Aortoesophageal fistula after thoracic aortic stent-graft placement: a rare but catastrophic complication of a novel emerging technique

Abstract

Objectives: Our goal was to report characteristics and outcomes of 6 patients with aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR).

Background: Neurologic events are severe complications of TEVAR. With growing experience of TEVAR, other yet unexpected devastating complications have emerged.

Methods: Between July 1999 and August 2008, 268 patients underwent TEVAR for various thoracic aortic diseases at our institution.

Results: Six of 268 patients (age 49 to 77 years, 50% female patients) developed AEF (incidence 1.9%) within 1 to 16 months after the procedure. Indications for TEVAR were acute aortic dissection (n = 3), chronic aortic dissection (n = 1), and thoracic aortic aneurysm (n = 2). Four patients presented with sudden massive hematemesis whereas 2 patients were readmitted for new-onset fever and elevated markers of inflammation that preceded hematemesis. Esophago-gastro-duodenoscopy identified deep esophageal ulcerations at the level of the implanted aortic stent-graft in 4 patients, but only mild erosive lesions within the proximal esophagus without signs of active bleeding in the remaining 2 patients. Surgical repair was performed in only 1 patient and declined in the remaining because of comorbidities and multiorgan system failure. Despite this, all patients died due to fatal rebleeding (n = 4) or mediastinitis (n = 2).

Conclusions: AEF is a rare and unusual complication of TEVAR that occurs relatively early after the procedure and is almost invariably fatal. New-onset fever with elevated inflammatory markers or hematemesis should heighten clinical suspicion of AEF in TEVAR patients and prompt computed tomography or esophago-gastro-duodenoscopy in the hope of detecting, triaging, and treating this early to improve the otherwise dismal outcomes of these patients.