What is the management and treatment of an aortoesophageal fistula?

Management of Aortoesophageal Fistula

TEVAR should be performed emergently as a lifesaving bridge procedure to control bleeding and stabilize hemodynamics, followed by device explantation and open surgical repair of both the aorta and esophagus, with lifelong suppressive antibiotic therapy. 1

Immediate Emergency Management

Hemorrhage Control

• Perform TEVAR immediately to control exsanguinating hemorrhage and stabilize hemodynamics in the acute setting 1
• This is a bridge therapy only, not definitive treatment—the mortality rate is 40-60% and infection recurrence is 33-60% if the device is not explanted 1
• TEVAR buys time for patient stabilization before definitive open repair 2, 3

Critical Pitfall

Do not consider TEVAR as definitive therapy. The American Heart Association consensus is clear: TEVAR must be followed by device explantation and open surgical repair to prevent fatal infection recurrence 1. Conservative management results in 60% in-hospital mortality with no late survival 3.

Definitive Surgical Management

Staged Approach (Recommended)

1. Stage 1 (Emergency): TEVAR for bleeding control 1, 2, 3
2. Stage 2 (Delayed): Open surgical repair including:
   • Device explantation 1
   • Aortic reconstruction with in situ graft replacement 1
   • Esophageal repair via direct suture or esophagectomy with staged reconstruction 4, 2, 3
   • Reinforcement with intercostal muscle flap or omentum to separate the repair from surrounding structures 1, 3

Surgical Considerations

• Esophageal management options: Direct suture with muscle flap reinforcement for small defects, or esophagectomy with gastric pull-up for extensive involvement 4, 3
• Buttress suture lines with fascia lata and cover grafts with vascularized tissue (omentum, latissimus dorsi, serratus muscle flap) 1
• Large esophageal defects may require diversion 1

Antibiotic Therapy

Duration and Approach

• Initial therapy: 6-8 weeks of parenteral antimicrobial therapy after definitive repair 1
• Long-term suppression: Lifelong suppressive antibiotic therapy should be administered in all patients with retained endovascular devices or after in situ repair 1
• This recommendation stems from the placement of foreign material in an infected field with high recurrence risk 1

Clinical Recognition

Classic Presentation (Chiari's Triad)

• Midthoracic pain or dysphagia 4, 5
• Sentinel episode of hematemesis (herald bleeding) 4, 5
• Followed by massive exsanguination 4, 5

Diagnostic Workup

• Blood cultures (often positive in infected cases) 6
• CT angiography showing periaortic gas, prosthetic gas around stent grafts, or contrast extravasation 6
• Cautious endoscopy to visualize the fistula and exclude other bleeding sources, but recognize that endoscopy may be negative and can dislodge protective clot 4, 5
• Thoracic aortography if CT is inconclusive 4

Etiology Context

• Most commonly secondary to esophageal cancer, trauma, foreign body, or erosion of vascular graft 1
• Occurs in 1.9% of patients after TEVAR for thoracic aneurysm 1
• Represents <10% of all aortoenteric fistulae 1

Prognosis

Untreated aortoesophageal fistula is uniformly fatal 4, 5. Even with aggressive surgical management, mortality remains 40-60% 1. The staged approach with TEVAR followed by definitive repair offers the best chance for survival, though morbidity remains high 2, 3. Conservative management must be avoided 6.