1).
Figure 1
Axial and multiplanar scans of preoperative computed tomography demonstrate a multi- sepimented mid-thoracic aortic pseudoaneurysm (*) with septic perigraft collection. The patent intercostal artery is visible at T10 (arrow).
Due to severe comorbidities, the patient was considered unfit for open repair and an endovascular approach to AEF was planned. Medical treatment was initially started with broad-spectrum antibiotics, morphine, blood and plasma transfusions to stabilize the patient, however, the following day he experienced severe gastro-intestinal bleeding with shock and respiratory distress. He was immediately intubated, fluid-resuscitated and referred to the operatory room. A rifampicin soaked Zenith TX2-P 42×162mm (William Cook Europe, Bjaerverskov, Denmark) was deployed in order to fit in a 38mm diameter of the proximal aorta. The proximal anastomosis was covered, carefully preserving the previously reimplanted intercostal artery, visible at the intraoperative angiogram. The patient immediately recovered hemodynamic stability and awakened neurologically intact. On the 2nd postoperative day, a CT scan confirmed the successful exclusion of the pseudoaneurysm; at the same time, a 8 Fr. percutaneous non-locking pigtail catheter (Boston Scientific Corporation, Natick, MA) was placed under CT-guidance to drain the perigraft collection. Microbiologic cultures of the abscess were positive for Escherichia coli and Corynebacterium species. Culture-specific parenteral antibiotics - piperacillin/tazobactam, fluconazole and teicoplanin - were started.
To evaluate the gastroenteric lesion, a Gastrografin (Schering, Berlin, Germany) swallow study was performed on 8th postoperative day with evidence of an extensive, persistent leak, from the esophagus lumen into the periaortic abscess. An esophageal nitinol stent 24×80mm with a polyurethane coating: Nitis - S™ (Taewong Medical, Seoul, Korea), was deployed to exclude the fistula; meanwhile the periaortic drainage was left in-situ. The diameter and length of stent were chosen according to the size of esophageal lumen estimated at the swallow study.
The patient did well: his fever subsided and laboratory findings revealed progressive resolution of the inflammatory markers. At 1 and 3 weeks after the procedure, reassessment CTs showed resolution of the mediastinal collection (Fig. 2). One month after the procedure, the drainage was removed and the patient was weaned from total parenteral nutrition, gradually resuming a normal diet. Suppressive broad spectrum antibiotic therapy was given. At 5 months follow-up, a satisfactory recovery was observed: no fever, no blood inflammatory markers elevation and no new episodes of gastro-intestinal bleeding were recorded. The CT scan revealed persistent resolution of the mediastinal collection and complete exclusion of the pseudoaneurysm.
Figure 2
Axial and 3D scans of postoperative computed tomography show the absence of aortic leaks and the resolution of the mediastinal abscess. Note the percutaneous drainage of the perigraft collection (arrow).
Discussion
Although several strategies have been reported in the literature including endovascular and in-situ repair with cryopreserved homograft, no general consensus exists on the optimal approach to an AEF.1 Coselli et al. reports that over 60% of patients die within 6hours from the presentation of symptoms. Overall mortality rates of open repair range from 30% to 80%.2 Therefore, a less-invasive approach may be particularly appealing in the presence of a frozen chest from previous aortic surgery and severe comorbid conditions.
Endovascular stent graft repair may itself cause an esophageal fistula by aortic erosion particularly in tortuous segments, however it had proved to be an appealing and effective durable option for patients with infected pseudoaneurysms of the thoracic aorta. Stanley et al.3 reported successful endovascular treatment of four patients with mycotic thoracic aortic aneurysms. There has always been concern about persistent infection when a stent graft is deployed in an infected field, however, in situ prosthetic reconstruction is often unavoidable, even with open repair.
The risk of persistent infection may be high in situations where contamination from the esophageal lesion is ongoing. Ting et al.4 reported a poor outcome in two of seven patients with persistent esophageal lesions resulting in continued contamination of the stent-graft.
Mok et al.5 documented a case of successful closure of a small esophageal fistula by injection of fibrin sealant, but this result has not been reproduced and did not match with our case where extensive esophageal lesions were documented. Fistulas between the esophagus and tracheobronchial tree have been effectively managed with covered stenting of either the esophagus or the airways. Recently a parallel placement of covered retrievable expandable metallic stents has been advocated as a safe and effective procedure for the palliative treatment of malignant esophageal and tracheobronchial strictures.6
To our knowledge, this is the first reported case of double endoluminal approach for AEF. Long term durability is uncertain and open treatment is still the first choice, however, endografts and long-term antibiotics provide a compassionate therapeutic option for temporary palliation in patients unfit for immediate surgery.
References
- . Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts. Ann Surg. 2007;246:853–859
- . Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft. J Vasc Surg. 1990;12:269–277
- . Endoluminal repair of mycotic thoracic aneurysms. J Endovasc Ther. 2003;10:511–515
- . Endovascular stent graft repair for infected thoracic aortic pseudoaneurysms–a durable option?. J Vasc Surg. 2006;44:701–705
- . Combined endovascular stent grafting and endoscopic injection of fibrin sealant for aortoenteric fistula complicating esophagectomy. J Vasc Surg. 2004;40:1234–1237
- . Malignant esophageal-tracheobronchial strictures: parallel placement of covered retrievable expandable nitinol stents. Acta Radiol. 2006;47:3–9
PII: S1078-5884(08)00277-3
doi:10.1016/j.ejvs.2008.05.004
© 2008 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Volume 36, Issue 3 , Pages 297-299, September 2008
