A rare complication of vascular surgery - subclinical esophageal perforation secondary to supra-aortic debranching and TEVAR: a case report.

Introduction and importance: Combined supra-aortic debranching and thoracic endovascular aortic repair (TEVAR) are well-established therapeutic options for complex aortic arch pathologies. Although rare, late complications such as esophageal injury can be life-threatening and require prompt multidisciplinary management. Several cases of delayed esophageal perforation complicated by mediastinitis have been reported in the literature. However, perforation presenting solely as a graft infection causing microembolizations remains exceedingly rare. Case presentation: A 56-year-old male patient with a history of multiple prior cardiovascular surgeries (including TEVAR and zone 1 debranching) and no other relevant medical or habitual risk factors was admitted with recurrent fever, painful ischemic petechiae of the left hand, and left-sided transient ischemic attacks. Imaging studies demonstrated infection of the carotico-subclavian polytetrafluoroethylene (PTFE) crossover graft. Esophagogastroduodenoscopy revealed esophageal perforation caused by erosion of the retroesophageal PTFE graft. Complete graft explantation, arterial homograft reconstruction, and surgical repair of the esophageal lesion were performed. Subsequently, the patient required partial graft resection due to pseudoaneurysm formation of the homograft, as well as percutaneous angioplasty for stenosis of the subclavian anastomosis. At present, the patient remains in a satisfactory and stable condition. Clinical discussion: Retroesophageally positioned grafts may lead to esophageal perforation through chronic mechanical compression and subsequent ischemic necrosis of the esophageal wall. In the present case, the graft itself appeared to tamponade the perforation, thereby limiting mediastinal contamination and contributing to the subclinical presentation. Conclusion: The present case highlights the potential for an atypical and insidious clinical presentation that may delay diagnosis. Early graft explantation and appropriate reconstruction may lead to favorable clinical outcomes.