Portal de Periódicos da CAPES

Successful Multistaged Surgical Management of Secondary Aortoesophageal Fistula With Graft Infection

2016; Elsevier BV; Volume: 101; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2015.10.099

1552-6259

Rana O. Afifi, Harith H. Mushtaq, Harleen K. Sandhu, Kamal Khalil, Hazim J. Safi, Anthony L. Estrera,

Vascular Procedures and Complications

Secondary aortoenteric fistula is a rare and dreaded complication of aortic graft replacement. This case demonstrates successful management of a patient with thoracic aortic graft infection resulting in aortoesophageal fistula and the feasibility of combined endovascular approach as a temporary measure to stabilize the patient in extremis, followed by a definitive surgical repair. The patient had a remote history of descending aortic repair and an emergent thoracic endovascular aortic repair for upper gastrointestinal bleeding 2 months ago. We performed a three-staged operation involving extraanatomic bypass, total infected aortic graft excision, and primary closure of the esophageal perforation with muscle flap coverage, from which he eventually recovered. Secondary aortoenteric fistula is a rare and dreaded complication of aortic graft replacement. This case demonstrates successful management of a patient with thoracic aortic graft infection resulting in aortoesophageal fistula and the feasibility of combined endovascular approach as a temporary measure to stabilize the patient in extremis, followed by a definitive surgical repair. The patient had a remote history of descending aortic repair and an emergent thoracic endovascular aortic repair for upper gastrointestinal bleeding 2 months ago. We performed a three-staged operation involving extraanatomic bypass, total infected aortic graft excision, and primary closure of the esophageal perforation with muscle flap coverage, from which he eventually recovered. Secondary aortoesophageal fistula (SAEF) is an uncommon but life-threatening condition. It is a pathologic communication between the aorta and esophagus in the setting of a previous treatment of thoracic aortic disease by a prosthetic graft. The reported incidence of SAEF after surgery is low (4.8%) [1Hollander J.E. Quick G. Aortoesophageal fistula: a comprehensive review of the literature.Am J Med. 1991; 91: 279-287Abstract Full Text PDF PubMed Scopus (221) Google Scholar]. Immediate surgical intervention in SAEF is imperative. However, the optimal surgical approach for management of patients with SAEF is controversial. Conservative treatment of SAEF is not a feasible option because most reported cases result in fatality [2Chiesa R. Melissano G. Marone E.M. Marrocco-Trischitta M.M. Kahlberg A. Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: a national survey.Eur J Vasc Endovasc Surg. 2010; 39: 273-279Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar]. Open surgical management with an in situ aortic graft replacement and concomitant esophageal repair has a reported in-hospital mortality rate of more than 55% [3Saito A. Motomura N. Hattori O. et al.Outcome of surgical repair of aorto-eosophageal fistulas with cryopreserved aortic allografts.Interact Cardiovasc Thorac Surg. 2012; 14: 532-537Crossref PubMed Scopus (24) Google Scholar, 4Kieffer E. Chiche L. Gomes D. Aortoesophageal fistula: value of in situ aortic allograft replacement.Ann Surg. 2003; 238: 283-290PubMed Google Scholar]. Thoracic endovascular aortic repair (TEVAR) offers a minimally invasive alternative and is especially valuable as a bridging procedure under emergent situations [5Canaud L. Ozdemir B.A. Bee W.W. Bahia S. Holt P. Thompson M. Thoracic endovascular aortic repair in management of aortoesophageal fistulas.J Vasc Surg. 2014; 59: 248-254Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. In this report, we describe a successfully managed case of SAEF by using a staged, multidisciplinary strategy of combined endovascular and open surgical approach. A 41-year-old man with a known history of testicular cancer 6 months before his admission was diagnosed with metastasis in the left lung. He underwent en-bloc pneumonectomy, proximal descending thoracic aortic (DTA) resection, and polyethylene terephthalate fiber (Dacron) graft placement because of encasement of the DTA by the malignant lesion. Three months later, he was diagnosed with SAEF after he presented with massive upper gastrointestinal bleeding and was hypotensive and in extremis. Emergent TEVAR was performed initially for stabilization. Several days after TEVAR, thoracostomy with evacuation of the left hemothorax, gastrojejunal feeding tube placement, and end cervical esophagostomy for complete esophageal diversion were performed. Two months later, he presented with fever, generalized malaise, weight loss, purulent discharge from his left chest drain, and bloody stool. He was transferred to our facility for management of the suspected aortic graft infection. On admission, the patient was hemodynamically stable. Admission hemoglobin level was 6 g/dl. Leukocytosis was absent, but drain cultures were positive for Pseudomonas aeruginosa and he was started on antibiotics. Chest computed tomography angiography showed signs of infected aortic graft (Fig 1). After multidisciplinary discussion, we decided to adopt a staged surgical approach. The patient underwent an extraanatomic bypass from the ascending aorta to the DTA through a midline sternotomy using a 16-mm polyethylene terephthalate fiber (Dacron) graft (Fig 2). The second stage was performed 3 days later, involving excision of the previously infected aortic graft, explantation of the endograft, and aortic exclusion. The following day, primary repair of the esophageal perforation and pedicled latissimus dorsi muscle flap coverage was performed as the final stage (Fig 3).Fig 3Latissimus dorsi muscle pedicled flap.View Large Image Figure ViewerDownload (PPT) Intraoperative cultures were positive for vancomycin-resistant Enterococcus species and Pseudomonas aeruginosa. Antibiotic coverage was administered accordingly. The patient had multiple chest washouts and, eventually, required six-rib thoracoplasty to eliminate the postpneumonectomy infected residual dead space. He was extubated on postoperative day 9. After the second-stage surgery, the patient had a right-side hemiplegia, and the head computed tomography scan revealed a left middle cerebral artery territory infarct. He was started on physical and occupational rehabilitation therapy and showed a steady, gradual recovery. On postoperative day 25, the patient was transferred to a rehabilitation hospital. At a 12-month follow-up, the patient showed remarkable neurologic recovery. He was referred to another hospital for definitive surgical management of the esophagus and underwent a staged procedure nearly 1.5 years after the aortic procedure, involving distal esophageal resection and gastric pull up with cervical esophageal anastomosis to gastric conduit for reestablishing gastrointestinal continuation. He was discharged home without further complications in a stable condition. Secondary aortoesophageal fistula is a relatively rare but frequently fatal condition that mandates early surgical intervention. The first report of successful surgical management of SAEF was described in 1978 by Smaha and colleagues [6Smaha L.A. Klima T. Leatherman L.L. Aortoesophageal fistula. Late complication after repair of thoracic aortic aneurysm.JAMA. 1978; 240: 2077-2078Crossref PubMed Scopus (16) Google Scholar]. The conventional open surgical approach, involving replacement of the DTA with concomitant resection of the infected aortic graft and esophageal repair or resection, is associated with high morbidity and mortality, ranging from 45.4% to 55% [3Saito A. Motomura N. Hattori O. et al.Outcome of surgical repair of aorto-eosophageal fistulas with cryopreserved aortic allografts.Interact Cardiovasc Thorac Surg. 2012; 14: 532-537Crossref PubMed Scopus (24) Google Scholar, 4Kieffer E. Chiche L. Gomes D. Aortoesophageal fistula: value of in situ aortic allograft replacement.Ann Surg. 2003; 238: 283-290PubMed Google Scholar]. Others have described an extraanatomic bypass from the ascending aorta to the distal descending or supraceliac aorta with excision of infected graft [7Wong R.S. Champlin A. Temes R.T. Wernly J.A. Aortoesophageal fistula after repair of descending aortic dissection.Ann Thorac Surg. 1996; 62: 588-590Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 8Madan A.K. Santora T.A. Disesa V.J. Extra-anatomic bypass grafting for aortoesophageal fistula: a logical operation.J Vasc Surg. 2000; 32: 1030-1033Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. As opposed to in situ reconstruction, the extraanatomic approach has a lower potential for graft reinfection and reduces the total ischemic time in patients who are already hemodynamically compromised. In our patient, we performed an extraanatomic bypass to minimize the risks of reinfection, followed by resection of the previous aortic grafts and definitive repair of the esophageal perforation through a primary repair. This was reinforced with a pedicled muscle flap (Fig 3) to buffer the esophageal repair and minimize recurrent infections and enteric connections. Recently, TEVAR has emerged as an alternative treatment to open surgery in SAEF, especially in unstable patients or those who are poor surgical candidates. Although it offers a less-invasive option and allows prompt exclusion of the SAEF, thus preventing bleeding, studies report a significant in-hospital mortality after TEVAR alone, secondary to high rates of reinfection, mediastinitis, sepsis, and SAEF recurrence [5Canaud L. Ozdemir B.A. Bee W.W. Bahia S. Holt P. Thompson M. Thoracic endovascular aortic repair in management of aortoesophageal fistulas.J Vasc Surg. 2014; 59: 248-254Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. Results were better with a combined approach in which TEVAR was followed by definitive open surgical repair, with an overall mortality of 52.5% with TEVAR alone versus 25% in combined cases [5Canaud L. Ozdemir B.A. Bee W.W. Bahia S. Holt P. Thompson M. Thoracic endovascular aortic repair in management of aortoesophageal fistulas.J Vasc Surg. 2014; 59: 248-254Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. The recurrence rate of SAEF after TEVAR alone was reported to be 20% versus 6.2% in combined TEVAR with open repair during a mean follow-up of 7.4 months (range, 1 to 33 months) [5Canaud L. Ozdemir B.A. Bee W.W. Bahia S. Holt P. Thompson M. Thoracic endovascular aortic repair in management of aortoesophageal fistulas.J Vasc Surg. 2014; 59: 248-254Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. Therefore, TEVAR is mostly recommended as a bridging procedure for stabilizing the patient in extremis, followed by more extensive reconstruction of the DTA and esophagus at a later stage [5Canaud L. Ozdemir B.A. Bee W.W. Bahia S. Holt P. Thompson M. Thoracic endovascular aortic repair in management of aortoesophageal fistulas.J Vasc Surg. 2014; 59: 248-254Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. In our case, TEVAR resulted in prompt cessation of bleeding and stabilization of the patient, allowing us to perform definitive treatment with open surgical repair at a later stage. In summary, SAEF is a complex, life-threatening condition. A multidisciplinary approach is advisable to achieve prompt control of bleeding, sometimes using TEVAR, total excision of the infected aortic graft, repair of the esophageal defect, reconstruction of the aortic continuity, and adequate antibiotic therapy. These are the keystones of managing patients with SAEF. The present case demonstrates that a staged approach with a multidisciplinary team could improve the patient’s survival. The authors wish to acknowledge the contributions of Troy Brown for document editing and Chris Akers for illustrations.