P-032 - AORTOESOPHAGEAL FISTULA. CASE REPORT OF CONSERVATIVE TREATMENT

TOPIC:
Case Reports
AUTHORS:
El Beyrouti H. (Department of Cardiac and vascular Surgery, University Medical Center, Johannes-Gutenberg University ~ Mainz ~ Germany) , Abdalhafez M. (Department of Cardiac and vascular Surgery, University Medical Center, Johannes-Gutenberg University ~ Mainz ~ Germany) , Doemland M. (Department of Cardiac and vascular Surgery, University Medical Center, Johannes-Gutenberg University ~ Mainz ~ Germany) , Halloum N. (Department of Cardiac and vascular Surgery, University Medical Center, Johannes-Gutenberg University ~ Mainz ~ Germany) , Al-Saegh S. (Department of Cardiac and vascular Surgery, University Medical Center, Johannes-Gutenberg University ~ Mainz ~ Germany) , Treede H. (Department of Cardiac and vascular Surgery, University Medical Center, Johannes-Gutenberg University ~ Mainz ~ Germany)
Introduction:
Management of aorto-esophageal fistula, especially after previous endovascular repair, is associated with high morbidity and mortality. Surgical debridement and replacement of infected segment are necessary. A wide spectrum of graft materials for extra-anatomic or in situ reconstruction is suggested such as homograft, biological or biosynthetic material and antibiotic impregnated grafts, but none of these is universally applicable due to occasional associated risks. We present the 1-year follow-up of a patient with secondary aortoesophageal fistula, after emergency endovascular treatment of a covered ruptured aortic ulcer of the thoracic aorta with successful endoscopic closure of the fistula by fibrin glue application.
Methods:
A 65-year-old female patient underwent percutaneous TEVAR in zone 2 supplemented with implantation of carotid-subclavian bypass and plug implantation into the subclavian artery because of ruptured aortic ulcer. The postoperative course was unremarkable except for asymptomatic elevated CRP values. Computed tomography (CT) also revealed normal findings. However, the patient experienced chest pain with dyspnea on exertion one month later. Computed tomography continued to show no change from the last checkup, and laboratory parameters still showed elevated CRP. A control magnetic resonance imaging (MRI) of the entire aorta revealed inflammatory vessel wall changes suggesting a large vessel vasculitis with wall thickening and increased contrast enhancement of the thoracic aorta. Cortisone therapy was continued orally with additional administration of tocilizumab. 3 weeks later, the control CT revealed small fluid accumulation in the upper mediastinum and along the descending aorta in the sense of mediastinitis with suspected esophageal or bronchial perforation. Bronchoscopy was able to exclude a bronchial fistula, but endoscopically a 2 mm esophageal fistula could be detected 24 cm from the dentate line. A multidisciplinary decision discussed open surgical repair including radical debridement of infected tissue and replacement of the aorta and esophagus. The patient denied the operation and preferred conservative therapy. After serial endoscopic vacuum treatment of the esophagus (4 changes over 15 days) with enteral food restriction, the fistula could be closed endoscopically by application of 1 ml fibrin glue with a good outcome in 1-year follow-up controls.
Results:
Under oral therapy with prednisolone (initially 3x 250mg SDH i.v., then PDN 60mg p.o. and currently 4mg daily) and Amoxiclav 875/12 the patient is currently symptom-free with regular inflammatory parameters. The last CT controls showed a decrease in mediastinitis signs and air trapping without residual findings as well as regular visualization of the entire aorta and supraaortic branches with an open carotid-subclavian bypass.
Conclusion:
An endoscopic vacuum therapy of the esophagus under oral antibiotic therapy may be feasible to treat aorto-esophageal fistulae. Surgical backup remains a necessity.