Successful rescue of a patient with aortoesophageal fistula secondary to anastomotic leak after esophagectomy.

backgroundAortoesophageal fistula (AEF) is a rare but invariably life-threatening conditio. The optimal treatment for AEF resulting from postoperative anastomotic leakage following esophageal cancer surgery remains a significant clinical challenge. Here, we report a detailed case of AEF caused by anastomotic leakage from a thoracic esophageal anastomosis after esophageal cancer resection, which was successfully managed with emergent thoracic endovascular aortic repair (TEVAR) for hemorrhage control, followed by elective surgical intervention comprising esophagogastric re-anastomosis and aortic fistula repair with a bovine pericardial patch. The patient achieved long-term survival. CASE PRESENTATION: A 68-year-old male underwent minimally invasive McKeown esophagectomy with intrathoracic esophagogastric anastomosis after neoadjuvant chemotherapy and immunotherapy for advanced esophageal squamous cell carcinoma (SCC). Postoperatively, the patient experienced fever followed by hematochezia and hematemesis. Emergency endoscopy was unsuccessful in controlling the active arterial bleeding at the inflamed anastomotic site. Enhanced CT angiography (CTA) did not reveal a definitive aortoesophageal fistula, and subsequent transarterial embolization of the right gastric artery (confirmed by procedural records) failed to control the condition. The patient developed hemorrhagic shock manifested by loss of consciousness and hypotension. A repeat enhanced CT scan revealed active contrast extravasation from the descending aorta into the gastric conduit. An emergency TEVAR was performed to stabilize the hemodynamics. On postoperative day 10, we performed surgical exploration, which confirmed resection of the esophagogastric anastomotic leak, direct repair of the aortic wall defect, and reconstruction via esophagogastric anastomosis with the remnant stomach. Intraoperatively, a stapler clip from previous endoscopic hemostasis was identified as the potential culprit for the fistula formation. Ten months after the onset of AEF, the patient continued chemotherapy and led a normal daily life.

conclusionThis case underscores that TEVAR is an effective and life-saving hemostatic method for managing life-threatening hemorrhage from AEF. However, TEVAR alone cannot ensure long-term survival due to its inability to control the underlying infection and address the gastrointestinal defect. Long-term survival requires subsequent definitive surgical repair of both the esophageal and aortic components.