Duke University Medical Center Durham, North Carolina
Introduction: The presence of air adjacent to the esophagus on imaging can be an emergent finding warranting surgical or endoscopic evaluation, and the etiology can be esophageal, pulmonary, or vascular in nature. We report a case of an aortoesophageal fistula (AEF) in a critically ill patient after a recent thoracoabdominal endovascular aortic aneurysm repair (TEVAR).
Case Description/Methods: A 70-year-old woman with hypertension and atrial fibrillation was in intensive care after a recent complicated TEVAR performed for aortic rupture. She was noted to have tachycardia and hypotension; she denied any nausea, melena, or hematochezia. Vital signs revealed a heart rate of 123 beats per minute and a blood pressure of 85/51 mm Hg. Physical exam showed a critically-ill appearing woman in no distress, a clear oropharynx, a non-tender abdomen, and a rectal exam without blood. Labs noted a leukocytosis of 19.0 x109/L, a Hgb of 6.8 g/dL, and a lactate of 2.1 mmol/L. Labs drawn 12 hours prior noted a Hgb of 8.2 g/dL and a lactate of 0.9 mmol/L. CT imaging of the chest (panels A-B) showed interval air in the excluded thoracic aneurysmal sac adjacent to the esophagus (arrow 1), which was intubated by an enteric tube (arrow 2). EGD (panels C-D) revealed two large non-bleeding perforations in the middle esophagus with possible fistulation to the mediastinum. The clinical presentation suggested post-TEVAR AEF, likely due to compressive ischemia and necrosis of the esophagus from the aneurysmal sac compounded by prolonged shock. Given high operative risk, an esophageal stent and gastrostomy tube were placed by cardiothoracic surgery.
Discussion: Post-TEVAR AEF formation is a rare but serious complication occurring in 1.7–1.9% of patients after TEVAR, and can be due to graft infection, aortic pressure necrosis, or esophageal erosion related to aortic expansion. Chiari’s triad, the hallmark symptoms of AEF, include mid-thoracic pain and sentinel hematemesis followed by massive hematemesis. However, massive hemorrhage may be observed soon after a sentinel episode of hematemesis or can be delayed by years. Imaging findings include air within the aortic thrombus or esophageal wall, expanding fluid collection around the graft, or extraluminal aortic contrast extravasation. Endoscopic findings include esophageal submucosal protrusions, ulcerative lesions, or fistula formation. In stabilized patients, management options include subtotal esophagectomy and aortic debridement and reconstruction.
