S2076 Consequences of Going over to the ‘Right’ Side in the Wrong Way: Impact of an Aberrant Subclavian Artery

Introduction: Tracheoesophageal fistulas (TEFs) in adults are uncommon and typically acquired. Traumatic or prolonged intubation account for up to 75% of acquired nonmalignant TEFs.1 No definitive guidelines exist for management of this complication which has poor prognosis without intervention. Case Description/Methods: A 68 year old male presented with SOB and fevers then had prolonged ICU course for COVID-ARDS. The hospital course was complicated by recurrent VAP and unsuccessful attempts to wean the ventilator. He was transitioned to tracheostomy after 34 days. GI was then consulted for PEG placement which was aborted after endoscopy showed what initially appeared to be an ulcer. Further inspection revealed that it was the tracheotomy cuff in the esophagus. (Image 1) PEG placement was deferred and patient underwent tracheostomy exchange for ETT, advanced distal to the site of the fistula, along with esophageal stent placement with CT surgery. Within days patient developed worsening hypoxia refractory to vent adjustments and profound shock then ultimately passed. Discussion: Prognosis for unrepaired TEF is poor with mean survival time 1-6 weeks.1 Risk factors for TEF in the setting of intubation include prolonged ventilation, immunosuppression, malnutrition, episodic hypotension, and NG/OG tube, thus, this patient was the ideal substrate. 2 Symptoms are non specific which delays diagnosis. Evaluation of TEF may include barium esophageal if patient is able to swallow or alternatively CT chest. Definitive diagnosis is made on endoscopy and/or bronchoscopy. Very rarely TEFs may close spontaneously without intervention.3 Strategies for repair include esophageal bypass, direct repair and stenting.2 Studies comparing esophageal stenting with other interventions are lacking. Furthermore, there is no data comparing intervention with esophageal stent by GI vs CT surgery. Approach to repair will depend on the clinical context and physician comfort level. Ideally, patients with TEFs should be extubated, if reasonable, since continued positive airway pressure after repair can increase the risk of dehiscence or stent migration.