Treatment of post-thoracic endovascular aortic repair aorto-esophageal fistula—only radical surgery can be effective: techniques and sequence of treatment

Aorto-esophageal fistulas (AEFs) are rare after thoracic endovascular aortic repair (TEVAR), being associated with the presence of mediastinal hematoma and the need for emergency TEVAR. Left untreated, AEFs are always lethal. “Redo”-stent-grafting can serve as a “bridging” procedure in hemodynamically unstable patients, but is not a durable therapy. Radical surgery is shown to be the most durable and effective treatment. This includes esophagectomy, stent-graft removal and aortic replacement followed by esophageal reconstruction, e.g., gastric pull-up operation. Aortic reconstruction can be performed by the use of self-made bovine pericardial tubes. A bilateral anterior (“clam-shell”) thoracotomy can be chosen for surgical exposure in revision cases after previous sternotomy, in which the ascending aorta, aortic arch and proximal descending aorta require reconstruction.