Youwen Chen1*, Junjie Xu2 and Zhijian Guo1
1Department of Cardiovascular Surgery, Chang Gung Memorial Hospital, China
2Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Taiwan
Background: Upper Gastrointestinal Bleeding (UGIB) is a major cause of morbidity and mortality accounting for approximately 56.5/100,000 hospitalizations with a mortality rate of 8.2%. Secondary aorto-esophageal fistula (SAEF), a pathologic anatomical communication between the aorta and oesophagus in patients previously treated for thoracic aortic disease with a prosthetic graft, is a rare but life-threatening cause of massive UGIB. SAEF is uniformly fatal if untreated and remains a formidable surgical problem in older, high-risk patients with sepsis or haemorrhagic shock. An infected aortic aneurysm combined with SAEF is uncommon and considered to be one of the most challenging problems faced by cardiovascular surgeons. Thoracic Endovascular Aortic Repair (TEVAR) is a minimally invasive alternative and is particularly valuable as a “bridging” procedure in emergency situations. However, TEVAR does nothing to address the issue of the defect in the digestive tract, which leaves these patients at high risk of Aorto-oesophageal Fistula (AEF) recurrence and/or endograft infection and leads to a high rate of re-intervention. Open repair after TEVAR is performed in 2.2% to 7.2% of patients at experienced centres, and the associated morbidity and mortality can be significantly higher than with primary open repair. We described a successful multi-stage combined approach for a patient with SAEF and endograft infection.Case
Presentation: A 73-year-old Asian male was diagnosed with a proximal descending saccular aortic aneurysm with a surrounding haematoma at another hospital 97 days prior to presentation. The patient underwent TEVAR of the descending thoracic aorta (Zone 3) a week later and was discharged from hospital 4 days postoperatively. He was re-hospitalized for recurrent UGIB, persistent fever (average, ~38.0°C to 38.7°C) with post-sternal pain and difficulties in 54 days prior to being transferred. TEVAR-associated postoperative SAEF with para-aortic infection and delayed type Ia endoleak were confirmed, and the patient underwent 6 open surgical conversions. Perioperative antibiotic treatment was initiated with combined broad-spectrum antibiotics and later adjusted to tigecycline and colistin methanesulfonate. The patient was discharged on the 117th postoperative day (1st surgery) with oral antibiotics. The patient’s sternal wound had healed, and there were no clinical signs of infection based on radiological (chest X-ray) and laboratory examinations. However, the patient’s long-term survival and prognosis still need to be monitored with continuous follow-up.Conclusion: TEVAR for SAEF is associated with a high risk of recurrence of AEF, endograft infection and mediastinitis and should be utilized as a “bridge” to a definitive surgical repair.
Gastrointestinal Bleeding; Aorto-oesophageal fistula; Endograft infection; Mediastinitis; Endoleak
Chen Y, Xu J, Guo Z. A Case of Successful Multi-Stage Open Surgical Conversion of a Secondary Aorto- Oesophageal Fistula with Endograft Infection after Thoracic Endovascular Aortic Repair. Clin Surg. 2019; 4: 2305.