Kartikeya Rajdev, MBBS
Fellow, Pulmonary, Critical Care & Sleep Medicine
University of Nebraska Medical Center, Omaha
Omaha, Nebraska, United States
Disclosure information not submitted.
Ujjwal Madan, MBBS
Medical Student
University College of Medical Sciences, New Delhi, United States
Disclosure information not submitted.
Maureen Mcelligott, MD
Fellow, Pulmonary, Critical Care & Sleep Medicine
University of Nebraska Medical Center, Omaha, United States
Disclosure information not submitted.
Maximiliano Hawkes, MD
Assistant Professor, Neurological Sciences and Critical Care Medicine
University of Nebraska Medical Center, Omaha, United States
Disclosure information not submitted.
Brian Boer, MD, PhD
Assistant Professor, Pulmonary, Critical Care & Sleep Medicine
University of Nebraska Medical Center, Omaha, United States
Disclosure information not submitted.
Title: Aortoenteric Fistula presenting with Massive Hematemesis: Controlled with TEVAR
Introduction:
Aortoenteric fistula is a rare but life-threatening condition that often presents with gastrointestinal bleeding. It occurs with aortic aneurysm, foreign body, gastrointestinal malignancy, including esophageal cancer. Thoracic endovascular aortic repair (TEVAR) is a minimally invasive, bridging procedure when massive bleeding occurs, to allow for fluid resuscitation.
Description:
A 76 y/o male with a past medical history of DVT on apixaban and esophageal adenocarcinoma completed chemo-radiation therapy 3yrs ago presented to the hospital with hematemesis. The patient had a h/o esophageal stricture (likely from radiation therapy) for which he received an esophageal stent 1yr prior to presentation (ptp). The stent was removed 1month ptp as it did not relieve his dysphagia and he had persistent chest pains. In the ED, he had frequent small volume bright red bloody emesis. CT scan with contrast revealed a 0.3x0.5cm outpouching of contrast along the right lateral margin of the posterior aortic arch which appears to extend into the esophageal wall and approaches the lumen. The patient deteriorated quickly with massive hematemesis and became hypotensive. An urgent central venous access was established and the patient was intubated. Cardiothoracic surgery was consulted following which he was taken to the OR for TEVAR and aortic endograft placement. His condition stabilized post-procedure. Endoscopy revealed recurrence of esophageal cancer. The patient received a gastrostomy tube and decided to go home with palliative care.
Discussion:
Aortoenteric fistula developing due to esophageal cancer can present with massive hematemesis resulting in hemodynamic instability. In such patients, TEVAR can temporarily prevent exsanguination. Endovascular stent grafting performed in TEVAR should be followed by open graft explantation and resection and repair of the esophagus, which constitutes definitive repair for surgically fit patients. There is a risk of graft infection in the absence of definitive repair. Currently, this technique is preferred over open thoracic aortic surgery due to its favorable risk profile and can prove to be a life-saving treatment option for unstable patients.