PMC6313998_01
Imaging at the initial treatment for the aortoesophageal fistula using the TEVAR method. (a) EGD revealed a type 2 lesion spanning 3/4 of the circumference of the middle thoracic esophagus. (b) Computed tomography scan (CT) revealed esophageal wall thickening with tumor, and there was loss of the normal fat plane between the esophagus and the adjacent aorta. Approximately 90  of the circumference of the aorta was in contact with the tumor, which suggested aortic invasion (yellow thin arrow). (c) CT scan revealed aortic erosion of the intravenous contrast material within the descending thoracic aorta and extraluminal foci of air between the adjacent esophagus and the aorta (yellow thin arrow). (d) CT angiography did not indicate active bleeding. (e) Emergency esophagogastroduodenoscopy showed a pale fragile esophageal lesion on the posterior wall, an area previously treated with chemoradiation therapy, with massive blood coagulation. (f) Marking clips were placed on the side opposite the lesion.
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He underwent an esophagogastroduodenoscopy (EGD) that revealed a type 2 lesion spanning 3/4 of the circumference of the middle thoracic esophagus (Figures 1(a) and 1(b)). AEF was considered and a computed tomography scan (CT) angiogram of the chest and abdomen was obtained (Figures 1(c) and 1(d)). Although we did not detect active bleeding, the CT scan revealed aortic erosion of the intravenous contrast medium within the descending thoracic aorta, as well as extraluminal foci of air between the adjacent esophagus and the aorta. Marking clips were placed on the side opposite the lesion (Figures 1(e) and 1(f)).
Imaging showed esophageal stenting to repair the aortic stent migration. (a) Aortography showed no active bleeding. (b) Using the marking clips as a reference point, a stent graft was inserted to control the massive esophageal bleeding (yellow bold arrow). (c) Esophagogastroduodenoscopy revealed that the aortic stent is exposed into the esophagus. (d) The stent narrowed the esophageal lumen, hindering the scope's passage past the lesion. (e) An esophageal stent was placed adjacent to the aortic stent to push it out and dilate the esophageal lumen. (f) The contrast medium flowed smoothly within the esophageal stent.
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Soon after endoscopy, as the patient's condition remained life-threatening, and in the absence of an advance directive from the patient, we performed emergency AEF repair using TEVAR (Figures 2(a) and 2(b)). EGD revealed that the aortic stent was exposed and protruded into the ruptured esophagus (Figures 2(c) and 2(d)). Therefore, an esophageal stent was placed adjacent to the aortic stent to push it out and dilate the esophageal lumen (Figures 2(e) and 2(f)).