We describe the case of a 75-year-old man who had undergone total laryngectomy with neck dissection and major pectoralis flap for recurrent squamous cell carcinoma after chemoradiation treatment. Post-operatively he developed a recurrent pharyngocutaneous fistula, managed with placement of a partially covered self-expandable metal stent (SEMS) (23 × 105-mm Wallflex; Boston Scientific Inc., Marlborough, Massachusetts, USA). The patient missed a scheduled follow-up for stent retrieval.
After several months he was admitted to our emergency department for hematemesis and severe anemia. Following hemodynamic resuscitation, an upper gastrointestinal (GI) endoscopy was performed. A spurting bleed at the distal end of the esophageal stent was observed ([Fig. 1], [Video 1]). First the stent was removed to expose the source of the bleed, followed by injection of 5 ml of cyanoacrylate glue (Glubran; GEM srl, Viareggio, Italy). Because of persistent active bleeding, a fully covered SEMS (24 × 180-mm Niti-S Beta; TaeWoong Medical, Gyeonggi-do, South Korea) was placed. After few seconds, abrupt bleeding recurred with rupture of the silicone covering of the stent ([Fig. 2]). Further injection of 3 ml of cyanoacrylate glue was repeated into the mesh, thereby controlling the bleeding almost completely ([Fig. 3]). An urgent CT angiography revealed an aortoesophageal fistula originating from an anomalous right-sided aortic arch. The cyanoacrylate tamponade effect on the fistula was sufficient to stabilize the patient and, after emergent multidisciplinary consultation, an endovascular bailout was planned.
Fig. 1 Spurting bleeding vessel at the distal end of the esophageal stent.
Video 1 Treatment of an aortoesophageal fistula with cyanoacrylate glue injection and placement of esophageal stent followed by aortic stent graft.
Qualität:
Fig. 2 Abrupt bleeding recurrence with rupture of the silicone covering of the stent.
Fig. 3 Nearly complete bleeding control after cyanoacrylate injection into the mesh.
The patient was referred to our cath lab where he immediately received a percutaneous aortic stent graft to stop the leak ([Fig. 4]). Of note, the aberrant origin of the supraortic trunks allowed for a successful arch covering without brain ischemic sequelae. The patient recovered uneventfully, and no further bleeding occurred. The esophageal SEMS was removed 1 month later and there was no evidence of a mucosal defect ([Fig. 5]).
Fig. 4 Fluoroscopic control after placement of the aortic stent graft.
Fig. 5 Esophageal mucosa after stent removal.
An aortoesophageal fistula has been reported as a dramatic adverse event of aortic disease, thoracic aortic surgery, foreign body ingestion, esophageal stent placement and esophageal malignancy with a high mortality rate [1]. To date there is no standardized treatment for this condition [2]
[3]. Furthermore, the role of cyanoacrylate glue as a rescue hemostatic tool to control active bleeding is well established [4]
[5]. This case describes the possible challenges in treating an aortoesophageal fistula with injection of cyanoacrylate glue and stent placement as a part of a multidisciplinary approach.
Endoscopy_UCTN_Code_CPL_1AH_2AD
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