A Case of Secondary Aortoesophageal Fistula Inserted a Covered Self-Expanding Esophageal Stent to Control Gastrointestinal Bleeding

A 73-year-old man presented with melena. After a thorough workup including esophageal endoscopy, computed tomography scans, and esophagography, the diagnosis of secondary aortoesophageal fistula was made. Two years previously, he had undergone endovascular stent-graft repair for the dissection of his descending thoracic aorta. Because of the generally poor condition of the patient and the high risk of any aggressive surgical intervention, we inserted a covered self-expanding esophageal stent on postadmission day 18. Esophagography after insertion did not show any evidence of a leak of contrast medium. Despite treatment with antibiotics, he developed sepsis and expired on day 52, but rebleeding did not occur in this period. We consider insertion of a covered self-expanding esophageal stent as a feasible option in the management of secondary aortoesophageal fistula in high-risk patients. 1. Introduction Secondary aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR) is relatively rare [1–6], with a reported incidence of 1.7% to 1.9% [4, 7]. Treatment options are very limited, as these patients are usually not candidates for open surgery. Outcomes with conservative management are almost always fatal due to recurrent hemorrhage or chronic mediastinitis. Of note, there are no treatments to manage spontaneous, recurrent hemorrhage. In this paper, we describe a case of secondary AEF with insertion of a covered self-expanding esophageal stent to control gastrointestinal bleeding. 2. Case Presentation A 73-year-old man presented with melena. He had a history of endovascular stent-graft repair for the dissection of a descending thoracic aorta at the age of 71 and a stent-graft repair for a pseudoaneurysm sac of the distal aortic arch at the age of 72. He was hemodynamically unstable, and the bulbar conjunctiva showed evidence of anemia at presentation. Esophago-gastro-duodenoscopy (EGD) on admission revealed a white polyp in the midesophagus but no signs of acute bleeding. Colonoscopy was unremarkable. A blood transfusion failed to raise the hematocrit. On postadmission day five, the patient had hematemesis, prompting repeat EGD. Closer inspection of the previously seen esophageal polyp showed that the white material at the base was in fact the wall of the aortic interposition graft (Figure 1). Chest computed tomography (CT) scans revealed a high-density spot in contact with the esophagus and low-density spots in the vicinity of the stent graft. Esophagography showed a fistulous tract toward the stent graft (Figure 2). We concluded that