Mechanism and Management of Aorto-Esophageal Fistulation after Thoracic Endovascular Aortic Repair

An aorto-esophageal fistula (AOF) is a pathological communication between the thoracic aorta and the esophagus. It can induce life-threatening hematemesis, which is unique among the other types of gastrointestinal hemorrhage in that the vomiting is bright red and represents an arterial bleed. Nevertheless, it is notable that over 70% of cases are associated with thoracic aortic aneurysms, particularly as a postoperative complication following open surgery, and arguably more so following endovascular repair. As thoracic endovascular aortic repair becomes a more common practice, it is important to remain vigilant for an increase in the incidence of AOF. A thorough consideration of potential AOF etiologies is essential, as these must be substantiated by clinical, laboratory, and imaging tests. The available management options and the likelihood of success depend largely on the diagnosis made. The stability of the fistula wall is fundamental to determine treatment options and is particularly important in case of a potentially fatal AOF. The stability of the organ wall determines the complication risk, and therefore which treatment the patient is most likely to tolerate. A new AOF classification system will allow for better diagnosis and clearer assessment of treatment options.