Thoracic Endovascular Repair as a Lifesaving Bridge to Definitive Repair in a Recurrent Aorto-Esophageal Fistula: A Case Report

We present a case of a 57-year-old male who presented with an acute onset of massive hematemesis and hypovolemic shock evidenced by a blood pressure of 90/60, heart rate of 128, hemoglobin of 63 g/dl, and metabolic acidosis with a pH of 6. He was otherwise well prior, except that he had a transhiatal esophagectomy and gastric pull-up for an adenocarcinoma for lower esophagus 15 years prior. He was fluid resuscitated and brought to the endoscopy suite to have an esophago-gastro-duodenoscopy (OGD) which revealed blood in the stomach (the neo-esophagus). The patient had a cardiac arrest before finding the source of the bleeding; hence, the OGD was aborted and cardiopulmonary resuscitation (CPR) commenced. He responded to one cycle of CPR and was intubated and fluid resuscitated. When hemodynamically stable, a computed tomography aortography (CTA) was performed, which demonstrated an aorto-esophageal fistula (AEF) and no other aortic abnormality. A rapid decision was made to proceed with a thoracic endovascular repair of the aorta (TEVAR) limited to that segment of aorta. The procedure was successful. He had a follow-up OGD weeks later which was normal. Four months later, he represented to hospital with hypovolemic shock secondary to massive hematemesis. Again, a diagnosis of AEF was confirmed on CTA, which was just proximal to the previous aortic stent graft. He again had emergency TEVAR covering the descending aorta from the level just below the left subclavian artery to just proximal to the celiac artery, which was again lifesaving and uncomplicated. Three months later, a repeat OGD revealed a large gastric ulcer with a visible segment of aortic stent graft in the base. At this time, he reported no symptoms and had a normal full blood count. He was then referred urgently to have definitive upper gastrointestinal and descending aorta repair. He underwent a thoracotomy, left heart bypass, repair of aorto-gastric fistula with primary stomach repair, and thoracic and abdominal aorta replacement with a Dacron graft. He made good recovery. His stent graft culture grew Candida albicans and vancomycin-resistant enterococcus.

Publication History

Article published online:
26 April 2021