Role of thoracic endovascular aortic repair in T4b esophageal cancer management: a systematic review

Abstract

The incidence of T4b esophageal cancer with aortic invasion but without distant metastasis is estimated to be between 3.8% and 4.6% of all esophageal cancer cases. Development of an aortoesophageal fistula in such cases is a rare but not unlikely event, leading to catastrophic consequences. The aim of this systematic review is to evaluate the importance of aortic stenting (Thoracic Endovascular Aortic Repair-TEVAR) and its optimal timing in the management of locally advanced esophageal cancer. A systematic literature search of the MEDLINE, Scopus, and Google Scholar databases was undertaken to identify relevant studies published up to March 2024. An individual patient data analysis was performed by forming a patient cohort with elective and salvage TEVAR subgroups, depending on the timing of the stenting. The study pool consisted of 25 studies incorporating 101 cases of locally advanced esophageal cancer, with a median age of 64 years (range 45-87 years). Of them, 50 patients underwent elective TEVAR compared with 51 patients receiving TEVAR in an acute salvage setting. Elective or prophylactic TEVAR was found to significantly increase esophageal resection rates (65.6% vs. 16.7% in the salvage subgroup, P < 0.001), concurrently reducing complication rates (8.3% vs. 36.1%, P < 0.001). Overall survival was also prolonged in the elective subgroup (8.3 vs. 4 months, P = 0.001), with elective stenting being the only independent predictor of improved survival. In conclusion, management with aortic stenting in high-risk patients may reduce the catastrophic consequences of massive bleeding, minimize complications, and enhance survival rates.

Keywords: TEVAR; endovascular repair; esophageal cancer; resectability; survival.