Endoscopic diagnosis of secondary aortoesophageal fistula

Secondary aortoesophageal fistula (AEF) is a catastrophic complication of endovascular graft placement [1]. The typical symptom of secondary AEF is massive gastrointestinal bleeding with a history of thoracic aortic aneurysm repair [2]. Endoscopy is the most sensitive and specific diagnostic study [3]. Endoscopy should be carefully performed, as it excludes other, more common causes of upper gastrointestinal bleeding, but should be terminated if a fistula is identified. We present an endoscopic finding of secondary AEF.

A 60-year-old woman was diagnosed with a mycotic thoracoabdominal aortic aneurysm and underwent resection of the aneurysm with an in-situ prosthetic interposition graft. Two weeks later, she developed massive hematemesis with hypotension. Emergency esophagoscopy revealed that the graft had eroded into the upper esophagus, with active bleeding ([Fig. 1]). Angiography with endovascular stenting and coil embolization were performed but failed to control the bleeding ([Fig. 2]). The patient died from exsanguinating hemorrhage.

Fig. 1 Endoscopic view showing the Dacron graft in the upper esophagus with bleeding.

Fig. 2 Aortogram showing the endovascular stent with coil embolization and continuous leakage.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AG

References

• 1 Sinar A R, Demaria A, Kataria Y P, Thomas F B. Aortic aneurysm eroding the esophagus.  Dig Dis Sci. 1977;  22 252-254
• 2 Carter R, Mulder G A, Snyder Jr E N, Brewer III L A. Aortoesophageal fistula.  Am J Surg. 1978;  136 26-30
• 3 Sosnowik D, Greenberg R, Bank S, Graver L M. Aortoesophageal fistula: early and late endoscopic features.  Am J Gastroenterol. 1988;  83 1401-1404