Thoracic endovascular aortic repair in management of aorto-oesophageal fistulas: a case series

Background Aorto-oesophageal fistula (AOF) is a rare, catastrophic disease with an extremely poor prognosis. A ruptured thoracic aortic aneurysm is a common aetiology for AOF. The clinical presentation is usually massive haematemesis and collapse. Timely diagnosis and appropriate treatment are crucial in managing AOF. Case summary We hereby report two cases of AOF, who underwent successful emergency thoracic endovascular aortic repair (TEVAR) to control active bleed and exsanguination. Case 1, an elderly lady with atherosclerotic aneurysm had TEVAR followed by open surgery for oesophageal rent and necrosed left main bronchus. Case 2 had mycotic tubercular aneurysm who later had infected graft-stent following TEVAR. Discussion Open surgery is the conventional treatment for AOF; however, TEVAR can be an alternative and less invasive approach in selected high-risk patients. Various management issues related to TEVAR with AOF have been discussed in the article.

Intra-Aneurysmal Rupture of an Atheroma during the Clipping of Large Atherosclerotic Aneurysm of the Middle Cerebral Artery: A Case Report with Video Demonstration

Ischemic complications including silent or symptomatic events are known to occur during the clipping of intracranial aneurysms, although at a relatively lower rate than during endovascular treatment. An atherosclerotic or calcified neck is one of the major contributors to postoperative ischemic sequelae from a surgically treated aneurysm. Atherosclerotic changes in intracranial vessels or within an aneurysm wall or neck area are often seen during surgery. However, we were not previously able to detect any showering of atheromatous emboli during temporary or permanent clipping procedures. We describe a case of an intra-aneurysmal rupture of a squeezed atheroma observed after permanent clipping of an atherosclerotic large middle cerebral artery aneurysm. After tentative clipping to treat the severe atherosclerotic aneurysm in this patient, we applied supplementary clipping to the atherosclerotic area of the aneurysmal sac. The resulting squeezing of the intra-aneurysmal atheroma caused a leakage into the subadventitial layer of the aneurysmal sac. We also discuss the potential ischemic complications of aneurysmal clipping surgery. We conclude that the surgical techniques used to treat these specific aneurysms require circumspect planning through a review of preoperative images.

Endovascular Repair with a Stent Graft in a Patient with Aortoduodenal Fistula after Radiation Therapy

Primary aortoduodenal fistula (ADF) is a direct communication between the abdominal aorta and the gastrointestinal tract without any previous vascular intervention and represents a rare but critical cause of repeated and massive gastrointestinal bleeding. Primary ADF often occurs as a result of atherosclerotic aneurysm and infection, but ADF involving a normal-size aorta is rare; furthermore, ADF related to radiation therapy is extremely rare. We present the case of a 56-year-old man with a history of bowel obstruction due to radiation enteritis who was admitted with severe hematemesis and hemorrhagic shock. Gastroduodenal endoscopy and contrast-enhanced computed tomography findings were unremarkable. Aortoduodenal fistula was suspected based on the diffuse calcification of the abdominal aorta confined to the radiation field and the presence of an aortoduodenal communication on angiography. Endovascular repair with a stent graft seemed to be a safer option than open surgery and was suited to the rapid control of bleeding from ADF because of the patients’ unstable hemodynamic state and the presence of intestinal adhesions. The fistula was successfully sealed by endovascular stent graft placement. Hematemesis did not recur postoperatively and anemia gradually improved. The patient died from pneumonia 33 days later.