Ann Thorac Surg 2005;80:1117-1120
© 2005 The Society of Thoracic Surgeons
Case report
Successful Treatment of an Aortoesophageal Fistula After Emergency Endovascular Thoracic Aortic Stent-Graft Placement
Martin Czerny, MD
*
,
Daniel Zimpfer, MD,
Tatjana Fleck, MD,
Roman Gottardi, MS,
Manfred Cejna, MD,
Maria Schoder, MD,
Johannes Lammer, MD,
Ernst Wolner, MD,
Martin Grabenwoger, MD,
Michael-Rolf Mueller, MD
Departments of Cardiothoracic Surgery and Interventional Radiology, University of Vienna Medical School, Vienna, Austria
Accepted for publication February 18, 2004.
* Address reprint requests to Dr Czerny, Waehringer Guertel 18-20, Vi-enna, Austria A-1090 (Email: bypass{at}eunet.at).
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Abstract
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We report the case of a 57-year-old man who underwent emergency stent-graft placement in August 2003 due to a contained rupture of a distal descending aortic aneurysm. After 1 month the patient was readmitted with chest pain as well as swallowing disorders. A computed tomographic scan revealed a fistula between the distal esophagus and the excluded aneurysm sac. The patient was treated by an esophagectomy, a cervical esophagostomy, as well as a feeding gastrostomy. The infectious parietal thrombus was partially debrided and the aneurysm sac was filled with vancomycin. After 3 months continuity was reinstalled with a pedicled isoperistaltic transverse colonic conduit. The patient recovered uneventfully. At a 3 month follow-up, he showed no signs of infection. However, he is still being treated with antibiotic therapy of ciprofloxacin for a minimum of 1 year.
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Introduction
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Endovascular stent-graft placement has developed as a safe and effective treatment modality in various diseases of the distal aortic arch as well as the descending aorta [1–4]. In addition, endovascular stent-graft placement is an excellent treatment modality for the acute aortic accident, such as contained ruptures of descending aortic aneurysms [5]. However, its effectiveness may be limited by late complications [6, 7]]. Aortoesophageal fistulas (synchronously complicating ruptured descending thoracic aneurysms) are known to be a severe complication, which makes an already sophisticated conventional surgical procedure even more demanding [8]. Options include the choice of graft material, effective debridement, and esophageal repair [8].
In August 2003, a 57-year-old man was submitted to our department presenting with chest pain and beginning hemodynamic instability. The contrast enhanced computed tomographic scan revealed a contained rupture of a distal descending aortic aneurysm with a maximum diameter of 10.0 cm with contrast medium effusion into the right pleural cavity as well as into the posterior mediastinum. An endovascular approach was deemed feasible. Subsequently the patient was taken into the interventional radiologists’ suite.
After achievement of general anesthesia, as well as exposure of the right common femoral artery, a 5 French pigtail catheter was advanced through the right brachial artery into the aortic arch to reconfirm characterization of the morphology and extent of the aneurysm as well as serial angiography. After systemic heparinization with 5,000 IU, the delivery system was advanced under fluoroscopic guidance until the tip reached the middle portion of the descending thoracic aorta. Afterward, two Talent stent-grafts (Medtronic, Santa Rosa, CA) with a maximum diameter of 42 mm and 46 mm each, and a length of 13 cm were inserted into the distal descending thoracic aorta. At completion angiography, no endoleak could be observed. The patient was discharged from the hospital 4 days after stent-graft placement.
After 1 month postoperatively, the patient was readmitted to the hospital with chest pain as well as swallowing disorders. In addition, infectious factors were elevated (the C-reactive protein was 17.5 mg/dL and the leukocyte count was 16.5 g/L). The patient’s body temperature was 38.5°C. A computed tomographic scan revealed regular perfusion of the stent-graft with no signs of endoleaks. However, a fistula between the distal esophagus and the excluded aneurysm sac was observed (Fig 1).
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Fig 1. Computed tomographic scan of fistula before esophagectomy with extravasation of swallowed contrast medium (arrow).
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We decided to focus on esophageal pathology and not on the potential infectious stent-grafts due to the fact that the general condition of the patient was deemed not suitable for an additional major vascular surgical operation such as thromboexclusion and ascending to abdominal aortic bypass. The patient was treated by esophagectomy, cervical esophagostomy, and a feeding gastrostomy. The perforation site was a coin-shaped defect with a maximum diameter of 3 cm (Fig 2). After having removed the esophagus, the stent-grafts became visible (Fig 3). The infectious parietal thrombus was partially debrided and the aneurysm sac was filled with vancomycin. We decided not to fully remove the parietal thrombus due to the potentially resulting instability of the overlapping stent-grafts. The patient recovered uneventfully. Vancomycin was used as antibiotic treatment for 3 weeks and thereafter the patient received a maintenance therapy of oral ciprofloxacin.
Three months after the initial procedure, continuity was reinstalled with a retrosternally guided, pedicled isoperistaltic transverse colonic conduit. The patient recovered uneventfully and has been free of any signs of infection 3 months after the last procedure. A completion computed tomographic scan revealed regular perfusion of the stent-graft without any signs of endoleaks or local infectious processes. A barium enhanced swallow test confirmed a regular passage without any anastomotic leaks.
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Comment
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We believe this is the first report in the literature of the successful treatment of a fistula between the distal esophagus and an excluded aneurysm sac after emergency endovascular stent-graft placement without removing the potentially infectious prosthetic stent-grafts.
Aortoesophageal fistulas synchronously complicating ruptured descending thoracic aneurysms are a known severe complication making already sophisticated conventional surgical procedures even more demanding [8]. However, metachronous fistulas are rarely seen. The mechanism of fistula development in our patient remains speculative. Pressure erosion of the aneurysm sac could have been a mechanism. Chronic inflammation due to the resorption of the posterior mediastinal hematoma may have represented another potential mechanism leading to fistula development.
With regard to treatment of aortoesophageal fistulas, a variety of surgical approaches is now available. Esophagectomy together with cervical esophagostomy and feeding gastrostomy are commonly applied due to the nonreconstructability of esophageal lesions. Most authors recommend prosthetic replacement of the diseased aortic segment with biological coverage of the alloplastic material with vital tissue such as omentum [8]. However, little is known with regard to treatment of infected thoracic endovascular stent-grafts. Due to the subsequent broadening of the invasiveness of the procedure, we decided to leave the stent-grafts in place. Thromboexclusion with ascending to abdominal aortic bypass would have represented an alternative. Parietal thrombus material was partially removed, and the remaining aneurysm sac was irrigated with beta-isodonic solution and sealed with vancomycin. We decided not to fully remove the parietal thrombus due to the potentially resulting instability of the overlapping stent-grafts. Little is known about the behavior of overlapping stent-grafts when oblique stability is lost by opening the aneurysmal sac and removing stability supporting tissue.
Another point of vital importance is maintenance of antibiotic therapy in these patients. Microbiologic cultures revealed a multi-sensitive staphylococcus aureus within the aneurysm sac. Therefore a chronic therapy with ciprofloxacin was initiated. With regard to duration of antibiotic therapy no guidelines are available. However we decided to leave the patient on maintenance therapy for at least 1 year.
After a period of 3 months, continuity was reinstalled with a retrosternally guided, pedicled isoperistaltic transverse colonic conduit. We chose an extra-anatomic conduction to avoid reopening of the right hemithorax. Alternatively a cervical esophagogastrostomy could have been performed. However a pedicled colonic conduit represents the more physiologic solution for an otherwise healthy individual.
In summary, management of an aortoesophageal fistula after endovascular stent-graft placement without removing the stent-grafts is feasible. This approach may extend therapeutic options when dealing with this rarely observed and complex entity.
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References
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- Czerny M, Fleck T, Zimpfer D, et al. Combined repair of an aortic arch aneurysm by sequential transposition of the supraaortic branches and consecutive endovascular stent-graft placement J Thorac Cardiovasc Surg 2003;126:930-932.
- Hutschala D, Fleck T, Czerny M, et al. Endoluminal stent-graft placement in patients with acute aortic dissection type B Eur J Cardiothorac Surg 2002;21:964-969.[Abstract/Free Full Text]
- Schoder M, Grabenwoger M, Holzenbein T, et al. Endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers of the descending thoracic aorta J Vasc Surg 2002;36:720-726.[Medline]
- Czerny M, Zimpfer D, Fleck T, et al. Endovascular treatment of atherosclerotic descending aortic aneurysms mid-term results J Endovasc Ther 2004;11:26-32.[Medline]
- Grabenwoger M, Fleck T, Czerny M, et al. Endovascular stent graft placement in patients with acute thoracic aortic syndromes Eur J Cardiothorac Surg 2003;23:788-793.[Abstract/Free Full Text]
- Schoder M, Cartes-Zumelzu F, Grabenwoger M, et al. Elective endovascular stent-graft repair of atherosclerotic thoracic aortic aneurysmsclinical results and midterm follow-up. Am J Roentgenol 2003;180:709-715.[Abstract/Free Full Text]
- Faries PL, Cadot H, Agarwal G, Kent C, Hollier LH, Marin ML. Management of endoleak after endovascular aneurysm repaircuffs, coils, and conversion. J Vasc Surg 2003;37:1155-1161.[Medline]
- von Segesser LK, Tkebuchava T, Niederhäuser U, et al. Aortobronchial and aortoesophageal fistulae as risk factors in surgery of descending thoracic aortic aneurysms Eur J Cardiothorac Surg 1997;12:195-201.[Abstract]
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Abstract
Introduction
