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J Thorac Cardiovasc Surg 2006;131:1409-1410
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Department of Vascular Surgery
b General Surgery, "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy.
Received for publication November 29, 2005; accepted for publication January 13, 2006. * Address for reprints: Enrico Maria Marone, MD, Chirurgia Vascolare, IRCCS H. San Raffaele, Via Olgettina 60, 20132 Milano, Italy. (Email: marone.enrico{at}hsr.it).
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Aortoesophageal fistula is an uncommon and highly fatal condition, even if opportunely treated. In rare cases it has been encountered in association with extensive corrosive injury. No cases of successful endovascular repair of aortoesophageal fistula caused by corrosives are reported in the English-language literature. We report a case of severe esophagogastritis caused by massive ingestion of hydrochloric acid complicated by aortoesophageal fistula. Combined surgical and endovascular treatment by means of a stent graft proved to be successful.
Clinical Summary
A 20-year-old man was brought to the emergency department after ingestion of hydrochloric acid with suicidal intent. At admission, he required endotracheal intubation, fluid resuscitation, and correction of metabolic acidosis. Endoscopy showed edema and necrosis of the palate, tongue, pharynx, larynx, epiglottis, and arytenoids. Computed tomography showed marked edematous thickening of the esophageal and gastric walls (Figure 1) and posterior gastric wall perforation with perigastric and perisplenic fluid effusion with free air. Urgent laparoscopy evidenced free blood in the supramesocolic area, necrosis, and perforation of the posterior wall of the stomach. The abdominal esophagus seemed spared. A laparoscopic total gastrectomy was completed. At the last phase of the operation, brisk arterial bleeding coming from the preaortic necrotic tissues ensued. After conversion in laparotomy, the hemostasis was optimized. A tube was then inserted in the esophageal stump, and a nutritional jejunostomy was accomplished.
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Endovascular treatment of malacic thoracic aorta was successfully performed the day after. The common femoral artery was exposed through a right groin incision. Through a left percutaneous femoral access, an angiogram localized the celiac axis, which was marked with a guide wire as the distal limit of the endograft. A 0.035-inch Amplatz super-stiff guide wire (Boston Scientific, Natick, Mass) was then passed up to the ascending aorta. The 18F delivery sheath was advanced in the distal descending thoracic aorta. A straight 26 x 238–mm Zenith self-expanding endograft (William Cook Europe A/S, Bjaeverskov, Denmark) was positioned to terminate immediately above the celiac axis. The completion angiogram showed satisfactory endograft deployment. One month later, a computed tomographic scan showed correct positioning of the endoprosthesis (Figure 2). The esophagus developed strictures and was replaced by means of retrosternal coloplasty. At 1-year follow-up, the endoprosthesis was shown to be correctly positioned, with no signs of infection and with persistent exclusion of the fistula.
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Aortoesophageal fistula is an uncommon and highly fatal condition, occurring most commonly in association with thoracic aortic aneurysms or aortic prosthetic grafts, ruptured atherosclerotic ulcers in the thoracic aorta, foreign bodies, esophageal or bronchogenic malignancies, esophageal resections, esophageal stenting, penetrating peptic esophageal ulcers, and traumas.
1
Only a few cases of aortoesophageal fistula caused by corrosive ingestion are reported in the literature.
In cases of surgically repaired aortoesophageal fistulas reported in the literature,
2,3
suture or prosthetic graft replacement of the aorta did not prove to be an adequate treatment because death from secondary hemorrhage often occurred because of late dehiscence and reopening of the aortic breach. The first case of aortoesophageal fistula repair with an endovascular stent graft was reported by Kato and associates
4
in 2000. In this case the fistula was caused by irradiation of an esophageal cancer, and therefore intervention was palliative. In our case the aim was a definitive and minimally invasive treatment in a critically ill young man with impending coagulopathy. Endovascular treatment after primary repair of the laceration in the esophagus and in the aorta and after extensive debridement was the only way to definitively treat this condition while avoiding further surgical stress to the patient. In our case the infective risk for the endoprosthesis was minimal because of preoperative broad-spectrum antibiotic therapy and deployment of the graft inside an intact aortic wall. Successful surgical treatment of aortoesophageal fistulas caused by corrosive injury is rarely reported in the literature, and no cases of endovascular repair of this condition have been reported. Because surgical treatment alone is not able to result in a definitive solution, endovascular repair of the fistula and strengthening of malacic aortic walls by means of a stent graft can be a life-saving and successful approach. Further experience and follow-up will eventually confirm this result.
References
This article has been cited by other articles:
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  P. F. Ford and M. A. Farber Role of Endovascular Therapies in the Management of Diverse Thoracic Aortic Pathology Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 134 - 143. [Abstract] [PDF]
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