Aortoesophageal fistula

Aortoesophageal fistulaAorto-oesophageal fistulae is a rare fistulous communication are pathologic communications between the aorta and oesophagus and resultsresult in life threatening -threatening upper gastrointestinal haemorrhage. It isThey are fatal in the absence of prompt management. 

Epidemiology

Aortoesophageal fistula has an incidence of 0.5 to 1.7% ⁸.  Rupture of aortic aneurysm within the oesophagus is the most common cause and constitutes 54.2fistulas are a rare entity that accounts for approximately 10% of all casesaortoenteric fistulae or an estimated frequency of less than 0.5% in patients admitted with upper gastrointestinal haemorrhage ^31-3. Other causes includeAn incidence of 1.7% to 1.9% has been reported in the setting of thoracic endovascular aortic repair (TEVAR) ^1,2,4.

Associations

It has been commonly associated with rupture of the descending thoracic aorta and the following conditions ^1-6:

• atherosclerotic plaqueaortic aneurysm

• foreign body aortic dissection

• foreign body

• malignancy: especially oesophageal cancer

• infectionsinfection: e.g. tuberculosis ¹

• radiotherapy

• postinterventional or postoperative complications

  • endovascular stent erosion

  • aortic graft infection

Diagnosis

CT AngiographyThe diagnosis of aortooesophageal fistulae is used to diagnose aortoesophageal fistula althoughprimarily based on imaging or CT angiography. Although upper gastrointestinal endoscopy may be performed to rule out other possible causes of upper gastrointestinal haemorrhage^2,36,7.

Clinical presentation 

The patient usually presents as a case of emergency with massive haemorrhage and haematemesis. Clinical presentation is classically described by the Chiari triad consisting of ^3,52-6:

• mid Thoracicthoracic pain 

• sentinel arterial haemorrhage 

• exsanguination following a symptom free-free period (seen in 80% of the patients)

Pathology

The etiopathogenesisBy definition, aortoesophageal fistulae are abnormal connections between the oesophagus and the aorta, usually resulting in the passage of aortoesophageal fistulablood from the aorta to the oesophagus or vice versa, i.e. air and oesophageal contents into the aorta ¹. Mechanisms include direct erosion in the case of foreign bodies or implants and/or pressure necrosis of the aortic wall and soft tissues between the oesophagus and aorta ^1,2.

Location

The most common location is only known in certain cases. Continuous arterial pulsations and resultant trauma is cited as a causethe descending thoracic aorta, but aortooesophageal fistulae have been also reported for the development of aortoesophageal fistula in patients with aortic stentsarch and ascending aorta ⁷. Rupture of an abscess following infection also leads to formation of aortoesophageal fistulas in some cases ⁷².

Radiographic features

CT angiography in an aortoesophageal fistula may show^1,83,5: 

• extravasation of contrast material

• gas effusionair bubbles in the aortic wall or around the graft

• direct connection between the aorta and oesophagus

• oesophageal narrowing

• false aneurysm 

• mediastinal haematoma 

• teat like outpouching from aorta into oesophagusstent migration

Radiology report

The radiology report should contain the following:

• diagnosis and location of the fistula with supporting features as

  • extravasation of contrast material 

  • stentair bubbles in the aortic wall or around the graft after TEVAR

• possible causes

  • implants (stent migration)

  • mural thrombusforeign bodies

  • true or false aortic aneurysms

  • aortic dissection

• additional features and complications

  • mediastinal haemorrhage

  • haematothorax

Treatment and prognosis 

AortoesophagealManagement usually includes a combination of bleeding control in the urgent phase and surgical intervention with radical debridement of the fistula hasand the contaminated zone as well as reconstruction of the aorta and the oesophagus later as a mortalitysemi-urgent intervention ¹. Initial treatment and bleeding control has been done with a Sengstaken-Blakemore tube in the past but is usually done with TEVAR nowadays ¹ followed by a perioperative management period and radical surgery once the patient is in the condition for the latter ¹.

Prognosis is not good with an estimated death rate of 77up to 60% within 6 months after symptom onset ^1,2.

History and requires urgent management ³.etymology 

Haematemesis is managed with the Sengstaken-Blakemore tube, which temporarily stabilises the patient with its tamponade effect ^1,3. 

Management ofThe first aortoesophageal fistula involves two steps: aortic repair and oesophageal repair. Aortic repair is usually performedwas described in 1818 by a minimally invasive procedure called thoracic endovascular aortic repair. Oesophageal repair involves oesophagectomy and oesophageal stent placementthe French naval surgeon Joseph-MarieDubreiul (1790-1852) ^1,3. 

Surgical management can also be done by open surgery, which has a higher mortality rate but allows a thorough management of infection in the presence of an infectious cause ^38,10. 

Differential diagnosis

Aortoesophageal fistula needs to be differentiated from other causes of upper gastrointestinal haemorrhage.

History and etymology 

Aortoesophageal fistula was first described in 1818 by a French naval surgeon Dubreiul ⁶. 

See also 

Aortoenteric fistula