1 / 10

Article Review

Secondary Aortoesophageal Fistula After Thoracic Endovascular Aortic Repair for a Huge Aneurysm Muradi A, et al. Diagn Interv Radiol 2013;19:81-84. Article Review. Presented by E. Rose, M.D. Introduction.

southern-olson
Download Presentation

Article Review

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Secondary Aortoesophageal Fistula After Thoracic Endovascular Aortic Repair for a Huge Aneurysm Muradi A, et al. Diagn Interv Radiol 2013;19:81-84 Article Review Presented by E. Rose, M.D.

  2. Introduction • Thoracic endovascular aortic repair (TEVAR) minimally invasive, generally excellent modality to treat descending thoracic aortic aneurysms • Complications may occur • Paraplegia • Stroke • Aortoesophageal fistula (AEF) • AEF is uncommon but often fatal

  3. Report of Case • 65 year-old man, advanced bladder cancer, acute renal failure admitted for chemotherapy • Staging CT found 90 mm thoracic aortic aneurysm displacing heart, esophagus • Underwent TEVAR procedure plus treatment for his cancer; no endoleak • Went home 10 days later

  4. Case, continued • 4 months later presented with fever 100.4, elevated WBC 13k, elevated C-reactive protein • Blood cultures negative • CT chest showed free air around stent grafts in aneurysm sac • Endoscopy revealed fistula, posterior surface of esophagus into aneurysm sac • Conservative treatment chosen due to cancer • Two months later, died from hemorrhagic shock due to massive hematemesis

  5. Initial Presentation CT image of the huge descending thoracic aortic aneurysm before (left) and maximum intensity projection image after (right) thoracic endovascular aortic repair (TEVAR). The preoperative diameter of the aneurysm was 90 mm. The descending thoracic aortic aneurysm was treated by TEVAR without any endoleak.

  6. Fistulization Esophagogastroduodenoscopy (inset) and CT images of the aortoesophageal fistula detected air bubbles around the stent graft in the aneurysm sac of the descending thoracic aorta (white arrow). The precise fistula site was not visible, but no contact between the stent graft and the fistula was observed. A fistula without any bleeding was seen at the inner surface of the midesophagus (inset, black arrow).

  7. Discussion • Secondary AEF is rare but fatal complication of TEVAR • 1.6 to 1.9% of cases • Same incidence as with open surgery • 24 cases reported in literature • 54% occur within 4 months • 75% mortality

  8. Possible Mechanisms • Direct erosion of relatively rigid stent graft through aorta into esophagus (most common) • Pressure necrosis of esophageal wall from pressure from stent • Ischemia of esophagus due to coverage of aortic side branches that serve esophagus • Infection

  9. Mechanism for Current Case • Suspect infection due to hematogenous seeding, plus pressure from the huge aneurysm sac • Patient presented only with fever and elevated indices of inflammation • High index of suspicion led to performing CT and endoscopy

  10. Dilemma • Many patients who were sick enough to have TEVAR in the first place were too compromised to tolerate such massive surgery • Secondary AEF is catastrophic complication of thoracic aortic surgery or TEVAR • No good solutions yet • Recommend close and regular follow-up by CT, endoscopy, blood work

More Related