Ann Thorac Surg 1996;62:1852-1854
© 1996 The Society of Thoracic Surgeons
Case Report
Successful Management of Secondary Aortoesophageal Fistula
James D. Luketich, MD,
K. Eric Sommers, MD,
Bartley P. Griffith, MD,
Arthur Boujoukos, MD,
Rodney J. Landreneau, MD,
Peter F. Ferson, MD,
Robert J. Keenan, MD
Presbyterian and Montefiore Hospitals of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Accepted for publication June 18, 1996.
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Abstract
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Aortoesophageal fistula is a rare complication after thoracic aortic aneurysm repair. Six previously reported cases of aortoesophageal fistula management have been uniformly fatal. We present our successful management and review the literature on this topic.
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Introduction
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Aortoesophageal fistula (AEF) is a rare and lethal complication. Primary AEF is usually caused by fistulization of an expanding atherosclerotic aneurysm into the esophagus or, less commonly, erosion of a reflux-associated esophageal ulcer into the aorta [1]. Secondary AEF occurs after previous grafting of the descending aorta and represents a communication between the aorta and the esophagus, usually at one of the suture lines. A review of the literature shows that repair of primary AEF has been successfully performed, although 6 cases of repair of secondary AEF had fatal outcomes [2]. We report a case of secondary AEF successfully managed by esophageal resection, bipolar exclusion, and in situ polytetrafluoroethylene graft aortic reconstruction followed by delayed esophageal reconstruction using a substernal gastric bypass.
A 67-year-old woman was emergently transported to our facility. She had previously undergone repair of a traumatic transection of the descending aorta with a collagen-impregnated Dacron interposition graft 4 years before admission. The patient had been vacationing in the Galapagos Islands and was transferred to Ecuador after presenting to a local hospital with massive hematemesis. An esophagoduodenoscopy was performed, and a diagnosis of aortoesophageal fistula was made by direct visualization of an arterial bleed into the esophagus. Thoracotomy and over-sewing of the aortoesophageal fistula was performed in Ecuador with initial control of bleeding. While recovering from this procedure the patient experienced recurrent hematemesis and was transferred by jet to our facility.
Upon presentation the patient was intubated but awake, alert, and hemodynamically stable. Cannulation of the left femoral vessels was performed in preparation for bypass. Spinal evoked potentials were measured to evaluate spinal ischemia during aortic cross-clamping. Flexible bronchoscopy was normal. Esophagoscopy was not repeated due to the concern over precipitating a hemorrhagic diathesis. An exploratory thoracotomy was performed through the previous left fifth intercostal incision. Dissection of dense adhesions was required to mobilize the lung, esophagus, and aorta. Proximal and distal dissection were performed to assure control of the aorta. The previously placed graft and the area of the fistula was partially dissected and revealed numerous Prolene (Ethicon, Somerville, NJ) sutures placed during the previous attempt at fistula closure. The graft itself was well incorporated, and there was no evidence of suppuration or gross infection. After mobilization and transection of the distal esophagus, femoral bypass was instituted and the aorta was clamped just proximal to the left subclavian artery and distal to the Dacron graft, which was excised. The proximal esophagus was divided and esophagectomy was performed. The aortic suture lines and esophageal bed were debrided and irrigated with antibiotic solution using a pulse irrigator. A polytetrafluoroethylene interposition graft was sutured in place and hemostasis obtained. The graft was wrapped in a pedicled pleural flap. Bypass was discontinued uneventfully. An end cervical esophagostomy was performed. Pathological examination confirmed the presence of an aortoesophageal fistula between the distal suture line of the Dacron graft and the thoracic esophagus. Her postoperative course was uneventful, with full neurologic function intact. A 4-week course of vancomycin was given for coagulase-negative Staphylococcus cultured from the removed graft. Torulopsis glabrata was cultured from the graft and treated for 6 months with fluconazole. She was discharged to a rehabilitation center on postoperative day 28.
Two months later the patient was readmitted and underwent a substernal gastric bypass for the reestablishment of gastrointestinal tract continuity. This operation was complicated by the development of a deep vein thrombosis that was treated successfully with anticoagulation. The patient is presently home, eating a regular diet, now 13 months out from her initial presentation with AEF.
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Comment
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The treatment of secondary AEF is not standardized. Six previously reported cases have all been fatal (Table 1
) [3–8]. Here we report a survivor of an aortoesophageal fistula occurring as a late complication of a thoracic aortic graft. Esophageal resection and removal of the infected graft were performed at the first stage of a two-stage approach. Removal of the esophagus precluded the possibility of recurrence or continued soilage from the gastrointestinal tract. The infected graft was replaced with an in situ polytetrafluoroethylene graft. A pleural flap was used to cover the graft. Omission of esophageal resection may have contributed to the fatal outcome in previous cases.
Mounting evidence from the analogous situation of aortoduodenal fistulas suggests that an in-situ approach may be preferable for certain patients with late infections of thoracic aortic grafts [9]. A review of the literature by Crawford and associates [10] suggests that infection caused by susceptible organisms (usually coagulase-negative Staphylococcus) may be better treated by aggressive debridement, in-situ grafting, and coverage with a viable flap or tissue. Grafts infected with nonsusceptible organisms should be managed by resection and extraanatomic bypass [11].
In summary, we report the successful treatment of AEF occurring secondary to a thoracic aortic graft procedure. Important management principles included a two-stage approach. At the first stage, esophageal resection, debridement, and in situ regrafting with a polytetrafluoroethylene graft protected by a pleural flap was performed. After recovery and long-term culture-directed antibiotic therapy, a second staged procedure included a substernal gastric bypass. The patient is 13 months out from presentation of her aortoesophageal fistula, on a regular diet, and back to her usual active lifestyle. Because fistulas between the aorta and gastrointestinal tract have a tendency to late recurrence, long-term follow-up will be necessary to confirm this initial success.
The cause of this fistula may have been related to the close proximity of the aortic suture line to the esophagus. Interposing pleura or intercostal muscle flaps could presumably present this potentially fatal complication.
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Footnotes
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Address reprint requests to Dr Luketich, Section of Thoracic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Ave, Suite 300, Pittsburgh, PA 15213-3221.
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References
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- Dossa CD, Pipinos II, Shepard AD, Ernst CB. Primary aortoenteric fistula: Part II. Primary aortoesophageal fistula. Ann Vasc Surg 1994;8:208–11.
- Graham ANJ, McGuigan JA, Curry RC. Aortoesophageal fistula secondary to thoracic aortic aneurysm repair. J Cardiovasc Surg 1993;34:381–3.[Medline]
- Seymour EQ. Aortoesophageal fistula as a complication of aortic prosthetic graft. Am J Roentgenol 1978;131:160–1.[Medline]
- Smaha LA, Klima T, Leatherman LL. Aortoesophageal fistula. Late complication after repair of thoracic aortic aneurysm. JAMA 1978;240:2077–8.[Medline]
- Strug BS, Slatzman DA, Feldman MI, Sabbath AH. Aortoesophageal fistula. Cardiovasc Res Cent Bull 1979;18:34–8.[Medline]
- Kayo D, Calmer A. Computerized tomographic evaluation of aortic prosthetic graft complications. South Med J 1985;78:296–8.[Medline]
- Wareing TH, Merrily WE. Aortoesophageal fistula: unusual complication. South Med J 1989;82:1306–8.[Medline]
- Crowley RA, Turney SZ, Hankins JR, Rodriquez A, Attar S, Shankar BS. Rupture of the thoracic aorta caused by blunt trauma. A fifteen year experience. J Thorac Cardiovasc Surg 1990;100:652–61.[Abstract]
- Krupski WC. Infected vascular graft. In: Cameron JL, ed. Current surgical therapy. 5th ed. St. Louis: Mosby, 1995.
- Crawford ES, Reardon MJ, Williams TW. Surgical considerations of infection following operations involving the descending thoracic aorta. World J Surg 1980;4:669–77.[Medline]
- Hargrove WC, Edmunds LH. Management of infected thoracic aortic prosthetic grafts. Ann Thorac Surg 1984;37:72–7.[Abstract]
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Abstract
Introduction
