What is the appropriate evaluation and management for dysphagia and odynophagia (painful swallowing) following closure of a pulmonary artery fistula with a stent graft and coil?

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Last updated: October 12, 2026 • View editorial policy

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Dysphagia and Odynophagia After Pulmonary Artery Fistula Closure

Immediately obtain a biphasic esophagram to evaluate for structural esophageal injury from the stent graft or coil, as mechanical compression or erosion of the esophagus is the most likely cause of these symptoms in this post-procedural context 1.

Immediate Diagnostic Approach

The combination of dysphagia (trouble swallowing) and odynophagia (chest pain with swallowing) following endovascular intervention with stent graft and coil placement raises urgent concern for:

  • Esophageal compression from the stent graft or coil
  • Esophageal erosion or fistula formation between the pulmonary artery and esophagus
  • Mediastinal hematoma causing mass effect
  • Inflammatory response to the foreign material

Primary Imaging Study

Order a biphasic esophagram first 1. This fluoroscopic study:

  • Detects both structural abnormalities (strictures, erosions, fistulas) and functional problems (motility disorders)
  • Has 96% sensitivity for detecting esophageal structural lesions 1
  • Provides superior mucosal detail compared to single-contrast studies
  • Allows real-time assessment of swallowing mechanics

If Esophagram is Non-Diagnostic

Proceed to CT neck and chest with IV contrast to evaluate:

  • Position of stent graft and coils relative to esophagus
  • Mediastinal hematoma or fluid collections
  • Evidence of erosion or fistula formation
  • Inflammatory changes

Do not rely on CT as initial imaging because it cannot assess esophageal mucosa or motility adequately 1.

Secondary Evaluation

If structural abnormalities are excluded but symptoms persist:

Perform upper endoscopy (EGD) to:

  • Directly visualize esophageal mucosa for erosions, ulcerations, or compression
  • Obtain biopsies if mucosal abnormalities are present
  • Rule out infectious or inflammatory esophagitis

Consider fiberoptic endoscopic evaluation of swallowing (FEES) 2, 3:

  • Assesses swallowing function with different food consistencies
  • Identifies aspiration risk (which occurs in 54-70% of post-cardiac procedure patients with dysphagia) 4, 3
  • Guides dietary modifications and aspiration precautions

Critical Management Considerations

Immediate Actions

  • NPO status until structural injury is ruled out
  • IV hydration to prevent dehydration
  • Proton pump inhibitor to reduce acid-related mucosal injury if erosion is present
  • Broad-spectrum antibiotics if there is concern for mediastinitis or esophageal perforation

If Structural Injury is Confirmed

The presence of an esophageal-vascular fistula or significant compression requires:

  • Immediate multidisciplinary consultation (interventional cardiology, thoracic surgery, gastroenterology)
  • Covered esophageal stent placement may be considered for fistula management, as coated expandable stents have demonstrated excellent palliation with minimal morbidity 5
  • Surgical revision may be necessary if endovascular options fail

If No Structural Abnormality Found

Initiate swallowing therapy with speech-language pathology 2:

  • Compensatory strategies (postural changes, diet modifications)
  • Swallowing exercises to improve coordination
  • Aspiration precautions based on FEES findings

Common Pitfalls to Avoid

  1. Delaying imaging: These symptoms after endovascular intervention require urgent evaluation—do not attribute them to "expected post-procedural discomfort"

  2. Starting with CT alone: CT misses mucosal lesions and functional problems that biphasic esophagram readily identifies 1

  3. Ignoring aspiration risk: Post-cardiac procedure patients have 54-87% rates of unsafe swallowing, with 93% having ineffective cough 3. Silent aspiration is common and increases pneumonia risk 3.3-fold 6

  4. Assuming symptoms will resolve spontaneously: Esophageal erosion from stent material can progress to life-threatening fistula formation 5, 7

Risk Stratification

Higher concern for serious complications if patient has:

  • Prolonged intubation post-procedure (>48 hours increases dysphagia risk) 6
  • Progressive symptoms rather than stable or improving
  • Fever, tachycardia, or sepsis signs suggesting mediastinitis
  • Hemoptysis or hematemesis indicating active bleeding from fistula

The 90-day mortality risk is significantly elevated in patients with dysphagia after cardiovascular procedures (HR 1.3-1.7 depending on procedure type) 8, making prompt diagnosis and intervention essential for reducing morbidity and mortality.

References

1
Guideline

acr appropriateness criteria<sup>®</sup> dysphagia.

Journal of the American College of Radiology, 2019

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