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

Andrea Kahlberg, Yamume Tshomba, Enrico M. Marone, Renata Castellano, Germano Melissano, Roberto Chiesa

Research output: Contribution to journalArticle

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.

Original languageEnglish
Pages (from-to)1782-1788
Number of pages7
JournalAnnals of Vascular Surgery
Volume28
Issue number7
DOIs
Publication statusPublished - Oct 1 2014

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Fistula
Thorax
Intercostal Muscles
Hemorrhage
Therapeutics
Sepsis
Emergencies
Hemodynamics
Aortic Rupture
Mortality
Hospitalization
Fever
Anti-Bacterial Agents
allogenic effect factor

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Medicine(all)

Cite this

Current results of a combined endovascular and open approach for the treatment of aortoesophageal and aortobronchial fistulae. / Kahlberg, Andrea; Tshomba, Yamume; Marone, Enrico M.; Castellano, Renata; Melissano, Germano; Chiesa, Roberto.

In: Annals of Vascular Surgery, Vol. 28, No. 7, 01.10.2014, p. 1782-1788.

Research output: Contribution to journalArticle

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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.",
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AU - Castellano, Renata

AU - Melissano, Germano

AU - Chiesa, Roberto

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N2 - 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.

AB - 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.

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