Current results of a combined endovascular and open approach for the treatment of aortoesophageal and aortobronchial fistulae

Abstract

Background: Aortoesophageal (AEF) and aortobronchial (ABF) fistulae are uncommon but invariably fatal if left untreated. Mortality rates of open surgery remain prohibitive. Thoracic endovascular aortic repair (TEVAR) was shown to be a valid alternative to control bleeding in emergency, allowing a reduction of perioperative mortality. However, it entails a significant risk of late sequelae, namely endograft contamination and sepsis, related to the untreated esophageal leak. The aim of this study is to present initial results of a combined "hybrid" (endovascular and open) strategy to treat AEF and ABF.

Materials and methods: From 2006 to 2013, 8 patients (6 men, mean age 63 ± 13 years) were operated at our institution for primary and secondary AEF (7 patients) or ABF (1 patient) by means of a combined approach: emergent endovascular exclusion of the aortic rupture, followed by staged open surgical repair of the esophageal or bronchial lesion with associated intercostal muscle flap interposition. Follow-up was available in all patients (mean 34 ± 26 months).

Results: TEVAR was successfully performed in all cases in emergency because of active bleeding or hemodynamic instability. Stabilization of hemodynamic parameters was obtained in all patients. Open surgical stage was performed either directly after TEVAR (n = 1) or after a mean delay of 6.9 ± 3.5 days (n = 7). No perioperative sepsis, bleeding, or death was observed. At follow-up, 7 patients were alive (87.5%). One patient died 1 year after the procedure because of sudden cardiocirculatory arrest of unknown origin. Another patient experienced 2 hospitalizations, at 3 and 8 months after the procedure, for recurrent fever requiring prolonged intravenous antibiotic therapy. No conversion or aortic bleeding was recorded during follow-up.

Conclusions: Immediate TEVAR followed by staged open repair of the esophageal or bronchial defect with intercostal muscle flap interposition appears to be a feasible treatment of AEF and ABF. Despite the fact that initial results are encouraging, further data on wider cohorts with longer follow-up are necessary to confirm the efficacy and durability of this strategy.