CASE REPORT: STAGED REPAIR OF PRIMARY AORTO-ESOPHAGEAL FISTULA

Objectives:

Background:
Primary aortoenteric fistulas (pAEF) are rare with an incidence reported up to 0.07% at autopsy. Literature review yields few reported cases, and rarer still are pAEFs in the thoracic aorta since 83% of cases are associated with AAAs. Patients with AEFs classically present with a triad of chest pain and dysphasia, a herald GI bleed, then exsanguination. Without treatment, AEFs are universally fatal, and with treatment, mortality is 50%. The complex pathology of pAEFs make repair more challenging, given an infected field, friable tissue, and patients who are often hemodynamically unstable. Staged repair using endografts as initial treatment for stabilization has been reported. We present a case where descending thoracic aorta to esophageal fistula was repaired such strategy was utilized successfully.

Methods:

Case Description:
A 74-year-old male presented to the ER after a fall complaining of chest pain and dysphagia. Workup revealed a penetrating descending thoracic aortic ulcer with a soft tissue density between aorta and esophagus. Patient underwent urgent placement of TEVAR stent graft. An EGD was later performed showing an ulcer in the distal esophagus. Endoscopic ultrasound showed no esophageal mass. Post-operative course was complicated by acute cholecystitis and a pulmonary embolism for which he underwent laparoscopic cholecystectomy and was placed on anticoagulation. Three months later, patient presented with a herald bleed in the form of hematemesis. Workup revealed degeneration of the distal thoracic aorta with pseudoaneurysm. He underwent urgent extension of TEVAR with exclusion of pseudoaneurysm. Patient was placed on broad spectrum antibiotics and antifungals, and a multidisciplinary team was assembled for second stage repair. After 10 days, open repair was performed through thoracoabdominal incision. Proximal control of aorta was achieved at T4 and distal control was proximal to the celiac artery. Patient was placed on left heart bypass. Aortotomy was performed, and upon explant of the stent grafts, the esophageal fistula was noted to emit bile. Infected tissue was debrided and rifampin soaked 24mm Dacron graft was used to reconstruct the aorta. Esophagus was repaired primarily from within aortic sac and with an omental pedicle flap buttress. A gastrojejunostomy tube was placed for enteral nutrition. Patient was discharged to rehab 22 days post-operatively.

Results:

Conclusion: Staged repair of pAEFs utilizing endovascular approach then definitive open repair can be successfully performed by a multidisciplinary team. Our patient underwent TEVAR for descending aorta to esophageal fistula followed by open thoracoabdominal aortic repair and primary esophageal repair with omental flap.