Thoracic Mycotic Aortic Aneurysm with Aortoesophageal Fistula and Uniformly Fatal Outcomes, a Case Series and Focused Literature Review.

Background: Thoracic mycotic aortic aneurysm with aortoesophageal fistula (TMAA-AEF) is rare and highly lethal. However, limited data are available on imaging evolution and factors precluding transition to definitive surgery. Methods: This retrospective, single-center case series included all consecutive adults with TMAA-AEF over a 10-year period. AEF was classified using predefined criteria; computed tomography (CT) studies were reviewed by two blinded radiologists with concordance assessed by percentage agreement. A focused review of 19 published studies was performed. Results: Four patients (three women; median age, 77 years) with severe comorbidities presented with sepsis and upper gastrointestinal hemorrhage. CT demonstrated saccular aneurysms, periaortic inflammation, and loss of the aortoesophageal fat plane in all cases, and periaortic gas and contrast extravasation in three of the four cases. Serial imaging showed rapid progression to pseudoaneurysm and, after thoracic endovascular aortic repair (TEVAR), peri-graft abscess. Three patients underwent emergency TEVAR (median, 8 days); one received supportive care after cardiac arrest. All four died; none reached definitive open reconstruction. Conclusions: All of the patients in this series died. Failure to achieve staged open reconstruction, driven by advanced sepsis and hemodynamic instability, was the common terminal pathway regardless of TEVAR use. No efficacy conclusion about TEVAR can be drawn from these data. Pre-planned multidisciplinary pathways to definitive surgery are essential in TMAA-AEF.