Treatment of an Aortoesophageal Fistula After Thoracic Endovascular Repair for an Extensive Aortic Arch Aneurysm

The authors present an urgent procedure that was performed to treat an aortoesophageal fistula, which developed after a thoracic endovascular aortic repair (TEVAR) for an extensive aortic arch aneurysm.

The patient was a 69-year-old man who had undergone abdominal aortic replacement for aortic rupture three years before. Two years previously, TEVAR using a Najuta stent graft and a left subclavian artery occlusion were performed to treat an aortic aneurysm that was 96 mm in diameter and extended from the aortic arch to the descending aorta. TEVAR was performed again five months prior using a TX2 device to treat a descending aortic aneurysm that was 87 mm in diameter. There had been no postoperative endoleak and initially the recovery was uneventful; however, the patient subsequently developed a fever. Computed tomography on admission revealed an aortoesophageal fistula.

A total descending aorta replacement, esophagectomy, stent graft removal, esophagostomy, and gastrostomy were performed urgently. A lateral thoracotomy was performed. Cardiopulmonary bypass was established with cannulation of the left axillary and femoral arteries and drainage via the right femoral vein, and systemic cooling was started. The descending aorta was opened, and a foul-smelling purulent drainage was encountered. Upper body circulatory arrest and clamping of the distal stent graft were performed at a rectal temperature of 20°C.

The proximal Najuta stent graft was removed using the open technique. A rifampicin-soaked graft was anastomosed to the aortic arch between the common carotid artery ostium and the left subclavian artery. The upper body circulation was restarted and lower body circulatory arrest was initiated, followed by the stent graft removal. The stent graft was removed easily by blunt hand dissection. A distal anastomosis was performed using the open technique with 4-0 Prolene® running suture. After the chest was irrigated with saline, an esophagostomy and gastrostomy were performed.

Esophageal reconstruction was performed five months after the operation, and the patient was doing well one year postoperatively.