Atypical Aortoesophageal Fistula with Atypical and Delayed Presentation and Negative Imaging Studies

Upper gastrointestinal bleeding from primary aortoesophageal fistula in a patient with aneurism of the thoracoabdominal aorta: Case report and literature review

Key Clinical Message

Upper gastrointestinal bleeding due to primary aortoesophageal fistula is a rare clinical condition burdened with high mortality rate. However, the outcomes are closely related to the level of clinical awareness, the complementary and multidisciplinary approach during the diagnostic workup, and the selected treatment option.

Abstract

We present an atypical case of an aneurysm of the thoracoabdominal aorta complicated with primary aortoesophageal fistula (AEF). A 55-year-old male with no previous diseases, presented with prolonged and intense back pain and upper gastrointestinal bleeding. The gastroscopy detected an unusual culprit lesion in the distal esophagus resembling an esophageal wall defect, and the computed tomography revealed an aneurysm of the thoracoabdominal aorta, remarkable surrounding hematoma, and active contrast extravasation. Despite the urgent surgical repair, a lethal outcome occurred. AEF patients require high clinical awareness and complementary multidisciplinary approach in order to provide a rapid diagnosis and optimal treatment.

Risk Factors for Mortality in Patients with Aortoesophageal Fistula Related to Aortic Lesions

Objective

Aortoesophageal fistula (AEF) related to aortic aneurysm and dissection is an uncommon but life-threatening condition. We performed a systematic review of risk factors for mortality and factors associated with the prognosis of AEF.

Methods

A systematic search of the PubMed, Embase, and Cochrane Library databases was performed. Clinical characteristics, diagnostic methods, and treatments were assessed in terms of their ability to predict mortality.

Results

The systematic review identified 184 eligible articles including 219 patients with AEF. Multivariable Cox regression revealed positive correlations of hemorrhagic shock (hazard ratio (HR): 1.824, 95% CI: 1.217-2.735, P = 0.004), sepsis (HR: 1.714, 95% CI: 1.112-2.641, P = 0.015), multiorgan failure (HR: 3.060, 95% CI: 1.470-6.368, P = 0.003), and conservative treatment (HR: 5.257, 95% CI: 3.405-8.116, P < 0.001) with mortality and a negative correlation between combination therapy (aortic graft replacement and esophagectomy) and mortality (HR: 0.319, 95% CI: 0.125-0.813, P = 0.017). Kaplan–Meier survival analysis showed that the 1-year cumulative survival rate was 42.5 ± 3.8%. The overall fistula-related mortality rate was 47.0% (103/219). The most common causes of death were bleeding (54.9%) and infection (29.2%).

Conclusions

We found that hemorrhagic shock, sepsis, and multiorgan failure were risk factors for death in patients with AEF. Additionally, conservative treatment was associated with a higher rate of mortality, while combined aortic graft replacement and esophagectomy improved the prognosis.

Management of aorto-esophageal fistula secondary after thoracic endovascular aortic repair: a review of literature

Aorto-esophageal fistula (AEF) is a rare and lethal entity, and the difficulty of making diagnosis of AEF is well-known. As promising results in the short-term effectiveness of thoracic endovascular aortic repair (TEVAR) promote its usage, the occurrence of AEF after TEVAR (post-TEVAR AEF) increases as one of the major complications. Therefore, we provide a review concerning the management strategy of post-TEVAR AEF. Although its representative symptom was reported as the triad of mid-thoracic pain and sentinel hematemesis followed by massive hematemesis, the symptom-free interval between sentinel hemorrhage and massive exsanguination is unpredictable. However, the physiological condition represents a surgical contraindication. Accordingly, early diagnosis is important, but either CT or esophago-gastro-duodenoscopy rarely depicts a typical image. The formation of post-TEVAR AEF might be associated with the infection of micro-organisms, which is uncontrollable with anti-biotic administration. The current first-line strategy is combination therapy as follows, (1) to control bleeding by TEVAR in the urgent phase, and (2) radical debridement and aortic/esophageal re-construction in the semi-urgent phase. In view of the high mortality and morbidity rate, it is proposed that the choice in treatment strategies might be affected by patient`s condition, size of the wall defects and the etiology of AEF. Practically, we should keep in mind the importance of making an early diagnosis and, once a suspicious symptom has occurred in a patient with a history of TEVAR, the existence of post-TEVAR AEF should be suspected. A prospective registry together with more developed technologies will be needed to establish a future strategy.