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Aortoesophageal Fistula After Thoracic Aortic Stent-Graft Placement

A Rare but Catastrophic Complication of a Novel Emerging Technique

Holger Eggebrecht, MD^_*,_*, Rajendra H. Mehta, MD, MS^||, Alexander Dechene, MD, Konstantinos Tsagakis, MD, Hilmar Kühl, MD, Sebastian Huptas, MD^_*, Guido Gerken, MD, Heinz G. Jakob, MD, Raimund Erbel, MD^_*

^_* Department of Cardiology, West-German Heart Center Essen, Essen, Germany
Department of Cardiothoracic Surgery, West-German Heart Center Essen, Essen, Germany
Department of Gastroenterology and Hepatology, University of Duisburg-Essen, Essen, Germany
Department of Diagnostic and Interventional Radiology and Neuroradiology, University of Duisburg-Essen, Essen, Germany
^|| Duke Clinical Research Institute, Durham, North Carolina

^_* Reprint requests and correspondence: Dr. Holger Eggebrecht, Department of Cardiology, West-German Heart Center, University of Duisburg-Essen, Hufelandstraße 55, 45122 Essen, Germany (Email: holger.eggebrecht{at}uk-essen.de).

Objectives: Our goal was to report characteristics and outcomes of 6 patients with aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR).

Background: Neurologic events are severe complications of TEVAR. With growing experience of TEVAR, other yet unexpected devastating complications have emerged.

Methods: Between July 1999 and August 2008, 268 patients underwent TEVAR for various thoracic aortic diseases at our institution.

Results: Six of 268 patients (age 49 to 77 years, 50% female patients) developed AEF (incidence 1.9%) within 1 to 16 months after the procedure. Indications for TEVAR were acute aortic dissection (n = 3), chronic aortic dissection (n = 1), and thoracic aortic aneurysm (n = 2). Four patients presented with sudden massive hematemesis whereas 2 patients were readmitted for new-onset fever and elevated markers of inflammation that preceded hematemesis. Esophago-gastro-duodenoscopy identified deep esophageal ulcerations at the level of the implanted aortic stent-graft in 4 patients, but only mild erosive lesions within the proximal esophagus without signs of active bleeding in the remaining 2 patients. Surgical repair was performed in only 1 patient and declined in the remaining because of comorbidities and multiorgan system failure. Despite this, all patients died due to fatal rebleeding (n = 4) or mediastinitis (n = 2).

Conclusions: AEF is a rare and unusual complication of TEVAR that occurs relatively early after the procedure and is almost invariably fatal. New-onset fever with elevated inflammatory markers or hematemesis should heighten clinical suspicion of AEF in TEVAR patients and prompt computed tomography or esophago-gastro-duodenoscopy in the hope of detecting, triaging, and treating this early to improve the otherwise dismal outcomes of these patients.

Key Words: aorta • complications • fistula • stents

Abbreviations and Acronyms   AEF = aortoesophageal fistula   CT = computed tomography   DTA = descending thoracic aorta   EGD = esophago-gastro-duodenoscopy   TAA = thoracic aortic aneurysm   TEVAR = thoracic endovascular aortic repair