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DOI: 10.1055/s-0030-1256167
© Georg Thieme Verlag KG Stuttgart · New York
Successful management of aortoesophageal fistula by combining endoscopic cyanoacrylate injection and endovascular stent grafting
J. W.-H. TanMD
Department of Cardiovascular Surgery
Buddhist Dalin Tzu
Chi General Hospital
No. 2, Min-Sheng Road
Dalin
Town
Chia-Yi
Taiwan, 622
Fax: +886-5-2648006
Email: neugine@gmail.com
Publication History
Publication Date:
18 March 2011 (online)
Aortoesophageal fistula (AEF) is a rare cause of catastrophic gastrointestinal bleeding. Thoracic aortic aneurysms are the leading cause of AEF [1]. Early diagnosis and prompt endovascular and/or surgical intervention before massive exsanguinating hemorrhage are key to survival [2]. Temporary endoscopic management with esophageal stent placement has been reported as a bridge therapy [3] [4]. We describe a case of AEF with active bleeding noted during an endoscopic examination that was treated with injection of N-butyl-2-cyanoacrylate (NBCA, Histoacryl), followed by successful placement of an endovascular aortic stent graft.
A 69-year-old man with a history of ruptured diverticula that had been managed surgically presented to the emergency department with a 1-day history of chest pain and tarry stool, with hematemesis and hematochezia on the morning of admission. His heart rate was 95 beats/min and his blood pressure was 214/111 mmHg. Laboratory data showed a rapid decline in hemoglobin (13.1 g/dL to 10.2 g/dL in 3 hours). Emergent esophagogastroduodenoscopy (EGD) revealed a 3-cm submucosal mass lesion with a spurting vessel 26 cm from the incisors ([Fig. 1 a]).
Two milliliters of NBCA mixed with lipiodol was injected locally, achieving temporary hemostasis. Contrast-enhanced computed tomography of the chest disclosed a descending thoracic aortic aneurysm with a 5-mm AEF ([Fig. 2]).
Aorta angiography revealed a 5-mm aneurysm without active extravasation in the mid thoracic aorta ([Fig. 3 a]).
The thoracic aortic aneurysm was repaired with a Cook Zenith II (34 mm × 77 mm) stent graft without complications ([Fig. 3 b]). EGD after stent grafting the same day showed a submucosal mass measuring 3 cm × 1.8 cm with an erosive lesion and NBCA coating ([Fig. 1 b]). After stent grafting, the patient suffered from intermittent episodes of chest and back pain. Intravenous broad-spectrum antibiotics were administered for a total of 8 weeks, followed by oral antibiotics. The patient recovered and remained healthy at 8 months follow-up.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AG
Competing interests: None
#References
- 1 Léobon B, Roux D, Mugniot A et al. Endovascular treatment of thoracic aortic fistulas. Ann Thorac Surg. 2002; 74 247-249
- 2 Topel I, Stehr A, Steinbauer M G et al. Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts. Ann Surg. 2007; 246 853-859
- 3 Park D H, Park J H, Lee S H et al. Temporary placement of a covered metal stent for the management of a bleeding aortoesophageal fistula. Endoscopy. 2007; 39 (Suppl 1) E61-E62
- 4 Zuber-Jerger I, Hempel U, Rockmann F et al. Temporary stent placement in 2 cases of aortoesophageal fistula. Gastrointest Endosc. 2008; 68 599-602
J. W.-H. TanMD
Department of Cardiovascular Surgery
Buddhist Dalin Tzu
Chi General Hospital
No. 2, Min-Sheng Road
Dalin
Town
Chia-Yi
Taiwan, 622
Fax: +886-5-2648006
Email: neugine@gmail.com
References
- 1 Léobon B, Roux D, Mugniot A et al. Endovascular treatment of thoracic aortic fistulas. Ann Thorac Surg. 2002; 74 247-249
- 2 Topel I, Stehr A, Steinbauer M G et al. Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts. Ann Surg. 2007; 246 853-859
- 3 Park D H, Park J H, Lee S H et al. Temporary placement of a covered metal stent for the management of a bleeding aortoesophageal fistula. Endoscopy. 2007; 39 (Suppl 1) E61-E62
- 4 Zuber-Jerger I, Hempel U, Rockmann F et al. Temporary stent placement in 2 cases of aortoesophageal fistula. Gastrointest Endosc. 2008; 68 599-602
J. W.-H. TanMD
Department of Cardiovascular Surgery
Buddhist Dalin Tzu
Chi General Hospital
No. 2, Min-Sheng Road
Dalin
Town
Chia-Yi
Taiwan, 622
Fax: +886-5-2648006
Email: neugine@gmail.com