Thoracic Endovascular Aortic Repair of Esophageal Cancer-Associated Aortoesophageal Fistula: A Case Report and Literature Review

Abstract

Background: Thoracic endovascular aortic repair of an aortoesophageal fistula is an effective emergency treatment for patients with T4-esophageal cancer, as it prevents sudden death, and is a bridge to surgery. However, the course of unresectable malignant aortoesophageal fistula treated with thoracic endovascular aortic repair alone is not well-known.

Case presentation: We report a 67-year-old Japanese man with T4-esophageal cancer who experienced a chemoradiation-induced aortoesophageal fistula and was rescued with thoracic endovascular aortic repair. He recovered after the procedure and survived for 4 additional months with management of a mycotic aneurysm and secondary aortoesophageal fistula with the exposure of the stent graft into the esophagus. Thoracic endovascular aortic repair of aortoesophageal fistula with T4-esophageal cancer extended life for nearly an average of 4 months in the reported cases. As a postoperative complication, the exposure of the stent graft into the esophagus is rare but life-threatening; the esophageal stent insertion was effective.

Conclusions: With postoperative management advances, thoracic endovascular aortic repair can improve survival and increase the quality of life of patients with T4-esophageal cancer.

Figure 1

Imaging at the initial treatment for the aortoesophageal fistula using the TEVAR method. (a) EGD revealed a type 2 lesion spanning 3/4 of the circumference of the middle thoracic esophagus. (b) Computed tomography scan (CT) revealed esophageal wall thickening with tumor, and there was loss of the normal fat plane between the esophagus and the adjacent aorta. Approximately 90° of the circumference of the aorta was in contact with the tumor, which suggested aortic invasion (yellow thin arrow). (c) CT scan revealed aortic erosion of the intravenous contrast material within the descending thoracic aorta and extraluminal foci of air between the adjacent esophagus and the aorta (yellow thin arrow). (d) CT angiography did not indicate active bleeding. (e) Emergency esophagogastroduodenoscopy showed a pale fragile esophageal lesion on the posterior wall, an area previously treated with chemoradiation therapy, with massive blood coagulation. (f) Marking clips were placed on the side opposite the lesion.

Figure 2

Imaging showed esophageal stenting to repair the aortic stent migration. (a) Aortography showed no active bleeding. (b) Using the marking clips as a reference point, a stent graft was inserted to control the massive esophageal bleeding (yellow bold arrow). (c) Esophagogastroduodenoscopy revealed that the aortic stent is exposed into the esophagus. (d) The stent narrowed the esophageal lumen, hindering the scope's passage past the lesion. (e) An esophageal stent was placed adjacent to the aortic stent to push it out and dilate the esophageal lumen. (f) The contrast medium flowed smoothly within the esophageal stent.