An aorto--oesophageal fistula following endograft: sealing of fistulae with omentum and replacement of the aorta

An aorto--oesophageal fistula following endograft: sealing of fistulae with omentum and... Abstract Aorto-oesophageal fistulae represent <10% of all aortoenteric fistulae and occur in 1.9% of patients who undergo thoracic endovascular aortic repair for treatment of thoracic aortic aneurysms. Untreated patients have a mortality close to 100%. A 74-year-old man had aorto-oesophageal fistulae secondary to thoracic endovascular aortic repair. He had a functioning left internal thoracic artery graft to the left anterior descending artery and a calcific distal aortic arch. He underwent replacement of the thoracic aorta and sealing of the fistulous tract with omentum, and the latter was used to wrap the neoaorta. Aortic operation, Oesophageal injury/perforation, Stents, Omentum, Infection INTRODUCTION The incidence of infections involving vascular and endovascular prostheses varies between 0.5% and 5% based on anecdotal case reports and small case series [1]. Infection is suggested to be the main mechanism of aorto-oesophageal fistula (AEF) formation following thoracic endovascular aortic repair (TEVAR) [2]. If undiagnosed and untreated, it carries a mortality rate of up to 100%. A 74-year-old man underwent coronary artery bypass grafting 8 years ago using the left internal thoracic artery. Eight months following TEVAR, he developed AEF. CASE REPORT A 74-year-old man presented with massive haematemesis and a haemoglobin count of 6.4 g/dl. He had haematemesis in the past 2 weeks requiring 2 units of packed cell transfusion every 48 h. Oesophagoscopy revealed a Grade B ulcer at the level of D6–7 and blood clots in the stomach. He had undergone coronary artery bypass grafting 8 years ago (left internal thoracic artery to left anterior descending artery, saphenous vein to diagonal and right posterior descending artery). TEVAR to the proximal descending thoracic aorta (DTA) for pseudoaneurysm was performed 8 months ago. Computed tomography showed ectopic gas in the posterior mediastinum suggestive of AEF. The aorta surrounding the region of left subclavian artery (LSA) had calcific plaques (Fig. 1). Figure 1 View largeDownload slide (A) Oblique section of the computed tomography scan showing the pseudoaneurysm in the descending thoracic aorta below the endograft. (B) Oesophagoscopy showing an ulcer in the oesophagus at D6–7 level. (C) Axial section showing ectopic gas in the posterior mediastinum in the perioesophageal area. Figure 1 View largeDownload slide (A) Oblique section of the computed tomography scan showing the pseudoaneurysm in the descending thoracic aorta below the endograft. (B) Oesophagoscopy showing an ulcer in the oesophagus at D6–7 level. (C) Axial section showing ectopic gas in the posterior mediastinum in the perioesophageal area. He underwent open surgical repair. Laparoscopically, a pedicle omental flap based on left gastroepiploic artery was harvested with the patient in a supine position. After exposing the left femoral vessels, a left lateral thoracotomy was performed through the sixth left intercostal space. Dacron grafts (7 mm) were anastomosed to the LSA and left common carotid artery (LCCA). Cardiopulmonary bypass was established through the left femoral vessels. Dacron grafts anastomosed to the LSA and LCCA were connected to cardiopulmonary bypass, and a flow of 10 ml/kg/min was maintained in each of the arteries. Surgery was performed under normothermia with a beating heart and right lung ventilation. Proximally, the aorta was cross-clamped between the innominate artery and the LCCA, whereas the distal clamp was applied on the DTA above the coeliac artery. The endovascular graft was explanted, and the periaortic area was debrided with irrigation of the posterior mediastinum. The DTA was replaced with a 26-mm rifampicin-soaked Dacron graft. The vascular graft of the LCCA and LSA was anastomosed to the aortic graft. A cruciate rent was made in the left hemidiaphragm to mobilize the omentum into the left hemithorax. The omental flap was used to fill the aorto-oesophageal groove, sealing the fistulous tract and was also used to wrap the DTA graft (Video 1). Nasojejunal feeding was started from the 6th postoperative day. After confirming the healing of the fistulae with oral contrast computed tomography scan, oral feeds were started after 6 weeks. Intravenous antibiotics were continued for 3 weeks. Cultures of the periaortic tissues did not grow any organisms. After 1 year of follow-up, he is doing well (Fig. 2). Figure 2 View largeDownload slide (A) 3D reconstructed computed tomography (CT) image showing the replaced descending thoracic aorta and reimplanted left common carotid artery and left subclavian artery. (B) CT oral contrast at 6 weeks showing no evidence of residual fistulous tract. (C) Axial CT scan showing the omentum filling the aorto-oesophageal groove. Figure 2 View largeDownload slide (A) 3D reconstructed computed tomography (CT) image showing the replaced descending thoracic aorta and reimplanted left common carotid artery and left subclavian artery. (B) CT oral contrast at 6 weeks showing no evidence of residual fistulous tract. (C) Axial CT scan showing the omentum filling the aorto-oesophageal groove. Video 1 Surgical procedure of the aforementioned case is being elaborated. Video 1 Surgical procedure of the aforementioned case is being elaborated. Close DISCUSSION AEF represents <10% of all aortoenteric fistulae and occur in 1.9% of patients who undergo TEVAR [3]. As the follow-up time after TEVAR increases, late complications including AEFs occur. There is a lack of consensus concerning the optimal treatment for AEF [4]. The primary goals of management include control of bleeding and haemodynamic stabilization, repair of the fistula and reconstruction of the aorta. Human omentum has an abundant blood supply with a high absorptive capacity, which encourages bacterial clearance. Further, it also promotes angiogenic activity in structures to which it is closely applied, thus supporting both ischaemic and inflamed tissues. Prosthetic grafts wrapped with omentum have the potential to prevent long-term postoperative graft infection and have a significant higher infection-free survival rate [5]. The problems in this patient were (i) old age with multiple comorbidities restricting us from preforming major oesophageal procedures, (ii) a functioning left internal thoracic artery graft to coronary artery preventing us from interrupting the LSA and (iii) calcific distal aortic arch making aortic cross-clamp difficult. Hence, we opted for a less radical treatment. By clamping the aorta proximal to the LCCA and continuously perfusing the LSA, we circumvented the latter 2 problems. The flow to the innominate artery, native coronary artery and the venous grafts of coronary artery bypass grafting were maintained by the beating heart with right lung ventilation. As cooling can induce ventricular fibrillation, we avoided hypothermia. ACKNOWLEDGEMENT We acknowledge Patta Radhakrishnan, Chief Surgical Gastroenterologist, SIMS Hospitals, for helping us in mobilizing the omental flap. Conflict of interest: none declared. REFERENCES 1 Carrel T, Schmidli J. Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta. Multimed Man Cardiothorac Surg  2011 (1101), doi:10.1510/mmcts.2010.004750. 2 Eggebrecht H, Mehta RH, Dechene A, Tsagakis K, Kühl H, Huptas S. Aortoesophageal fistula after thoracic aortic stent-graft placement: a rare but catastrophic complication of a novel emerging technique. JACC Cardiovasc Interv  2009; 2: 570– 6. Google Scholar CrossRef Search ADS PubMed  3 Wilson WR, Bower TC, Creager MA, Amin-Hanjani S, O’Gara PT, Lockhart PB et al.   Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association. Circulation  2016; 134: e412– 60. Google Scholar CrossRef Search ADS PubMed  4 Akashi H, Kawamoto S, Saiki Y, Sakamoto T, Sawa Y, Tsukube T et al.   Therapeutic strategy for treating aortoesophageal fistulas. Gen Thorac Cardiovasc Surg  2014; 62: 573– 80. Google Scholar CrossRef Search ADS PubMed  5 Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms. Eur J Cardiothorac Surg  2013; 43: 1177– 82. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

An aorto--oesophageal fistula following endograft: sealing of fistulae with omentum and replacement of the aorta

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© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Abstract

Abstract Aorto-oesophageal fistulae represent <10% of all aortoenteric fistulae and occur in 1.9% of patients who undergo thoracic endovascular aortic repair for treatment of thoracic aortic aneurysms. Untreated patients have a mortality close to 100%. A 74-year-old man had aorto-oesophageal fistulae secondary to thoracic endovascular aortic repair. He had a functioning left internal thoracic artery graft to the left anterior descending artery and a calcific distal aortic arch. He underwent replacement of the thoracic aorta and sealing of the fistulous tract with omentum, and the latter was used to wrap the neoaorta. Aortic operation, Oesophageal injury/perforation, Stents, Omentum, Infection INTRODUCTION The incidence of infections involving vascular and endovascular prostheses varies between 0.5% and 5% based on anecdotal case reports and small case series [1]. Infection is suggested to be the main mechanism of aorto-oesophageal fistula (AEF) formation following thoracic endovascular aortic repair (TEVAR) [2]. If undiagnosed and untreated, it carries a mortality rate of up to 100%. A 74-year-old man underwent coronary artery bypass grafting 8 years ago using the left internal thoracic artery. Eight months following TEVAR, he developed AEF. CASE REPORT A 74-year-old man presented with massive haematemesis and a haemoglobin count of 6.4 g/dl. He had haematemesis in the past 2 weeks requiring 2 units of packed cell transfusion every 48 h. Oesophagoscopy revealed a Grade B ulcer at the level of D6–7 and blood clots in the stomach. He had undergone coronary artery bypass grafting 8 years ago (left internal thoracic artery to left anterior descending artery, saphenous vein to diagonal and right posterior descending artery). TEVAR to the proximal descending thoracic aorta (DTA) for pseudoaneurysm was performed 8 months ago. Computed tomography showed ectopic gas in the posterior mediastinum suggestive of AEF. The aorta surrounding the region of left subclavian artery (LSA) had calcific plaques (Fig. 1). Figure 1 View largeDownload slide (A) Oblique section of the computed tomography scan showing the pseudoaneurysm in the descending thoracic aorta below the endograft. (B) Oesophagoscopy showing an ulcer in the oesophagus at D6–7 level. (C) Axial section showing ectopic gas in the posterior mediastinum in the perioesophageal area. Figure 1 View largeDownload slide (A) Oblique section of the computed tomography scan showing the pseudoaneurysm in the descending thoracic aorta below the endograft. (B) Oesophagoscopy showing an ulcer in the oesophagus at D6–7 level. (C) Axial section showing ectopic gas in the posterior mediastinum in the perioesophageal area. He underwent open surgical repair. Laparoscopically, a pedicle omental flap based on left gastroepiploic artery was harvested with the patient in a supine position. After exposing the left femoral vessels, a left lateral thoracotomy was performed through the sixth left intercostal space. Dacron grafts (7 mm) were anastomosed to the LSA and left common carotid artery (LCCA). Cardiopulmonary bypass was established through the left femoral vessels. Dacron grafts anastomosed to the LSA and LCCA were connected to cardiopulmonary bypass, and a flow of 10 ml/kg/min was maintained in each of the arteries. Surgery was performed under normothermia with a beating heart and right lung ventilation. Proximally, the aorta was cross-clamped between the innominate artery and the LCCA, whereas the distal clamp was applied on the DTA above the coeliac artery. The endovascular graft was explanted, and the periaortic area was debrided with irrigation of the posterior mediastinum. The DTA was replaced with a 26-mm rifampicin-soaked Dacron graft. The vascular graft of the LCCA and LSA was anastomosed to the aortic graft. A cruciate rent was made in the left hemidiaphragm to mobilize the omentum into the left hemithorax. The omental flap was used to fill the aorto-oesophageal groove, sealing the fistulous tract and was also used to wrap the DTA graft (Video 1). Nasojejunal feeding was started from the 6th postoperative day. After confirming the healing of the fistulae with oral contrast computed tomography scan, oral feeds were started after 6 weeks. Intravenous antibiotics were continued for 3 weeks. Cultures of the periaortic tissues did not grow any organisms. After 1 year of follow-up, he is doing well (Fig. 2). Figure 2 View largeDownload slide (A) 3D reconstructed computed tomography (CT) image showing the replaced descending thoracic aorta and reimplanted left common carotid artery and left subclavian artery. (B) CT oral contrast at 6 weeks showing no evidence of residual fistulous tract. (C) Axial CT scan showing the omentum filling the aorto-oesophageal groove. Figure 2 View largeDownload slide (A) 3D reconstructed computed tomography (CT) image showing the replaced descending thoracic aorta and reimplanted left common carotid artery and left subclavian artery. (B) CT oral contrast at 6 weeks showing no evidence of residual fistulous tract. (C) Axial CT scan showing the omentum filling the aorto-oesophageal groove. Video 1 Surgical procedure of the aforementioned case is being elaborated. Video 1 Surgical procedure of the aforementioned case is being elaborated. Close DISCUSSION AEF represents <10% of all aortoenteric fistulae and occur in 1.9% of patients who undergo TEVAR [3]. As the follow-up time after TEVAR increases, late complications including AEFs occur. There is a lack of consensus concerning the optimal treatment for AEF [4]. The primary goals of management include control of bleeding and haemodynamic stabilization, repair of the fistula and reconstruction of the aorta. Human omentum has an abundant blood supply with a high absorptive capacity, which encourages bacterial clearance. Further, it also promotes angiogenic activity in structures to which it is closely applied, thus supporting both ischaemic and inflamed tissues. Prosthetic grafts wrapped with omentum have the potential to prevent long-term postoperative graft infection and have a significant higher infection-free survival rate [5]. The problems in this patient were (i) old age with multiple comorbidities restricting us from preforming major oesophageal procedures, (ii) a functioning left internal thoracic artery graft to coronary artery preventing us from interrupting the LSA and (iii) calcific distal aortic arch making aortic cross-clamp difficult. Hence, we opted for a less radical treatment. By clamping the aorta proximal to the LCCA and continuously perfusing the LSA, we circumvented the latter 2 problems. The flow to the innominate artery, native coronary artery and the venous grafts of coronary artery bypass grafting were maintained by the beating heart with right lung ventilation. As cooling can induce ventricular fibrillation, we avoided hypothermia. ACKNOWLEDGEMENT We acknowledge Patta Radhakrishnan, Chief Surgical Gastroenterologist, SIMS Hospitals, for helping us in mobilizing the omental flap. Conflict of interest: none declared. REFERENCES 1 Carrel T, Schmidli J. Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta. Multimed Man Cardiothorac Surg  2011 (1101), doi:10.1510/mmcts.2010.004750. 2 Eggebrecht H, Mehta RH, Dechene A, Tsagakis K, Kühl H, Huptas S. Aortoesophageal fistula after thoracic aortic stent-graft placement: a rare but catastrophic complication of a novel emerging technique. JACC Cardiovasc Interv  2009; 2: 570– 6. Google Scholar CrossRef Search ADS PubMed  3 Wilson WR, Bower TC, Creager MA, Amin-Hanjani S, O’Gara PT, Lockhart PB et al.   Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association. Circulation  2016; 134: e412– 60. Google Scholar CrossRef Search ADS PubMed  4 Akashi H, Kawamoto S, Saiki Y, Sakamoto T, Sawa Y, Tsukube T et al.   Therapeutic strategy for treating aortoesophageal fistulas. Gen Thorac Cardiovasc Surg  2014; 62: 573– 80. Google Scholar CrossRef Search ADS PubMed  5 Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms. Eur J Cardiothorac Surg  2013; 43: 1177– 82. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 1, 2018

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