aortoesophageal fistula is a rare , devastating and usually fatal condition which has multiple aetiological factors . the first report , in 1818 , described the death of a 28-year - old soldier who exsanguinated after ingesting a beef bone fragment .
a comprehensive review , published by hollander and quick , which included 500 cases of fistula , identified three major causes of aortoesophageal fistula , the main aetiologic factor being aortic disease with 54.2% of cases secondary to rupture of a descending thoracic aorta aneurysm into the oesophagus . foreign body ingestion ( 19.2% ) and advanced esophageal carcinoma ( 17.0% ) were the next commonest causes .
regardless of cause , the optimal management of the fistula remains controversial , and recent literature has focused on the role of endovascular techniques and open thoracic surgery .
however , high mortality from the condition usually results from massive uncontrolled haemorrhage prior to these interventions being possible .
although non - surgical measures to control the initial haemodynamic insult caused by haemorrhage have been described , this remains a relatively unexplored area of management .
a 47-year - old caucasian man with recently diagnosed advanced esophageal cancer attended the imaging department for an ultrasound scan . in the waiting area , the patient had a massive haematemesis and proceeded into a peri - arrest state .
tech , seoul , distributed by mtw , wesel , germany ) was inserted across the lesion .
ct confirmed an esophageal tumour in continuity with the right main bronchus with an associated right lung abscess .
an overlapping fully covered 12  18 alveolus aero stent ( alveolus , charlotte , n.c . ,
1 ) , presumably because the bronchial fistula had been adequately sealed with the stents , creating an undrained collection in the lung which subsequently fistulated through to the pleural cavity .
while awaiting a video - assisted thoracoscopic surgical procedure to drain and seal the abscess and empyema , he spontaneously drained the abscess by coughing up nearly 1 litre of pus in 24 h ; this led to a dramatic improvement in his clinical state and resolution of his chest x - ray changes .
a week before the ultrasound scan he experienced mid - thoracic pain and small episodes of haematemesis . when he collapsed , he was tachycardic ( heart rate 128 bpm ) with unrecordable blood pressure .
its clearance identified a large arterial bleeding point , just above the proximal end of the stent in the mid - esophagus ( fig .
a further 28 mm diameter niti - s covered esophageal stent ( taewong medical , seoul , korea ) was inserted to tamponade the bleeding point ( fig .
despite aggressive resuscitation with fluids and 8 units of blood , there was no improvement in his haemodynamic status until after stent deployment .
the patient was transferred to the intensive care unit where fresh bleeding continued to be aspirated from his nasogastric tube overnight .
a further 8 units of blood and 6 units of fresh frozen plasma were transfused to maintain his haemoglobin between 7 and 7.7 g / dl . with this
ct angiography was performed and demonstrated an aortoesophageal fistula at the level of the carina with ongoing bleeding into the mediastinum ( fig .
was inserted into the thoracic aorta distal to the origin of the left subclavian artery sealing the fistula .
he survived for 2 months at home , during which he was able to attend to his personal affairs , before dying of disseminated malignancy .
this case highlights the successful non - surgical management of a massive bleed caused by aortoesophageal fistula .
the esophageal stent acted as a means to tamponade and provided partial initial control of the bleeding point .
this allowed time for appropriate endovascular intervention in the form of a thoracic endoluminal stent device to further stabilise the haemodynamic status of the patient .
the challenge to recognise and treat successfully before the patient exsanguinates is probably why success stories for closure of aortoesophageal fistulas are few .
high clinical suspicion and recognition of warning symptoms such as mid - thoracic pain and sentinel arterial upper gastrointestinal haemorrhage is crucial .
transient self - limiting ' herald ' bleeds may precede fatal exsanguination by more than 24 h .
this ' window of opportunity ' allows early transfer to a specialist centre . high clinical suspicion and
first reported using an endoluminal stent graft for repair of abdominal aortic aneurysms , thoracic endovascular aortic repair ( tevar ) has become more common in the management of aortoesophageal fistula , with much of the literature focusing on endovascular and open surgical management .
a recently reported successful surgical approach   advocated open transthoracic esophageal resection , cervical esophagectomy and gastrostomy .
the patient had developed a fistula secondary to previous tevar , so the authors could not decide the best approach to salvage the thoracic aorta .
although successful in stabilising the patient , this highly invasive approach may not be suitable for patients with advanced esophageal malignancy .
less invasive successful endovascular management of fistulas in patients with esophageal malignancy has been reported .
one report   describes the use of a dacron prosthesis interposed into the descending thoracic aorta to restore aortic flow as successful endovascular intervention ; the same patient later underwent an esophagectomy for definitive treatment .
a separate report   describes successful endovascular intervention to stabilise bleeding , although again this patient also went on to require further definitive gastrointestinal surgical management .
further reports [ 9 , 10 , 11 ] appear to suggest that although tevar is a useful method for achieving hemodynamic stability , for definitive long - term management the patient will require some form of open surgical intervention .
of course with advanced esophageal malignancy , patients may simply not be suitable for surgery , leaving tevar as their only option .
the problem with tevar remains that it does not prevent immediate exsanguination in patients admitted with fistula .
it was found in patients who underwent tevar that early esophageal repair appeared to improve survival .
literature on the successful esophageal management of the initial exsanguination remains limited , with the successful use of a sengstaken - blakemore tube prior to tevar being reported .
newer techniques have been emerging , such as the use of cyanoacrylate embolisation of the fistula followed by tevar .
the use of esophageal stenting as a means of controlling initial exsanguination remains a relatively unexplored area of management . in conclusion , with early recognition , esophageal stenting may have a role in the initial emergency control of bleeding due to aortoesophageal fistula , but clearly , immediate access to anaesthetic , interventional endoscopic and radiological services is mandatory .
 aortoesophageal fistulas are a rare but commonly fatal complication of esophageal cancer 
 . reports of successfully managed cases are few , with high mortality and morbidity usually resulting from failure to control the initial massive haemodynamic insult . 
 we report the case of a 47-year - old caucasian man with recently diagnosed advanced esophageal cancer who suffered an episode of massive haematemesis . 
 emergency gastroscopy revealed an arterial bleeding point in the proximal esophagus . 
 a self - expanding metal esophageal stent was placed to achieve initial partial haemostasis . 
 ct angiography confirmed an aortoesophageal fistula . 
 an endoluminal stent device was thus inserted within the thoracic aorta stabilising the bleeding point . 
 the patient subsequently made an uneventful recovery and was discharged on long - term antibiotics for palliative care . 
 he survived for 2 months at home before dying of disseminated malignancy . 
 the successful use of esophageal stenting as a means of achieving haemostasis , allowing time for endovascular intervention , is as yet a relatively unexplored area of management of this rare condition . 
Introduction
Case Report
Discussion