A Successful Three-Stage Surgical Treatment for Aortoesophageal Fistula After Thoracic Endovascular Aortic Repair and Esophageal Stent Repair Lijian Cheng, MD, Junming Zhu, MD, Xiangyang Liu, MD, Wei Liu, MD, Haiou Hu, MD, Jie Zhang, MD, Jiexiong Liang, MD, and Lizhong Sun, MD Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Engineering Research Center for Vascular Prostheses, Beijing; Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing; and Departments of Gastroenterology and General Surgery, Anzhen Hospital, Capital Medical University, Beijing, China
A 39-year-old man with Stanford B aortic dissection was treated by thoracic endovascular aortic repair (TEVAR) and experienced an aortoesophageal fistula (AEF). After repeated TEVAR and esophageal stent implantation, the hematemesis did not cease although the whole thoracic descending aorta was covered by stents. A three-stage operation was performed, and an AEF 9 cm long was found during the operation. To our knowledge, this may be the largest AEF ever reported. The patient survived without adverse events. (Ann Thorac Surg 2016;102:e503–5) Ó 2016 by The Society of Thoracic Surgeons
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horacic endovascular aortic repair (TEVAR) is the treatment of choice for patients with Stanford type B aortic dissection. However, with the increasing numbers of type B aortic dissection patients who undergo TEVAR, certain unpredicted adverse events may occur, such as aortoesophageal fistula (AEF), which is a rare but fatal adverse event after TEVAR [1]. Here we report the successful treatment of a patient with a large AEF after TEVAR and an esophageal stent repair. In November 2014, a 39-year-old man was accepted in our institution. Before this, the patient had been treated in several other hospitals for nearly 3 months. His previous treatment was as follows: on July 29, 2014, the patient received a diagnosis of chronic Stanford type B aortic dissection. He underwent the first TEVAR on August 1, 2014, because of an enlarged aorta (Fig 1A) and recurrent back pain. Three days after the procedure, the patient experienced fever, with a highest body temperature of 38.5 C. His leukocyte count and inflammatory factors were considerably elevated. Although intravenous Accepted for publication March 17, 2016. Address correspondence to Dr Zhu, 2 Anzhen Rd, Ward 5A, Chaoyang District, Beijing, China 100029; email:
[email protected].
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
broad-spectrum antibiotics were administered, the therapeutic effect was poor. One month later, he experienced hematemesis once, and the volume was 200 mL. An AEF was diagnosed by computed tomography (CT) (Fig 1B) and gastroscopy. A TEVAR with the chimney technique was performed. The left subclavian artery, left vertebral artery, distal aortic arch, and entire descending thoracic aorta to the level above the celiac artery were covered by stent grafts, but the hematemesis did not cease. An esophageal stent was implanted to exclude the esophageal fistula. Unfortunately, the esophageal stent slid into the patient’s stomach 3 hours after the procedure (Fig 1C). Two weeks before he was accepted by our institution, the patient experienced massive hematemesis and hypovolemic shock. After emergency resuscitation, the patient’s vital signs were restored, and he was weaned from mechanical respiratory support. A three-stage surgical plan was made. A series of extraanatomic bypass procedures was performed at the first stage. A 22-mm tetrafurcated Dacron graft (Hemashield, Boston Scientific, Natick, MA) was applied to graft the ascending aorta to the innominate artery, left common carotid artery, left subclavian artery, and abdominal aortic bypass through a combined median thoracoabdominal incision (Fig 1D). After all these bypass procedures, the proximal aortic arch (between the innominate artery and left common carotid artery) was disconnected. The stumps of both sides of the aortic arch were closed by continuous suturing. After the thoracic incision was closed, a gastrostomy and jejunostomy were performed to provide enteral nutrition. During the gastrostomy procedure, we found that the esophageal stent was in the cecum (Fig 2A). An appendectomy was performed, and the esophageal stent was removed. The second-stage procedure was performed 3 weeks later. The descending thoracic aorta with the infected TEVAR stent and the ruptured esophagus were resected through the left thoracotomy (Figs 2B, 2C). During the operation, we found a huge esophageal defect 9 cm long (Figs 2B, 2C). A cervical esophagostomy was performed concomitantly. The patient survived and did not experience hematemesis or show signs of infection. The patient received oral antibiotic agents for 2 months after the first two staged surgical procedures. Six months later, he underwent the final operation: a colonic interposition for an esophageal procedure. During follow-up, the patient survived without any adverse events.
Comment Aortoesophageal fistula is a rare cause of upper gastrointestinal bleeding. The incidence of AEF varies from 0.4% to 4% [2]. Conservative therapy for AEF is highly not recommended [1]. Recently, some authors have reported using TEVAR as a solution for AEF [3]. According to our experience, and recently reported results [3, 4], TEVAR can be used as a bridge in emergency 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.03.055
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CASE REPORT CHENG ET AL AORTOESOPHAGEAL FISTULA
Fig 1. Computed tomographic (CT) views of different stages. (A) Enlargement of aorta before first thoracic endovascular aortic repair. (B) Contrast-enhanced CT scan showing aortoesophageal fistula with air bubbles around the stent (arrow). (C) Esophageal stent in stomach (arrow). (D) During follow-up.
Fig 2. Staged operation. (A) Esophageal stent found in cecum (arrow). (B) Length of aortoesophageal fistula and removed thoracic endovascular aortic repair stent. (C) Esophageal fistula (arrow).
Ann Thorac Surg 2016;102:e503–5
Ann Thorac Surg 2016;102:e503–5
situations. It can exclude the ruptured aorta from the esophagus and prevent massive bleeding for a short time, but a subsequent operation should be considered as soon as possible. Otherwise, infection of the mediastinum cannot be eliminated by the administration of antibiotics, nor must an artificial graft be exposed to the contaminated area. In this patient, although the whole descending thoracic aorta was covered by TEVAR stents, hematemesis did not cease. In this case, the TEVAR stent may have played a role in the progress of esophageal erosion. Although the mortality is high, an open surgical procedure is still considered the radical treatment for AEF [3, 5]. Many approaches have been used in the surgical treatment of AEF after TEVAR. Basically, two major surgical approaches have been used: the in situ procedure and the bypass procedure [6]. For patients with a small fistula and controlled systemic infection, in situ operation is a good choice. The advantage of the in situ surgical procedure is repair of both the esophagus and the aorta in a one-stage operation, but it often needs a special artificial graft [7] or an adjunctive surgical approach such as an omental packing procedure. Otherwise, the risk of recurrent graft infection will increase. Especially with such a huge defect, like that in our patient, the in situ operation is more risky. Successful treatment can be obtained by choosing a bypass operation and cervical esophagostomy. A 9-cm esophageal defect brought about a massive mediastinum infection, and it also made a one-stage esophageal reconstruction more risky. The cervical esophagostomy and total removal of the infected aorta and the stents
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thoroughly disinfected the seriously contaminated mediastinum. The aortic bypass operation also reduced the possibility of recurrent infectious adverse events.
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