The worst adverse event for an endoscopist after esophageal stent placement: an aortoesophageal fistula

We describe the case of a 75-year-old man who had undergone total laryngectomy with neck dissection and major pectoralis flap for recurrent squamous cell carcinoma after chemoradiation treatment. Post-operatively he developed a recurrent pharyngocutaneous fistula, managed with placement of a partially covered self-expandable metal stent (SEMS) (23 × 105-mm Wallflex; Boston Scientific Inc., Marlborough, Massachusetts, USA). The patient missed a scheduled follow-up for stent retrieval.

After several months he was admitted to our emergency department for hematemesis and severe anemia. Following hemodynamic resuscitation, an upper gastrointestinal (GI) endoscopy was performed. A spurting bleed at the distal end of the esophageal stent was observed ([Fig. 1], [Video 1]). First the stent was removed to expose the source of the bleed, followed by injection of 5 ml of cyanoacrylate glue (Glubran; GEM srl, Viareggio, Italy). Because of persistent active bleeding, a fully covered SEMS (24 × 180-mm Niti-S Beta; TaeWoong Medical, Gyeonggi-do, South Korea) was placed. After few seconds, abrupt bleeding recurred with rupture of the silicone covering of the stent ([Fig. 2]). Further injection of 3 ml of cyanoacrylate glue was repeated into the mesh, thereby controlling the bleeding almost completely ([Fig. 3]). An urgent CT angiography revealed an aortoesophageal fistula originating from an anomalous right-sided aortic arch. The cyanoacrylate tamponade effect on the fistula was sufficient to stabilize the patient and, after emergent multidisciplinary consultation, an endovascular bailout was planned.

Fig. 1 Spurting bleeding vessel at the distal end of the esophageal stent.

Video 1 Treatment of an aortoesophageal fistula with cyanoacrylate glue injection and placement of esophageal stent followed by aortic stent graft.

Fig. 2 Abrupt bleeding recurrence with rupture of the silicone covering of the stent.

Fig. 3 Nearly complete bleeding control after cyanoacrylate injection into the mesh.

The patient was referred to our cath lab where he immediately received a percutaneous aortic stent graft to stop the leak ([Fig. 4]). Of note, the aberrant origin of the supraortic trunks allowed for a successful arch covering without brain ischemic sequelae. The patient recovered uneventfully, and no further bleeding occurred. The esophageal SEMS was removed 1 month later and there was no evidence of a mucosal defect ([Fig. 5]).

Fig. 4 Fluoroscopic control after placement of the aortic stent graft.

Fig. 5 Esophageal mucosa after stent removal.

An aortoesophageal fistula has been reported as a dramatic adverse event of aortic disease, thoracic aortic surgery, foreign body ingestion, esophageal stent placement and esophageal malignancy with a high mortality rate [1]. To date there is no standardized treatment for this condition [2] [3]. Furthermore, the role of cyanoacrylate glue as a rescue hemostatic tool to control active bleeding is well established [4] [5]. This case describes the possible challenges in treating an aortoesophageal fistula with injection of cyanoacrylate glue and stent placement as a part of a multidisciplinary approach.

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• References

• 1 Boerlage TC, Hermanides HS, Moes DE. et al. Aorto-oesophageal fistula after oesophageal stent placement in a patient with Roux-en-Y gastric bypass. Ann R Coll Surg Engl 2016; 98: e178-e180
• 2 Civilini E, Bertoglio L, Melissano G. et al. Aortic and esophageal endografting for secondary aortoenteric fistula. Eur J Vasc Endovasc Surg 2008; 36: 297-299
• 3 Uno K, Koike T, Takahashi S. et al. Management of aorto-esophageal fistula secondary after thoracic endovascular aortic repair: a review of literature. Clin J Gastroenterol 2017; 10: 393-402
• 4 Auriemma F, Anderloni A, Carrara S. et al. Cyanoacrylate hemostasis for massive bleeding after drainage of pancreatic fluid collection by lumen-apposing metal stent. Am J Gastroenterol 2018; 113: 1582
• 5 Gralnek IM, Dumonceau JM, Kuipers EJ. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 1-46