Long-term Outcome After Staged Approach to Emergent Aortoesophageal Fistula Repair

6385 

Cardiothoracic Resident Case Report Competition 

Audrey Khoury (1), John Diehl (2), Jason Long (2), Michael Meyers (3), Federico Parodi (3), Gita Mody (4)

(1) N/A, N/A, (2) N/A, United States, (3) University of North Carolina at Chapel Hill, Chapel Hill, NC, (4) University of North Carolina, Chapel Hill, NC

Audrey Khoury    -  Contact Me
N/A

John Diehl    -  Contact Me
N/A

Jason Long    -  Contact Me
N/A

Michael Meyers    -  Contact Me
University of North Carolina at Chapel Hill

Federico Parodi    -  Contact Me
University of North Carolina at Chapel Hill

Gita Mody    -  Contact Me
University of North Carolina

Audrey Khoury    -  Contact Me
N/A

Aortoesophageal fistula (AEF) is a rare but life-threatening condition that often presents with Chiari's triad (mid-thoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval). Most AEFs are caused by an aneurysmal aorta and almost always heralded by gastrointestinal bleeding. In emergent cases, thoracic endovascular aortic repair (TEVAR) often serves as a temporizing measure and a bridge to surgery. Here, we report a case of staged AEF management in a 70-year-old patient with a history of hypertension, hyperlipidemia, type II diabetes, hypothyroidism, gastroesophageal reflux disease, chronic obstructive pulmonary disease and a 40 pack-year smoking history who presented with hematemesis and abdominal pain. Imaging showed a descending thoracic aortic aneurysm with concern for AEF. She was taken emergently to the operating room (OR) for aneurysm exclusion and esophageal exploration. The vascular surgery team performed a TEVAR with placement of a Cook Zenith Alpha ZTA-P 32-156 stent graft without coverage of the left subclavian artery. Intra-operatively, the patient had ST segment elevations that were concerning for myocardial infarction, and further surgical procedures to control the likely esophageal perforation were deferred. The following day, after clinical stabilization and cardiology clearance, she was taken back to the OR for exploration and source control. EGD demonstrated an ischemic, partially necrotic segment of the esophagus adjacent to the aortic aneurysm (approximately 24-26 cm from the incisors). Given endoscopic evidence of AEF, we proceeded with esophagectomy via right thoracotomy in order to resect the ischemic segment and divert enteric content from the aortic stent graft. During esophageal debridement, copious bleeding (approximately 1 liter) was noted from the necrotic wall of the aneurysm sac requiring en masse suture repair. The chest was closed, and she underwent cervical esophagostomy, exploratory laparotomy, gastrostomy and jejunostomy tube placement. To relieve left mainstem bronchus compression from the aneurysm sac, the interventional pulmonology team also placed a covered metal stent in the left mainstem bronchus. She was discharged to long-term acute care hospital on post-operative day (POD) 22. Four months later, she underwent retrosternal gastric conduit creation and was discharged home on POD 12. Given the emergent repair with a TEVAR and positive intraoperative cultures, the patient was continued on life-long suppressive antibiotics. Her diet was advanced in an outpatient setting. She is doing well 36 months after initial presentation.

AEF is a rare, life-threatening condition that can often be managed with a staged surgical approach. In this case, TEVAR was a successful temporizing measure prior to partial esophagectomy with cervical esophagostomy before gastric conduit creation four months later. Aortic graft replacement is pursued in certain patients and may contribute to slightly better long-term outcomes compared with TEVAR alone. Esophagectomy contributed to better overall prognosis for AEF compared with no esophageal intervention, esophageal repair, and esophageal stent. More work is needed to determine which patients should be offered aortic graft replacement following emergently placed TEVAR.

Thoracic