Aortoesophageal fistula with endovascular repair

Case contributed by Dr Michael P Hartung

Presentation

Hematemasis.

Patient Data

Gender: Male
CT

Presentation - CT PA

Aortoesophageal fistula involving the distal descending thoracic aorta, filling the distal esophagus and stomach with contrast enhanced blood. Esophagus is thickened and irregular at the site of fistula, but relatively smooth distally. The nonopacified material in the stomach surrounded with contrast likely represents clotting blood from earlier bleeding before the scan. 

No acute pulmonary embolus. 

DSA (angiography)

Thoracic endovascular aortic repair (TEVAR)

The first series shows leak of the right distal descending thoracic aorta (near upper 1/4 of image) indicating the site of the fistula. The second annotated image highlights the location of the leak from the first series. 

Post-repair series shows a covered aortic graft which successfully stopped the leak.

Case Discussion

Striking case of aortoesophageal fistula detected on a CTPA study, caused by a nonmalignant ulcer (confirmed later by EGD). The patient presented with hematemesis, and acute pulmonary embolus was suspected. In this case, the patient rapidly declined and coded in the ED following CT, and underwent urgent TEVAR by vascular surgery. 

It is essential for the radiologist to know which service should intervene on vascular emergencies, and to ensure that the correct service is contacted immediately to intervene. In a busy ED with varying levels of expertise and familiarity with uncommon diagnoses, it may take directly stating that this finding is life-threatening and requires urgent intervention in order to properly convey the importance of prompt action. 

While this did not happen in this case, consulting the wrong service (such as gastroenterology or cardiothoracic surgery) could result in a delay in treatment and patient morbidity as that team evaluates the patient and realizes the wrong service has been consulted. 

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Case information

rID: 73781
Published: 22nd Jan 2020
Last edited: 20th Jul 2020
System: Vascular
Inclusion in quiz mode: Included

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