AEF is a severe life-threatening condition with a high mortality rate . After confirmation of diagnosis, patients should be treated immediately; otherwise, they may die of a hemorrhage or uncontrollable infection. In the past, AEF was managed with surgical thoracic esophagectomy and esophagogastrostomy to correct the fistula and esophagus. In addition to traditional open surgery for AEF treatment, endovascular stent-graft therapy is an effective method for preventing aortic rupture . However, stent-graft therapy is associated with a high risk of spinal cord ischemia and other postoperative complications such as blood leaks, stenosis, and thrombosis within the stent or its migration .
In this case, the patient had aneurysms in both the descending aorta and the aortic arch. Thoracic endovascular aortic repair did not result in the closure of the aortic arch aneurysm. Therefore, we selected median sternotomy and stent placement to exclusive the descending aortic aneurysm and simultaneously repair another aortic arch aneurysm. We planned to place an esophageal stent to close the esophageal tear after repairing the aneurysm. However, the esophageal damage was too severe for stent treatment. No obvious signs of mediastinal infection were observed after surgery. Therefore, we chose to administer food through the duodenal tube to cure the esophageal ulcer. CTA and gastroendoscopy showed time-dependent recovery of the esophageal fistula without any infection and other complications. At 6 months of follow-up, CTA showed that the aortic stent position was fixed without dislodgement. However, the infection of the vascular stent caused reformation of the aortic aneurysm and rupture into the esophagus, leading to hemorrhagic shock and death 8 months after surgery.
Treatment of esophageal fistula is critical. Small esophageal fistulas without obvious infection can be treated by direct suturing . However, cautious application is essential because of its association with a high risk of recurrent infection and mortality . Infection, especially mediastinal infection, would cause problems for both surgery and interventional therapy. For patients with obvious mediastinal emphysema, simultaneous surgical debridement should be performed along with vascular replacement to reduce the risk of infection. After surgery, long-term treatment with appropriate antibiotics therapy is also necessary.
Secondary AEF is a fatal complication of thoracic endovascular aortic repair, although the incidence is only 1.6–1.9%. Emergent endovascular repair could increase the possibility of secondary AEF irrespective of the type of stent used . Good short- and mid-term results were obtained for endovascular stent-graft implantation in many AEF management cases. Therefore, in patients with AEF, stent-graft implantation may be indicated only as an emergency management technique for controlling hemorrhage and avoiding AEF aggravation. Once the etiological factor of AEF is confirmed and the infection is controlled, a secondary surgery for esophageal reconstruction might be necessary for long-term survival.
In conclusion, open chest vascular stent implantation is an effective short-term treatment for AEF. This procedure could help surgeons to effectively exclusive the aneurysm and simultaneously repair other aortic lesions. In patients without mediastinal infections, conservative therapy with enteral nutrition through a duodenal tube is a simple and feasible modality for esophageal fistula. A second-stage operation for esophageal reconstruction may be performed once the patient can tolerate surgery. In addition, such patients need long-term antibiotic therapy even lift-long, and be strictly monitored blood tests and computed tomographic scans after discharge.