Successful treatment of secondary aortoesophagealfistula after thoracic endovascular aortic repair

HISTORY AND CLINICAL SYMPTOMS: A 58-year-oldman was admitted to our hospital with acute chest pain and subfebriletemperatures. Two years ago, endovascular aortic stent-graft placementhad been performed for acute type B aortic dissection complicatedby malperfusion syndrome. DIAGNOSTIC ASSESSMENT: CT angiographyshowed a discrete soft-tissue attenuation mass between the aortaand esophagus. The patient developed progressive swallow disorderand esophago-gastro-duodenoscopy demonstrated deep esophageal ulcerationsat the level of the implanted aortic stent-graft. Intravenous treatmentwith broad spectrum antibiotics was started. The FDG-PET/CTscan showed increased FDG uptake and air entrapment in the affectedregion establishing the diagnosis of aortoesophageal fistula formation. THERAPY AND OUTCOME: Given the generallypoor condition of the patient and the high risk of any aggressivesurgical intervention, a new limited surgical approach was chosenconsisting of open transthoracic esophageal resection, blind closureof the stomach and cervical esophagostomy. A percutaneous endoscopicgastrostomy tube was placed. After three months, esophageal continuitywas restored by retrosternal colon interposition. The presentedtherapeutic management resulted in a full recovery of the patient. CONCLUSION: Aortoesophageal fistulais a rare complication of thoracic aortic stent-graft placement.Patient may present with unspecific symptoms such as fever and risedinflammatory markers, but may also present with massive upper gastrointestinalbleeding. The herein presented limited therapy with esophageal resectionrepresents a promising to the otherwise difficult therapy of aortoesophagealfistula.