Aortoesophageal fistula following emergency thoracic endovascular aortic repair: 2 case reports and brief review.

RATIONALE: Aortoesophageal fistula (AEF) following thoracic endovascular aortic repair (TEVAR) is a rare but highly fatal complication. Despite successful initial repair, factors such as large aneurysms and mediastinal hematoma may lead to persistent esophageal compression and ischemia, culminating in delayed AEF. This report presents 2 fatal cases to highlight the diagnostic challenges and management pitfalls of this condition, underscoring the need for increased vigilance in high-risk patients even after successful procedures. PATIENT CONCERNS: Case 1: A 60-year-old male was hospitalized after a traffic accident with multiple injuries, including a pseudoaneurysm of the aortic arch. Over an 8-day interval, its size expanded from 3.7 × 2.5 cm to 6.6 × 6.0 × 4.8 cm. He underwent TEVAR but developed postoperative dysphagia and died suddenly at home 22 days after discharge due to massive hematemesis. Case 2: A 53-year-old male presented with acute chest and back pain accompanied by lethargy. Imaging revealed a giant thoracic aortic aneurysm (10.8 × 9.2 × 16.1 cm) compressing the esophagus and trachea. Emergency TEVAR was performed, but he returned 50 days later with cough, fever, dyspnea, and severe anemia. DIAGNOSES: Both patients were confirmed to have AEF. In Case 1, autopsy revealed a 3.5 × 2.0 cm mid-esophageal rupture. Case 2 was diagnosed via computed tomography angiography, which showed a 5.0 cm fistulous tract between the aorta and esophagus. INTERVENTIONS: Both patients underwent emergency TEVAR using fenestrated stent grafts. After AEF development, Case 2 received transfusions (8 units of packed red blood cells) and broad-spectrum antibiotics but declined further surgical intervention. Case 1 did not receive any intervention prior to his death. OUTCOMES: Both patients died from exsanguination due to AEF: Case 1 at 22 days and Case 2 at 50 days after initial surgery. Neither patient underwent definitive surgical repair of the fistula. LESSONS: AEF should be suspected in TEVAR patients with risk factors like large aneurysms or mediastinal hematoma, especially if new symptoms such as dysphagia or fever appear weeks later. Prompt CT angiography is critical. Non-operative management is fatal, and only aggressive surgery offers a potential cure. Prevention requires meticulous stent sizing and measures to reduce infective and mechanical risks.