Endovascular aortic repair for aorto-esophageal fistula in a young man: have all loose ends been tied?

A 36-year-old man presented with a history of large-volume hematemesis. Clinical examination revealed severe pallor, hypotension, and feeble peripheral pulses. After initial resuscitation, an upper gastrointestinal (GI) endoscopy was performed, which revealed an ulcerated lesion at about 32 cm from the incisors ([Fig. 1]). An attempt was made to close the ulcer with endoclips but was unsuccessful ([Fig. 2]). Contrast-enhanced computed tomography (CT) revealed a large hematoma around the thoracic aorta, contrast outpouching, and expanding thrombus along the adjacent esophagus, suggesting the diagnosis of an aorto-esophageal fistula ([Fig. 3]). The aortic rent was closed using an 8 to 10-mm patent ductus arteriosus closure device, and a nasogastric tube was placed for feeding.

Fig. 1 Endoscopy image revealing an ulcer at about 32 cm in the esophagus.

Fig. 2 Endoscopic clip application at the site of esophageal ulcer.

Fig. 3 Computed tomography angiography shows a large hematoma around the thoracic aorta and contrast outpouching with expanding thrombus along the adjacent esophagus.

He was apparently asymptomatic for 39 days, after which he had a repeat bout of hematemesis. Evaluation revealed displacement of the closure device. At this juncture, thoracic endovascular aortic repair was performed and an aortic stent graft (VAMF, 26-26-150; Medtronic, Minneapolis, Minnesota, USA) was placed ([Fig. 4]). On subsequent follow-up, endoscopy revealed a fistulous opening, and the aortic stent graft could be visualized through the opening (video image). The option of surgery and placing a covered esophageal stent was discussed with the patient. However, he was unwilling to undergo the procedure, and therefore nasojejunal feedings were continued for 2 months to prevent infection of the stent graft and allow for healing of the fistula. Subsequent endoscopy revealed healing of the fistulous opening with granulation tissue at the site of the previous fistulous opening ([Fig. 5]).

Fig. 4 Chest X-ray revealing the position of the aortic stent graft.

Fig. 5 Near complete closure of the esophageal opening with granulation tissue at the site.

An idiopathic aorto-esophageal fistula is a rare cause of upper GI bleeding, especially in young men with no prior history of aortic surgery [1]. Early diagnosis and management are crucial owing to the high mortality associated with this condition [2]. In this video case, we presented the course of a young man diagnosed with an aorto-esophageal fistula ([Video 1]). In addition, we highlighted the importance of healing towards the esophageal site to prevent infection of the aortic stent graft.

Video 1 Endovascular aortic repair of aorto-esophageal fistula with aortic stent graft after displacement of original closure device.

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Publication History

Article published online:
03 November 2020

• References

• 1 Nabi Z, Asif S, Reddy DN. A rare cause of upper gastrointestinal bleed: bulge in lower esophagus is the clue. Gastroenterology 2020; 159: 50-52
• 2 Deijen CL, Smulders YM, Coveliers HME. et al. The importance of early diagnosis and treatment of patients with aortoenteric fistulas presenting with herald bleeds. Ann Vasc Surg 2016; 36: 28-34