The patient was a 43-year-old man with a history of hypertension and
a Stanford type B dissecting aortic aneurysm, which had been managed 9 years
previously with an aortoplasty. He was admitted to hospital after 3 weeks of
dysphagia for solid food and intermittent substernal discomfort. He had massive
bloody vomiting and syncope. An emergent computed tomography (CT) scan showed
dilatation of the medio-inferior saccular outpouching at the posterior aortic
arch. An aortoesophageal fistula (AEF) was diagnosed and an endovascular stent
was placed. An urgent upper gastrointestinal endoscopy revealed fresh blood and
necrotic tissue at about 30 cm from the incisors. A
Sengstaken–Blakemore tube was immediately inserted and the bleeding
stopped.
A CT scan performed after deployment of the aortic stent-graft
showed ongoing extravasation from the thoracic aneurysm ([Fig. 1]). We chose to use further palliative
treatment with a 10-cm covered self-expandable esophageal metal stent being
placed to cover the fistula. He underwent a chest CT scan with reconstruction
11 days later, which showed good positions for both the aortic and esophageal
stents ([Fig. 2]).
The esophageal stent was removed after an esophagogram showed no
evidence of leakage. Upper gastrointestinal endoscopy later identified a hole
with some granulation tissue ([Fig. 3]) and a
hemoclip was used to close the fistula. Follow-up with an upper
gastrointestinal endoscopy later demonstrated healing of the defect ([Fig. 4]).
Fig. 1 Computed tomography (CT)
scan after insertion of an aortic endovascular stent-graft, demonstrating
extravasation from the thoracic aneurysm.
Fig. 2 Computed tomography (CT)
scan with reconstruction showing concomitant use of aortic and esophageal
stents.
Fig. 3 Upper gastrointestinal
endoscopy showing an esophageal defect and granulation tissue 30 cm
distal to the incisors.
Fig. 4 Upper gastrointestinal
endoscopy showing healing of the esophageal defect 20 days after the endoscopic
repair.
AEF is an uncommon disorder that carries a high rate of morbidity
and mortality. Thoracic aortic aneurysms account for more than
50 % of the cases [1]. In 1914, Chiari
described a triad of symptoms that included mid-thoracic pain, sentinel upper
gastrointestinal hemorrhage, and exsanguination after a brief period
[2], all of which were experienced by our patient. Upper
gastrointestinal endoscopy may reveal a mass in the esophageal wall and copious
amounts of coagulated and fresh blood.
Early diagnosis and accurate localization of the lesions contribute
to a better prognosis. Without prompt treatment, this condition is always fatal
because of hemorrhage or septic complications. Despite several choices of
treatment, little consensus exists on the optimal intervention. Immediate
insertion of a Sengstaken–Blakemore tube for exsanguination offers the
chance for further treatment. In patients who are high risk for open surgical
repair, deployment of an endovascular stent-graft can serve as a palliative or
temporary treatment [3]. Recovery of the esophagus may be
difficult in AEF. The use of esophageal stenting as a tool for bridging to
surgery has also been reported [4]
[5]. In this case, the AEF was treated successfully with an
endovascular stent-graft followed by an esophageal stent and hemoclip. No
similar cases have been previously reported. Further use of these techniques in
the future may validate this result.
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