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INTRODUCTION:
We report a successful treatment of infected thoracic aortic stent graft complicated with aortoesophageal fistula (AEF).
METHODS:The patient is a 33-year-old male who received thoracic aortic endografting for aortic transection following a motor vehicle accident. He developed fever after 12 weeks and CT of the chest demonstrated the air around this endograft. Esophagogram demonstrated an AEF. He was transferred to our hospital under the diagnosis of graft infection with AEF. The patient underwent urgent surgery. Through the left sixth intercostal space, an enlarged proximal to mid-descending aorta was exposed. Due to the dense adhesions around the aortic arch, profound hypothermic circulatory arrest (PHCA) was utilized. The infected aorta was excised and replaced from the transverse arch to T10 descending aorta and the prior two stent grafts were removed. The esophageal perforation was not clear due to the mediastinal phlegmon. The omentum flap was placed around the entire graft and esophagus on the following day. Despite the extensive antibiotics treatment, the patient developed infective endocarditis with increasing mediastinal hematoma, and CT revealed a new pseudoaneurysm of the ascending aorta. On postoperative day 19, the patient underwent extra-anatomical bypass. The right axillary artery and femoral vein bypass was established before median sternotomy. While on bypass, the heart was mobilized anteriorly and the diaphragm was incised down to the hiatus and the small sac was opened to expose the abdominal aorta. A 22-mm-Dacron graft was anastomosed to above the celiac axis under a partial clamp. The proximal anastomosis was then performed to the ascending aorta. Also, the aortic valve was repaired by resecting the vegetation on the non-coronary cusp and repairing the leaflet with pericardial patch. Then the pseudoaneurysm was entered under PHCA with antegrade cerebral perfusion via the right axillary artery graft. The distal end of the prior descending thoracic graft and the ascending aorta distal of the proximal anastomosis of the ascending-abdominal aortic graft were both oversewn and infected areas were debrided. The innominate and the left common carotid arteries were reconstructed with 10-mm-Dacron graft using the branched-technique with the inflow from the ascending-abdominal aortic graft. The patient was weaned from bypass and an abbreviated closure performed. The chest was kept open till the following day to allow another copious irrigation and then closed. On postoperative day 23, the remaining pseudoaneurysm was resected through the left thoracotomy and distal descending aorta was oversewn and closed at the level of T10. A jejunostomy feeding tube was inserted. The patient was transferred to long-term acute care. After recovery, a barium swallow confirmed the esophageal perforation and an esophageal stent was placed allowing healing of the perforation.
RESULTS:The patient is now discharged home after 5 months and there is no sign of recurrent infection after 5 months.
CONCLUSIONS:The secondary AEF is a dreadful disease. Thorough debridement is required to control the infection and the treatment often requires multiple staging.