CR5. When TEVAR Is Not Enough: Hybrid Repair of Aorto-Esophageal Fistula. A Case Report

Aorto-esophageal fistula (AEF) is a rare but fatal condition. We describe the management of a patient who developed AEF following esophagectomy for esophageal adenocarcinoma, requiring a hybrid endovascular and surgical strategy.Case Report:A 43-year-old man underwent esophagectomy with the Ivor Lewis technique for distal esophageal adenocarcinoma. The postoperative course was complicated by the development of an esophago-bronchial fistula (EBF) and an AEF, resulting in hemorrhagic shock. The EBF was managed with multiple esophageal stent placements. Emergency TEVAR was performed for the AEF, achieving rapid hemodynamic stabilization. After five months, the patient presented with recurrent hemoptysis: computed tomography angiography (CTA) revealed a 7-mm aortic pseudoaneurysm just above the proximal margin of the endograft. An endovascular extension was performed using two additional TEVAR modules, with coverage of the left subclavian artery and stenting of the left common carotid artery. Recurrence of EBF required new esophageal stent placement. A PET scan revealed a hypermetabolic collection adjacent to the descending aorta, and surgical extraction of the esophageal prostheses was planned. CTA revealed further disease progression, characterized by increased aortic infiltration and the development of two additional pseudoaneurysms: a distal lesion proximal to the celiac trunk and a proximal lesion involving the aortic arch at the origin of the left carotid artery stent.After multidisciplinary discussion, a staged hybrid strategy was adopted. Initial TEVAR excluded the distal pseudoaneurysm, followed by eradication of the infectious source with esophagectomy and removal of the gastric conduit via right thoracotomy and cervical esophageal diversion. Three days later, definitive aortic repair was performed with aortic arch replacement using the frozen elephant trunk technique (FET). The aortic arch tissue in zone 2 was found to be severely friable, and the distal anastomosis was made directly onto the previously implanted TEVAR. An E-vita Open Neo 28 prosthesis was placed, and the distal anastomosis was completed. Inspection of the supra-aortic vessels revealed protrusion of the previously implanted carotid stent into the aortic arch, which was easily resected.The carotid wall was extremely friable and could not be safely mobilized; therefore, the anastomosis between the carotid artery and an 8-mm Dacron graft was protected by placement of a covered stent.Intraoperative cultures grew Escherichia coli and Mycoplasma salivarium. Follow-up CTA confirmed complete pseudoaneurysm exclusion and adequate surgical reconstruction.The patient was discharged from intensive care after 11 days and transferred to the referring hospital.Discussion and Conclusion:AEF following esophagectomy is a rare but highly lethal condition. TEVAR is essential for emergency stabilization but may be insufficient in the presence of infection, leading to progressive aortic wall destruction. In this case, TEVAR achieved acute stabilization but failed to prevent disease progression.Hybrid strategies combining endovascular and open repair provided definitive treatment. FET technique allowed complete exclusion of affected aortic segments.Management of complicated AEF requires a staged, multidisciplinary approach, appropriate timing of each step, and intraoperative flexibility.Hybrid strategies should be considered complementary rather than a failure of endovascular therapy.

Authors
Valeria Santamaria (1), Khaoula Nasser (2), Marco Vola (3), daniel Grinberg (4)
Institutions
(1) Hopital cardiologique Louis Pradel, Lyon, NA, (2) Hôpital Cardiologique Louis Pradel, Lyon, NA, (3) N/A, Saint Etienne, France, (4) Hopital cardiologique Louis Pradel, Lyon, NY

Adult Cardiac