Aorto-oesophageal and Aortobronchial Fistulae Following Thoracic Endovascular Aortic Repair: A National Survey☆

Article Outline

• Abstract
• Methods
• Results
• Discussion
• Conflict of Interest
• References
• Copyright

Abstract 

Objective

We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results.

Methods

We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme.

Results

Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 ± 12.5 months, overall survival was 16% (3/19).

Conclusions

The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

Keywords: Aorto-oesophageal fistula, Aortobronchial fistula, Infection, TEVAR, Thoracic aorta endovascular repair

Aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae are uncommon and highly fatal conditions that occur most frequently secondary to thoracic trauma, aortic aneurysms, ruptured penetrating aortic ulcers, oesophageal or bronchogenic malignancies and thoracic surgery.¹ In particular, the incidence of AEF/ABF as a complication of open repair of the thoracic and thoraco-abdominal aorta ranges from 0.5%–1.7%.², ³

Since its introduction in the early 1990s,⁴ thoracic endovascular aortic repair (TEVAR) has become the most important therapeutic alternative for high-risk patients with thoracic aortic disease. With growing numbers of interventional thoracic aortic procedures and increasing follow-up periods, late complications of TEVAR have become increasingly evident over time, including post-procedural AEF and ABF.⁵, ⁶, ⁷, ⁸ However, relatively little is known about these sequelae because of their rarity, the fairly recent clinical introduction of endovascular techniques and the lack of multicentre reports.

The objective of this study was to evaluate the incidence of post-TEVAR AEF/ABF, investigate clinical features and determinants and assess the efficacy of therapeutic measures by means of a national survey conducted in Italy.

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Methods 

We conducted a cross-sectional survey on a voluntary basis among Italian universities and hospital centres with a thoracic endovascular programme. A text document-based survey developed by us was distributed in November 2007 by e-mail to the medical directors of Italian departments of vascular surgery or cardiothoracic surgery known to have experience with thoracic aorta stent grafting. Centres that performed TEVAR on a regular basis, even if they lacked direct experience with AEF/ABF treatment, were invited to participate. Accompanying the questionnaire was a letter explaining the aims of the study and the compiling modalities. Each centre that failed to respond was contacted by telephone or solicited by e-mail. The survey ended in December 2008. Participating centres (listed in Table 1) were requested to provide data from patients that underwent TEVAR for noninfectious aortic disease between 1998 and 2008, and data from patients presenting a post-TEVAR AEF and/or ABF in the same period. In addition, data regarding results of endovascular repair of an established AEF or ABF were collected within the same survey. These data, however, pertain to different patients with different pathologies, and were reported in a separate publication.³⁹ Patient names or identifiers were not requested or provided.

Table 1. Centres participating to the survey.

Demographics and preoperative risk factors, including coronary artery disease, pulmonary disease and renal failure were defined as previously reported.⁹ The anatomic location of the proximal landing zone was defined according to the ‘aortic arch map'proposed by Ishimaru (0–4).¹⁰ The results of TEVAR were described according to the reporting standards for endovascular aortic aneurysm repair.¹¹ Renal dysfunction was defined as a rise in serum creatinine exceeding the baseline value by 30% and surpassing an absolute level of 2.0 mg dl⁻¹.¹² Myocardial infarction was suggested by electrocardiographic changes and confirmed by elevation of cardiac enzymes, regardless of symptoms. Respiratory failure was defined as ventilator dependence lasting >72 h, the need for postoperative reintubation, clinical data or culture confirmation of pneumonia or the need for tracheostomy.¹²

Patients were followed-up according to the protocol of each institution; in all cases, this included thoracic contrast-enhanced computed tomography (CT) or magnetic resonance (MR) imaging and an outpatient clinical evaluation.

Patients who developed AEF/ABF following TEVAR were compared with the global cohort of patients who underwent TEVAR in terms of preoperative and intra-operative variables of interest, using the Fisher exact test or χ² test for categorical data, and the unpaired t-test or Mann–Whitney test for continuous data, as appropriate. All analyses were run using SAS 8.02 software (SAS Institute Inc., Cary, NC, USA).

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Results 

In general, 17 out of the 39 contacted centres, including that of the authors, provided patient data (Table 1). Between 1998, 2008, 1113 patients underwent TEVAR. Of these patients, 19 patients developed an AEF or ABF during follow-up (1.7%). Demographics and preoperative risk factors of patient presenting postoperative AEF/ABF are summarised in Table 2. Three cases included in this survey were reported in a previous series.¹³, ¹⁴, ¹⁵

Table 2. Demographics, risk factors and procedural details of patients presenting a postoperative AEF/ABF.

Characteristics	No. Patients (%)
Overall	19
Age (years, mean ± SD)	73.8 ± 7.1
Gender (male)	16 (84)
Coronary artery disease	7 (37)
Diabetes mellitus	2 (10)
Hypertension	15 (79)
Cerebrovascular disease	3 (16)
Pulmonary disease	11 (58)
Renal failure	5 (26)
Smoking	7 (37)
American Society of Anaesthesiologists class
1	0 (0)
2	0 (0)
3	11 (58)
4	8 (42)
5	0 (0)
Proximal landing zone
Zone 0	0 (0)
Zone 1	1 (5)
Zone 2	2 (10)
Zone 3	8 (42)
Zone 4	8 (42)

Indications for TEVAR (Table 3) included atherosclerotic aortic aneurysm, penetrating ulcer, intramural haematoma, acute and chronic dissection, traumatic injury, coarctation and anastomotic pseudo-aneurysm following previous aortic open repair. Only anastomotic pseudo-aneurysm was significantly associated with AEF/ABF development (16% vs. 2%; P = 0.009). In addition, emergently performed procedures were associated with an increased risk of AEF/ABF (37% vs. 13%; P = 0.008; Table 3).

Table 3. Comparison of indications and modality of TEVAR, in the global cohort and in patients who developed AEF/ABF.

Characteristics	All TEVAR patients (%)	AEF/ABF patients (%)	P*
Overall	1113	19
Indication to TEVAR
Atherosclerotic aneurysm	782 (70.3)	13 (68.4)	.806
Penetrating ulcer/Intramural haematoma	48 (4.3)	2 (10.5)	.203
Acute dissection	74 (6.6)	0 (0.0)	.630
Chronic dissection	98 (8.8)	0 (0.0)	.399
Traumatic injury	83 (7.5)	1 (5.3)	1.0
Aortic coarctation	4 (0.4)	0 (0.0)	1.0
Anastomotic pseudoaneurysm	24 (2.1)	3 (15.8)	.009
TEVAR performed in emergency	143 (12.8)	7 (36.8)	.008

* Fisher exact test.

Six types of commercially available stent grafts from five different manufacturers were employed (Table 4). The mean stent graft proximal diameter was 37.9 ± 5.3 mm. A mean number of 1.4 ± 0.5 devices per patient were implanted. The mean aortic length to be covered was 171.8 ± 61.1 mm. An intended stent graft oversizing at the proximal landing zone of 10–19% was used in 11 cases (58%), 20% in six cases (32%) and 21–30% in two cases (10%). Cerebrospinal fluid drainage was instituted in three patients (16%). The mean duration of the procedure was 160 ± 139 min, and the mean estimated blood loss 534 ± 516 ml. Ballooning was performed in 12 cases (63%). Concomitant supra-aortic vessel debranching was performed in three cases (16%).

Table 4. Stent grafts implanted in patients who developed an AEF/ABF.

Primary technical success was obtained in 17/19 cases (Table 5). One patient underwent implantation of a proximal additional cuff to treat a type I endoleak. Perioperative complications occurred in eight patients (42%), including renal dysfunction in five cases, respiratory failure in five cases and stroke in one case. Compared to the global cohort of patients who underwent TEVAR, the occurrence of perioperative complications was significantly associated with late AEF/ABF development (42% vs. 12%; P < 0.001), particularly in cases with postoperative renal dysfunction (P < 0.001) and respiratory failure (P = 0.001).

Table 5. Comparison of TEVAR results, in the global cohort and in patients who developed AEF/ABF.

Characteristics	All TEVAR patients (%)	AEF/ABF patients (%)	P*
Overall	1113	19
Primary technical success	998 (89.7)	17 (89.5)	1.0
30-day morbidity: overall	129 (11.6)	8 (42.1)	<.001
Paraplegia/paraparesis	47 (4.2)	0 (0.0)	1.0
Renal dysfunction	38 (3.4)	5 (26.3)	<.001
Respiratory failure	48 (4.3)	5 (26.3)	.001
Stroke	16 (1.4)	1 (5.3)	.252
Myocardial infarction	18 (1.6)	0 (0.0)	1.0
Residual type I endoleak	48 (4.3)	1 (5.6)a	.572

* Fisher exact test.

The mean interval between TEVAR and fistula detection was 10.9 ± 15.4 months. The fistula involved the oesophagus in 13 cases (68%) and the left bronchial tree in one case (5%); there was concomitant broncho-oesophageal involvement in five cases (26%). The symptoms at presentation and the diagnostic modalities that disclosed AEF/ABF are reported in Table 6. In one patient who died of sudden haemorrhagic shock, an AEF was diagnosed only at autopsy. CT scans performed upon admission revealed only one associated endoleak in a patient who was previously treated for a thoracic descending aortic aneurysm (1/18; 6%). No stent-graft fractures were observed. Blood cultures were positive in three cases (16%). Isolated microorganisms included Enterococcus sp. and Mycobacterium tuberculosis.¹⁴

Table 6. Clinical features at presentation and preoperative diagnostic studies.

Variable	No. Patients (%)
Total patients	19
Symptoms at presentation
Haematemesis/haemoptysis	13 (68)
Fever	11 (58)
Shock	5 (26)
Thoracic pain	1 (5)
Dyspnea	2 (10)
Dysphagia	1 (5)
Melena	4 (21)
Diagnostic studies showing AEF/ABF
Computed tomography	18 (95)
Gastrointestinal/bronchial endoscopy	6 (32)
Oesophagogram	1 (5)
Labeled leukocyte scintigraphy	1 (5)

All of the patients who did not undergo any intervention died within 30 days (8/8). Eleven patients (58%) underwent AEF/ABF emergent repair (Table 7). Treatment included aortic surgical repair in two patients, with associated oesophageal reconstruction in one of them. Aortic re-endografting was performed in three patients, with associated oesophageal reconstruction in one of them. Six patients underwent oesophageal and/or bronchial repair alone (Fig. 1). Perioperative mortality was 64% (7/11). Of the survivors, one patient died 6 months after the operation due to unrelated causes. Another patient underwent successful multiple re-interventions, including total oesophagectomy and thoracic aortic reconstruction under deep hypothermic circulatory arrest. At a mean follow-up of 17.7 ± 12.5 months, the overall survival was 16% (3/19).

Table 7. Clinical outcome in patients presenting a post-TEVAR AEF/ABF.

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• Figure 1 

  Aortoesophageal fistula following TEVAR. A) Preoperative CT scan demonstrating air bubbles in the thrombus (arrows). B) Intra-operative photograph during surgical conversion shows thoracic stent-graft removal, and aortic in situ reconstruction with a silver-coated prosthetic graft.

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Discussion 

First described by Dubrueil in 1818 and by Girardet in 1914,¹⁶, ¹⁷ AEF and ABF are well-known rare causes of massive gastrointestinal and respiratory bleeding that are associated with high morbidity and mortality. Although the most common cause of fistulisation is the erosion of a thoracic aortic aneurysm,¹⁸ secondary AEF and ABF are also known to develop late after thoracic aortic surgery in up to 1.7% of patients.², ³ Our survey revealed that the incidence of post-TEVAR AEF and ABF is comparable to the incidence after open repair surgery; therefore, in this respect, endovascular treatment of the thoracic aorta does not appear to provide any advantage over conventional repair.

We found that pseudo-aneurysm as an indication for TEVAR represents a significant risk factor for late fistulisation. Compression of the oesophagus or the airways by the pseudo-aneurysm may result in a local inflammatory response, formation of stable adhesions and tissue necrosis, leading to erosion and final fistulisation. Although endovascular treatment has been proposed as a less-invasive and safe alternative to open surgery for repair of thoracic pseudo-aneurysms,¹⁹, ²⁰ our data show that TEVAR may lead to long-term serious complications in this setting.

Endoluminal repair of thoracic aortic disease requiring emergent or urgent treatment has yielded encouraging early results with low morbidity and mortality rates compared with open surgery.²¹ However, our survey revealed that emergent TEVAR is associated with an increased risk of late AEF/ABF development, indicating a need for caution after these procedures. The mechanisms underlying this finding are unclear, but we speculate that aortic lesions that require emergent repair often entail extravasation of blood and periaortic haematoma, with increased local inflammatory response and compression of surrounding organs. These factors, which are not ameliorated by aortic stent grafting, may play a role in late fistulisation.²²

We also found that the occurrence of perioperative complications after TEVAR, particularly renal dysfunction and respiratory failure, were significant predictors of AEF/ABF development. A closer follow-up of these patients may help to recognise AEF/ABF early, although there is no evidence that early detection should improve the prognosis.

Post-TEVAR fistulae have been reported to occur as a result of endoleak into the residual aneurysm sac, erosion of the stent graft through the aorta and ischaemic necrosis of the oesophageal/bronchial wall resulting from stent coverage of their feeding arteries.⁷, ⁸, ²³ However, our survey found that the rate of residual type I endoleak in patients presenting an AEF/ABF was comparable to that of the global cohort; only one patient had an endoleak at the time of AEF detection. This result could be due to the low incidence rate of endoleaks (type II error); therefore, we believe that patients presenting endoleak should be always closely followed up.

Different thoracic stent grafts were used in the patients who developed AEF/ABF. Specific device characteristics, the number of stent grafts used and the length of the covered aorta were not significantly associated with AEF/ABF development. We found that 42% of patients presenting late AEF/ABF had a proximal oversizing of 20% or more, regardless of the manufacturer's recommendations. Although this cannot be appointed as a risk factor because the proportion of oversized grafts in the global cohort of TEVAR patients is unknown, excessive stent graft oversizing has been previously shown to result in long-term deterioration of the arterial wall, stent-graft migration and aortic aneurysm enlargement,²⁴, ²⁵ and should be taken into account as a possible additional mechanism of fistulisation.²⁶, ²⁷

AEF/ABF were observed at different time intervals during the follow-up, and therefore their occurrence appears to be unpredictable. The most common presenting symptom was upper gastrointestinal or respiratory bleeding, followed by chronic fever. CT scan was the first imaging study performed in most of the cases, because it is easy to carry out in emergency conditions. Although CT scans rarely detect fistulous tracts, suggestive signs of AEF/ABF are present in most patients, including air bubbles into the thrombus, periaortic fluid collection, oesophageal or bronchial wall thickening and lung consolidation.¹⁹, ²⁸, ²⁹ Endoscopy is the most sensitive and specific method for the diagnosis of AEF/ABF,³⁰ but often requires sedation and entails the risk of dislodging clots during the progress of the endoscope, which can cause fatal bleeding.³¹

Mortality after surgery for thoracic aortic fistulae has been shown to reach 61% in cases of primary etiology³² and 78% in cases of secondary fistulae.³³ Conventional treatment includes surgical aortic repair, which is most commonly performed via a left posterolateral thoracotomy. Recently, TEVAR was proposed as an alternative strategy for the surgical management of AEF and ABF.³⁴, ³⁵ Although less-invasive, this technique presents important limitations, mainly the high risk of graft contamination. Several authors have proposed a variety of combinations of TEVAR with surgical aortic repair, oesophageal stent grafting, tracheobronchial or oesophageal reconstruction, mediastinal drainage or even endoscopic use of fibrin glue at the level of the fistula.³⁶, ³⁷, ³⁸ The long-term efficacy and safety of these techniques, however, has yet to be determined.

The operative mortality of post-TEVAR AEF/ABF repair was 63.6% in our series. No significant differences in terms of either early or late mortality were observed between AEF and ABF. Although, in our study, mortality appeared to be independent of the surgical technique used, we cannot make general recommendations for the surgical treatment of AEF and ABF due to the small number of cases. Consistent with previous findings, according to our survey, both AEF and ABF were invariably fatal if left untreated.

In conclusion, although rare, AEF and ABF are considerable late sequelae of TEVAR, particularly in patients who underwent emergent procedures or who experienced perioperative complications. Both surgical and endovascular treatment are associated with high mortality, but conservative treatment is not a viable option. Further studies are needed to assess the optimal management of these complications.

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Conflict of Interest 

No competing interest declared.

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References 

1. Hollander JE, Quick G. Aortoesophageal fistula: a comprehensive review of the literature. Am J Med. 1991;91:279–287
   • View In Article
   • Abstract
   • Full-Text PDF (4548 KB)
   • CrossRef
2. Lawrie GM, Earle N, De Bakey ME. Evolution of surgical techniques for aneurysms of the descending thoracic aorta: twenty-nine years experience with 659 patients. J Card Surg. 1994;9(6):648–661
   • View In Article
   • MEDLINE
   • CrossRef
3. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17(2):357–368
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (1331 KB)
   • CrossRef
4. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994;331(26):1729–1734
   • View In Article
   • MEDLINE
   • CrossRef
5. Neuhauser B, Czermak BV, Fish J, Perkmann R, Jaschke W, Chemelli A, et al. Type A dissection following endovascular thoracic aortic stent-graft repair. J Endovasc Ther. 2005;12(1):74–81
   • View In Article
   • MEDLINE
   • CrossRef
6. Böckler D, Schumacher H, Ganten M, von Tengg-Kobligk H, Schwarzbach M, Fink C, et al. Complications after endovascular repair of acute symptomatic and chronic expanding Stanford type B aortic dissections. J Thorac Cardiovasc Surg. 2006;132(2):361–368
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (1051 KB)
   • CrossRef
7. Eggebrecht H, Mehta RH, Dechene A, Tsagakis K, Kühl H, Huptas S, et al. Aortoesophageal fistula after thoracic aortic stent-graft placement: a rare but catastrophic complication of a novel emerging technique. JACC Cardiovasc Interv. 2009;2(6):570–576
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (884 KB)
   • CrossRef
8. Porcu P, Chavanon O, Sessa C, Thony F, Aubert A, Blin D. Esophageal fistula after endovascular treatment in a type B aortic dissection of the descending thoracic aorta. J Vasc Surg. 2005;41(4):708–711
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (305 KB)
   • CrossRef
9. Chiesa R, Melissano G, Marrocco-Trischitta MM, Civilini E, Setacci F. Spinal cord ischemia after elective stent-graft repair of the thoracic aorta. J Vasc Surg. 2005;42(1):11–17
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (143 KB)
   • CrossRef
10. Melissano G, Civilini E, Bertoglio L, Calliari F, Setacci F, Calori G, et al. Results of endografting of the aortic arch in different landing zones. Eur J Vasc Endovasc Surg. 2007;33(5):561–566
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (133 KB)
    • CrossRef
11. Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg. 2002;35(5):1048–1060
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (102 KB)
    • CrossRef
12. Marrocco-Trischitta MM, Melissano G, Kahlberg A, Setacci F, Segreti S, Spelta S, et al. Glomerular filtration rate after left renal vein division and reconstruction during infrarenal aortic aneurysm repair. J Vasc Surg. 2007;45(3):481–486
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (104 KB)
    • CrossRef
13. Bonavina L, Lupattelli T, Bona D, Trimarchi S, Nano G, Rampoldi V, et al. Bronchoesophageal fistula after endovascular repair of ruptured aneurysm of the descending thoracic aorta. J Vasc Surg. 2005;41(4):712–714
    • View In Article
14. Marroni M, Cao P, Verzini F, Corneli P, Mazzola R, Stagni G. Thoracic aortic graft infection after disseminated tuberculosis. Lancet Infect Dis. 2005;5(4):251
    • View In Article
    • Full Text
    • Full-Text PDF (67 KB)
    • CrossRef
15. Jonker FH, Heijmen R, Trimarchi S, Verhagen HJ, Moll FL, Muhs BE. Acute management of aortobronchial and aortoesophageal fistulas using thoracic endovascular aortic repair. J Vasc Surg. 2009 Nov;50(5):999–1004
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (191 KB)
    • CrossRef
16. Dubrueil O. Observations sur la perforation de l'esophage et de l'aorte thoracique par une portion d'os avale: avec de reflexions. J Univ Sci Med. 1818;9:357–363
    • View In Article
17. Girardet A. Doppelte perforation eines tuberkelknotens in die aorta und die bifurcation der trachea. Deutsch Med Wochenschor. 1914;40:1425–1428
    • View In Article
18. Coselli JS, Crawford ES. Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft. J Vasc Surg. 1990;12(3):269–277
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (3714 KB)
    • CrossRef
19. Midulla M, Dehaene A, Godart F, Lions C, Decoene C, Serge W, et al. TEVAR in patients with late complications of aortic coarctation repair. J Endovasc Ther. 2008;15(5):552–557
    • View In Article
    • CrossRef
20. Riesenman PJ, Farber MA, Mendes RR, Marston WA, Fulton JJ, Mauro M, et al. Endovascular repair of lesions involving the descending thoracic aorta. J Vasc Surg. 2005;42(6):1063–1074
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (214 KB)
    • CrossRef
21. Bell RE, Taylor PR, Aukett M, Sabharwal T, Reidy JF. Results of urgent and emergency thoracic procedures treated by endoluminal repair. Eur J Vasc Endovasc Surg. 2003;25(6):527–531
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (319 KB)
    • CrossRef
22. Picichè M, De Paulis R, Fabbri A, Chiariello L. Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management. Ann Thorac Surg. 2003;75(6):1998–2006
    • View In Article
    • MEDLINE
    • CrossRef
23. Girdauskas E, Falk V, Kuntze T, Borger MA, Schmidt A, Scheinert D, et al. Secondary surgical procedures after endovascular stent grafting of the thoracic aorta: successful approaches to a challenging clinical problem. J Thorac Cardiovasc Surg. 2008;136(5):1289–1294
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (335 KB)
    • CrossRef
24. Sternbergh WC, Money SR, Greenberg RK, Chuter TA. Zenith Investigators. Influence of endograft oversizing on device migration, endoleak, aneurysm shrinkage, and aortic neck dilation: results from the zenith multicenter trial. J Vasc Surg. 2004;39(1):20–26
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (147 KB)
    • CrossRef
25. Schurink GW, Aarts NJ, van Baalen JM, Schultze Kool LJ, van Bockel JH. Stent attachment site-related endoleakage after stent graft treatment: an in vitro study of the effects of graft size, stent type, and atherosclerotic wall changes. J Vasc Surg. 1999;30(4):658–667
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (183 KB)
    • CrossRef
26. Marone EM, Esposito G, Kahlberg A, Tshomba Y, Brioschi C, Zannini P, et al. Surgical treatment of tracheoinnominate fistula after stent-graft implantation. J Thorac Cardiovasc Surg. 2007;133(6):1641–1643
    • View In Article
    • Full Text
    • Full-Text PDF (789 KB)
    • CrossRef
27. VonFricken K, Karamanoukian HL, Ricci M, Taheri A, Bergsland J, Salerno TA. Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta. Ann Thorac Surg. 2000;70(4):1407–1409
    • View In Article
    • MEDLINE
    • CrossRef
28. Bergqvist D, Björck M. Secondary arterioenteric fistulation–a systematic literature analysis. Eur J Vasc Endovasc Surg. 2009;37(1):31–42
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (221 KB)
    • CrossRef
29. Prokakis C, Koletsis E, Apostolakis E, Dedeilias P, Dougenis D. Aortoesophageal fistulas due to thoracic aorta aneurysm: surgical versus endovascular repair. Is there a role for combined aortic management?. Med Sci Monit. 2008;14(4):RA48–RA54
    • View In Article
30. Akaraviputh T, Sriprayoon T, Prachayakul V, Sakiyalak P. Endoscopic diagnosis of secondary aortoesophageal fistula. Endoscopy. 2008;40(2):E90
    • View In Article
    • CrossRef
31. Benson MJ, Rouse D, van Someren N, Wingate DL, Swain CP. Fatal hemorrhage from an aorto-esophageal fistula precipitated by flexible endoscopy. Gastrointest Endosc. 1991;37(2):193–196
    • View In Article
    • Full-Text PDF (4419 KB)
    • CrossRef
32. Dossa CD, Pipinos II, Shepard AD, Ernst CB. Primary aortoenteric fistula: part II. Primary aortoesophageal fistula. Ann Vasc Surg. 1994;8(2):207–211
    • View In Article
    • Full-Text PDF (238 KB)
    • CrossRef
33. Pipinos II, Reddy DJ. Secondary aortoesophageal fistulae. Ann Vasc Surg. 1999;13(6):649–652
    • View In Article
    • Full-Text PDF (207 KB)
    • CrossRef
34. Léobon B, Roux D, Mugniot A, Rousseau H, Cérene A, Glock Y, et al. Endovascular treatment of thoracic aortic fistulas. Ann Thorac Surg. 2002;74(1):247–249
    • View In Article
    • MEDLINE
    • CrossRef
35. Marone EM, Baccari P, Brioschi C, Tshomba Y, Staudacher C, Chiesa R. Surgical and endovascular treatment of secondary aortoesophageal fistula. J Thorac Cardiovasc Surg. 2006;131(6):1409–1410
    • View In Article
    • Full Text
    • Full-Text PDF (130 KB)
    • CrossRef
36. Van Doorn RC, Reekers J, de Mol BA, Obertop H, Balm R. Aortoesophageal fistula secondary to mycotic thoracic aortic aneurysm: endovascular repair and transhiatal esophagectomy. J Endovasc Ther. 2002;9(2):212–217
    • View In Article
    • MEDLINE
    • CrossRef
37. Civilini E, Bertoglio L, Melissano G, Chiesa R. Aortic and esophageal endografting for secondary aortoenteric fistula. Eur J Vasc Endovasc Surg. 2008;36(3):297–299
    • View In Article
38. Mok VW, Ting AC, Law S, Wong KH, Cheng SW, Wong J. Combined endovascular stent grafting and endoscopic injection of fibrin sealant for aortoenteric fistula complicating esophagectomy. J Vasc Surg. 2004;40(6):1234–1237
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (204 KB)
    • CrossRef
39. Chiesa R, Melissano G, Marone EM, Kahlberg A, Marrocco-Trischitta MM, Tshomba Y. Endovascular treatment of aortoesophageal and aortobronchial fistulae. J Vasc Surg. 2010;
    • View In Article