P1419 - The Hardest Working Clot: When a Sentinel Bleed Results in Early Detection of an Aorto-Esophageal Fistula Caused by a Transcatheter Aortic Valve Replacement
New York University School of Medicine New York, NY, United States
Sindhura Kolli, MD1, Ahmed Al-Khazraji, MD2, Bhanu Singh, MD3, Vennis Lourdusamy, MD3, Moiz Ahmed, MD4, Rupa Sharma, MD3, Joel Baum, MD3, Raghav Bansal, MD, FACG2, Aaron Walfish, MD3, Joshua Aron, MD3, Krishna C. Gurram, MD3 1New York University School of Medicine, New York, NY; 2Elmhurst Hospital Center, Elmhurst, NY; 3Elmhurst Hospital Center, Queens, NY; 4Icahn School of Medicine at Mount Sinai (Elmhurst Hospital Center), Elmhurst, NY
Introduction: A transcatheter aortic valve replacement (TAVR) carries a 2% risk of postoperative upper gastrointestinal bleeding. It presents as extensive bleeding resulting in hemorrhagic shock or respiratory failure. In this case, an early clot with sentinel bleeding prevented the widening of a full thickness aortoesophageal fistula formed from the TAVR placement, was symptomatic enough to prompt an earlier esophagogastroduodenoscopy (EGD) and prevented a probable fatality.
Case Description/Methods: An 85-year-old male with a past medical history of AAA repair, GERD, HLD, TIA, aortic dissection s/p coronary bypass graft, AS with TAVR 5 months prior presented with hematemesis after initiating colonoscopy bowel prep. He also had unintentional 30-lb weight loss over 3 months, fecal incontinence, and melena. Medications include a daily aspirin. Abdominal CT demonstrated an 8cm aortic arch aneurysm, a 5cm descending thoracic aortic aneurysm, and a 5.8 x 4 cm collection posterolateral to the aorta with proximal dilation of the esophagus. EGD demonstrated a partially obstructing protruding mass in the esophagus 20 cm from the incisors with sentinel bleeding from an adherent clot. The mass was determined to be extrinsic compression from the aortic arch aneurysm with the TAVR seen through the aortoesophageal fistula (Image 1A-1B). The stomach and duodenum were unremarkable. Patient was transferred to vascular surgery where a 1cm compressed Amplatzer Vascular Plug II embolization and reinforcement of the endoleak was done. Patient remained hemodynamically stable and discharged home with a vascular follow up.
Discussion: Aorto-esophageal fistula following TAVR is a rare complication with a wide etiology ranging from infections, antithrombotic use, pressure necrosis, angiodysplasia, underlying PUD, or uncontrolled comorbidities such as HTN. Our patient’s risk factors were his elderly age, comorbidities, use of daily aspirin, and contribution from the pressure or ischemic necrosis of the aortic aneurysm compressing on the esophagus. Presentation involves hemoptysis, chest pain, hemorrhagic shock, respiratory failure and frank bleeding. CTA is considered the initial test of diagnosis as endoscopy, though sensitive, could rupture the clot and unleash massive bleeding. In this case, sentinel bleeding and visualization of the TAVR through the fistula was enough to diagnose and retreat to be treated appropriately with embolization and reinforcement.
Figure: FIGURE 1. A: Extrinsic compression from the aortic arch aneurysm causing a protrusion and visualization of the TAVR B: Sentinel bleeding from the fistula tear
Disclosures:
Sindhura Kolli indicated no relevant financial relationships.
Ahmed Al-Khazraji indicated no relevant financial relationships.
Bhanu Singh indicated no relevant financial relationships.
Vennis Lourdusamy indicated no relevant financial relationships.
Moiz Ahmed indicated no relevant financial relationships.
Rupa Sharma indicated no relevant financial relationships.
Joel Baum indicated no relevant financial relationships.
Raghav Bansal indicated no relevant financial relationships.
Aaron Walfish indicated no relevant financial relationships.
Joshua Aron indicated no relevant financial relationships.
Krishna Gurram indicated no relevant financial relationships.
Sindhura Kolli, MD1, Ahmed Al-Khazraji, MD2, Bhanu Singh, MD3, Vennis Lourdusamy, MD3, Moiz Ahmed, MD4, Rupa Sharma, MD3, Joel Baum, MD3, Raghav Bansal, MD, FACG2, Aaron Walfish, MD3, Joshua Aron, MD3, Krishna C. Gurram, MD3. P1419 - The Hardest Working Clot: When a Sentinel Bleed Results in Early Detection of an Aorto-Esophageal Fistula Caused by a Transcatheter Aortic Valve Replacement, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.