Clinical utility of emergency thoracic endovascular aortic repair and timing of definitive surgery in esophageal cancer patients with Aortoesophageal fistula

Abstract

Background: Aortoesophageal fistula (AEF) is a rare and fatal complication of esophageal cancer. Emergency thoracic endovascular aortic repair (eTEVAR) is performed as a bridging therapy in unstable patients and then definitive surgery can be performed. However, the appropriate timing of surgery on standby is unclear. In this case series report, we discuss appropriate timing of surgical treatment after eTEVAR for AEF based on our findings and a review of published literature. Methods: We retrospectively reviewed three patients with advanced esophageal cancer who underwent eTEVAR for AEF from 2013 to 2020 at a single center. Primary endpoints were technical success and mortality. Secondary endpoints included changes in white blood cell (WBC) and C-reactive protein (CRP) levels, rebleeding, and endovascular reintervention. Technical success was defined as exclusion of the fistula without type I and III endoleaks on post-surgical angiography. Results: Technical success rate was 100%. Median survival time was 67 days. No 30-day or 60-day mortality was observed but the all-cause mortality rate was 100%. WBC and CRP levels decreased and general condition improved within 10 days of eTEVAR and patients were discharged without definitive surgery. However, two of the three patients were readmitted to our hospital because of pneumonia, mediastinitis, or hematemesis. One died of repeated hematemesis, one died of progression of esophageal cancer, and the other had unknown details. Conclusion: eTEVAR is useful for unstable AEF patients with esophageal cancer. If patients are eligible for definitive surgery after eTEVAR for AEF, the appropriate timing of definitive surgery might be within 10 days of the eTEVAR procedure.

Keywords

• TEVAR
• Esophageal cancer
• Aortoesophageal fistula