Aortoesophageal fistula: Long-term survival with aggressive multidisciplinary management

Aortoesophageal fistula (AoEF) is a rare but complex problem that carries high mortality. This study describes our institutional experience with the management of AoEF.

There were 17 patients with AoEF who were managed in our center (2005-2023). Medical records were reviewed for baseline characteristics, history of esophageal or aortic disease, diagnostic evaluation, surgical treatment, and follow-up. Overall survival (OS) was analyzed using the Kaplan-Meier method and log rank tests.

Most patients had previous aortic operations (12/17, 71%)-7 thoracic endovascular aortic repair (TEVAR), 3 open/TEVAR, and 2 open repairs. The etiology of AoEF was aortic disease in 13 (76%) and anastomotic leak after esophagectomy in 4 (24%). Upon presentation, 2 (12%) patients were not offered intervention, whereas 6 (35%) had emergency TEVAR to control bleeding. Twelve (67%) patients were treated with curative intent, 1 patient did not survive an initial aortic operation. Of the remaining 11 patients, esophageal operations happened before aortic repair in 7 (64%), concurrently in 3 (27%), and after in 1 (9%). This included diversion esophagectomy in 7 (64%) and primary repair in 3 (27%). Definitive aortic surgery included aorta replacement with rifampin-soaked grafts in 8 (67%) and homografts in 4 (33%). In-hospital mortality occurred in 1 of 12 (8%) cases. One- and 2-year OS was 83% and 74%. OS was lower in patients not receiving curative-intent treatment (P < .001).

Management of AoEF is complex. However, aggressive multidisciplinary intervention with definitive esophageal and aortic repairs can result in good long-term survival in selected patients.