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• W2912080111 abstract "Secondary aorto-esophageal fistula (AEF) is a rare but fatal complication of thoracic aortic stent-graft placement or previous aortic or esophageal surgery. We present a case of secondary AEF post graft for thoracic aorta aneurysm and the dilemma in its management. A 78 year-old woman with history of aortic arch aneurysm with placement of an aortic graft in 2014 presented to our hospital for evaluation and management of non-resolving fevers and chills. Before she was seen at another hospital with E. coli bacteremia, fever, and chills. In the course of her workup she underwent EGD that showed fresh blood at 20 cm with a possible “opening” between the esophagus and the aorta. Esophagram showed a traction diverticulum in the upper third of esophagus near the aortic stent. Indium scan did not show any activity around the graft. Ertapenem was started but she remained febrile and was transferred to our hospital for further management. On arrival, patient was afebrile but had rigors. Blood cultures grew lactobacillus. Our service was consulted for an evaluation of the esophagus. EGD showed a deep mucosal defect at 20 cm with aortic graft visible through the defect. Patient was planned for a left thoracotomy to remove the aortic graft and reconstruct the esophagus. A pre-operative PCI was performed as she was found to have two vessel coranary artery disease on cardica work up. Antiplatelet and direct thrombin inhibitors were started. Thereafter, she developed massive hematemesis. Emergent EGD showed large amounts of blood in esophagus and stomach. Continuous low grade bleeding appeared to be from the upper esophagus where aortic stent had eroded into esophagus. The patient expressed her wishes to avoid heroic measures and opted for comfort care instead. Presentation of secondary AEFs can be highly variable and a high index of suspicion is required to make a timely diagnosis.The classic Chiari triad of mid-thoracic pain, initial sentinel hemorrhage, followed by exsanguination after symptom free interval is seen in only around half of patients. Endoscopy is recommended to rule out other causes of bleeding. CT angiography or aortography should be done promptly in patients where the index of suspicion for AEF is high. As shown in this case, anticoagulation should be used cautiously if AEF is suspected. While surgical repair is the mainstay for management, esophageal stents and cyanoacrylate injection have been reported in high-risk operative candidates.Figure: Upper Endoscopy showing a possible “opening” in the esophagus at 20 cm.Figure: Upper Endoscopy showing a deep mucosal defect in the esophagus at 20 cm with aortic graft visible through the defect." @default.
• W2912080111 created "2019-02-21" @default.
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• W2912080111 date "2017-10-01" @default.
• W2912080111 modified "2023-10-18" @default.
• W2912080111 title "Aortoesophageal Fistula in a Patient With CAD: A Clinical Conundrum" @default.
• W2912080111 doi "https://doi.org/10.14309/00000434-201710001-01762" @default.
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