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Ann Thorac Surg 2002;74:247-249
© 2002 The Society of Thoracic Surgeons

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Case report

Endovascular treatment of thoracic aortic fistulas

^a Department of Cardiovascular Surgery A and B, Rangueil Hospital, Toulouse, France
^b Department of Radiology, Rangueil Hospital, Toulouse, France

Accepted for publication January 21, 2002.

* Address reprint requests to Pr Fournial, Service de Chirurgie Cardio-Vasculaire B, CHU Rangueil, 1 av J Poulhes, 31403 Toulouse, Cedex 4, France
e-mail: fournial.g{at}chu-toulouse.fr

	Abstract

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Aortoesophageal and aortobronchial fistulas constitute a problem in therapy because of the high rates of morbidity and mortality associated with operation. From May 1996 to March 2000, we treated by an endovascular procedure one aortoesophageal and three aortobronchial fistulas. There was no postoperative death. We noted one peripheral vascular complication that required a surgical procedure, one postoperative confusion, and one inflammatory syndrome. In one case, because of a persistent leakage after 21 months, we had to implant a second endovascular stent graft. A few weeks later the reopening of this patient’s esophageal fistula led to his death by mediastinitis 25 months after the first procedure. The few cases published seem to bear out the interest, observed in our 4 patients, of an endovascular approach to treat complex lesions such as fistulas of the thoracic aorta especially in emergency or palliative cases.

	Introduction

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Aortoesophageal (AEF) and aortobronchial (ABF) fistulas are rare but almost always fatal in absence of treatment, and incur problems of difficult operations associated with high morbidity and mortality rates. The introduction and rapid spread of endovascular stent grafts for the thoracic aorta has led several teams, including our, to use them in such cases.

	Case reports

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Patient 1
Mr C, 61 years of age, was operated on January 1979 by aortoaortic bypass for a coarctation discovered in adulthood. In December 1986, because of a symptomatic stenosis, his aortic valve was replaced by a Bjork stent. In May 1996, two episodes of medium hemoptysis disclosed a pseudoaneurysm of the inferior anastomosis of the aortoaortic bypass. After CT scan assessment, transesophageal ultrasound scan, and angiography, a Talent stent was implanted. The proximal part was fitted into the aortoaortic bypass and the inferior part into the descending thoracic aorta, thus completely excluding the pseudoaneurysm (Fig 1). Vascular complications required a right iliofemoral bypass and a left common femoral artery embolectomy. At 3 years follow-up, the patient was asymptomatic, and check-ups showed a good result without residual leakage.

View larger version (123K): [in this window] [in a new window]   Fig 1. Computed tomographic scan reconstruction obtained from patient 1. The stent graft is visible inside the aortoaortic bypass.

View larger version (179K): [in this window] [in a new window]   Fig 2. Arteriography obtained from patient 2. Transesophageal ultrasound scan check was performed during the endovascular procedure.

Patient 3
Mr L, 80 years old, had a history of two cerebral vascular events with motor sequels and of lower limb arteriopathy. On November 26, 1998, he had a spontaneous hematemesis under antivitamin K. Esophagogastroduodenal endoscopy revealed a 1-cm-diameter esophageal ulcer based on an extrinsic swelling. Thoracoabdominal CT scan revealed a 70-mm aneurysm of the mid descending thoracic aorta with a close contact to the esophagus. On January 12, a covered Talent stent graft was implanted by a right femoral approach. Postoperative examination showed slight surrounding leakage at the distal extremity of the stent. Recovery was without complication. No recurrence of digestive hematemesis was observed. Follow-up showed no significant change of this leak. The CT scan after 21 months revealed both an active leak and an increase in the aneurysm diameter (Fig 3). On October 18, 2000, we implanted a second endovascular stent graft blocking this leak. The CT scan, 1 month later, showed no more leak and some decrease in the aneurysm diameter. In December, on a new CT scan, some air could be seen, suggesting the reopening of the esophageal fistula. The patient’s condition deteriorated as a mediastinitis appeared. No other procedure was indicated, and this patient died February 2001, 25 months after the first procedure.

View larger version (123K): [in this window] [in a new window]   Fig 3. Computed tomographic scan obtained from patient 3. The leakage is visible surrounding the stent graft.

View larger version (91K): [in this window] [in a new window]   Fig 4. Arteriography obtained from patient 4. Exclusion of the aneurysm by the stent graft is shown.

	Comment

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These drawbacks and the good medium-term results of endovascular treatment for thoracic aorta lesions [1, 3, 4] have led several teams to adopt endovascular treatment of AEFs and ABFs. Karmy-Jones and associates [5] reported an ABF that developed on an anastomotic pseudoaneurysm in an 83-year-old woman. She was treated in emergency, after intensive care and stabilization, by means of a stent constructed by the team. Campagna and coworkers [6] reported an ABF after two operations on the descending thoracic aorta, treated by a stent graft.

Endovascular procedures may entail complications. Leaks are quite frequent, but most of them only require regular checks. Sometimes (increase in diameter of the aneurysm) they need a correction, and an endovascular procedure may be used, as in our third case. We also had one vascular complication requiring operation, one inflammatory syndrome, and one case of neuropsychic disturbance, which were both transitory. One case of a lethal complication was reported by VonFricken and colleagues [7]: an endovascular stent graft implanted to treat an anastomotic aneurysm of the descending aorta underwent a migration associated with an aortobronchial fistula. The emergency surgical treatment had a fatal outcome. The fact that the stent is in direct contact with a septic environment makes infection a real possibility, as reported with an abdominal stent graft [8] and in our lethal complication of the third patient.

Endovascular treatment of AEF and ABF seems much less invasive in these patients with high risk for operation. Moreover, the follow-up duration is comparable to that reported in surgical cases, and the medium-term results appear as good, if not better. We think that in palliative treatment of fistulas on tracheal or esophageal cancers, stent graft should be preferred to classic surgical treatment. The remaining problem is to have enough stents available for emergency grafting, when they could be the most useful to stop often fatal hemorrhaging as quickly and safely as possible.

Considering our cases of AEF and ABF and those of the literature, stent grafting appears promising, especially under certain conditions such as emergency and palliative treatment. Nevertheless, it would be desirable for other cases to be reported, including failures and complications, to provide firmer foundations to establish this practice.

	References

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1. Fournial G., Rousseau H., Concina P., et al. Traitement endovasculaire des anévrismes de l’aorte thoracique. Editions Scientifiques et Médicales Elsevier SAS. Encycl Med Chir, Techniques chirurgicales—Chirurgie vasculaire. 2000:1-7.
2. Da Silva E.S., Tozzi F.L., Otochi J.P., et al. Aortoesophageal fistula caused by aneurysm of the thoracic aorta: successful surgical treatment, case report and literature review. J Vasc Surg 1999;30:1150-1157.[Medline]
3. Dake M.D., Miller D.C., Semba C.P., Mitchell R.S., Walker P.J., Liddell R.P. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aorta aneurysms. N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
4. Rousseau H., Soula P., Perreault P., et al. Delayed treatment of traumatic rupture of the thoracic aorta with endoluminal covered stent. Circulation 1999;99:498-504.[Abstract/Free Full Text]
5. Karmy-Jones R., Lee C.A., Nicholls S.C., Hoffer E. Management of aortobronchial fistula with an aortic stent-graft. Chest 1999;116:255-257.[Abstract/Free Full Text]
6. Campagna A.C., Wehner J.H., Kirsch C.M., et al. Endovascular stenting of an aortopulmonary fistula presenting with hemoptysis: a case report. J Cardiovasc Surg 1996;37:643-646.[Medline]
7. VonFricken K., Karamanoukian H.L., Ricci M., Taheri A., Bergsland J., Salerno T.A. Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta. Ann Thorac Surg 2000;70:1407-1409.[Abstract/Free Full Text]
8. Chuter T.A., Lukaszewicz G.C., Reilly L.M., et al. Endovascular repair of a presumed aortoenteric fistula: late failure due to recurrent infection. J Endovasc Ther 2000;7:240-244.[Medline]

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