3. Discussion
Thoracic aortic endovascular repair (TEVAR) is increasingly used for thoracic aortic aneurysms and aortic dissections. This is mainly due to the less invasiveness of this procedure compared with aortic graft replacement. Aortic esophageal fistula (AEF) is a relatively rare but life-threatening disease [9], and some cases of AEF are caused by complications after TEVAR surgery[10, 11]. A voluntary national survey conducted in Italian universities and hospital centers showed that 19 of 1113 patients (1.7%) who received TEVAR treatment between 1998 and 2008 developed AEF or main bronchial fistula during follow-up [10]. A European multi-center study showed [12]that the total number of cases of TEVAR surgery was 2387, and 36 (1.5%) had AEF during the follow-up period.
Several potential causes of AEF after TEVAR have been reported[1, 13, 14]. First of all, the self-expanding force of the stent graft may cause direct erosion of the aorta, resulting in pressure necrosis of the esophageal wall. Second, the stent graft blocks the proper esophageal artery, resulting in avascular necrosis of the esophageal wall. Finally, the stent graft may also be infected, leading to infectious erosion of the esophageal wall. Regardless of the cause, the result is very serious, potentially fatal, and must be resolved with the highest possible curative effect.
Regarding the timing of surgery, we believe that if the diagnosis of AEF after TEVAR is clear, the control of sepsis should be given priority. Among the 6 patients in this group, 5 patients were relatively stable and had no signs of hemorrhage and progressively worsening septic shock due to fistula of adjacent organs. Sensitive antibacterial drugs were given priority, followed by elective surgical treatment. One patient with repeated gastrointestinal bleeding underwent emergency endovascular surgery to control the bleeding, and underwent surgical treatment within a limited time.
Many treatments have been used for AEF after TEVAR, mainly conservative and surgical treatments [15, 16]. Akashi et al.[17] reported that conservative treatment often has fatal consequences, and conservative treatment is not recommended. Uno et al. [18]found that another TEVAR operation or combined esophageal stent implantation can isolate the aortic blood flow and achieve the goal of controlling bleeding to treat AEF. However, after deployment of the internal graft, some patients are at risk of uncontrollable mediastinal infection and death. Most scholars believe that open surgery is the root treatment of AEF[2-5].. Aortic replacement combined with esophagectomy and debridement at the same time or in stages is an effective treatment, but complications such as hemorrhage and sepsis may occur[6-8].
A European multicenter study showed [12] that 36 patients with AEF after TEVAR were clinically confirmed. According to different treatment methods, patients were divided into 4 groups. The 1-year mortality rate of the conservative treatment group reached 100%, which is consistent with the results of other studies[19, 20]. The second group of patients only received esophageal stent treatment, and the survival rate after 1 year was 17%. In the third group, patients underwent esophagectomy without aortic replacement, and the 1-year survival rate was 43%. The fourth group underwent both esophagectomy and aortic replacement surgery and implanted stents. The 1-year survival rate of patients in this group was slightly higher, at 46%. However, in other published studies, when a radical surgical protocol is used, the 1-year survival rate has been shown to exceed 50% [21, 22]. A multi-center study in Japan has shown [8] that 39 clinically identified patients with AEF after TEVAR, through different treatment options, have also confirmed that esophagectomy combined with aortic replacement can provide a long-term treatment strategy for patients with AEF after TEVAR. , Has a higher survival rate.
At present, patients with AEF after TEVAR are mainly used for cardiopulmonary bypass or even hypothermic circulatory arrest to remove the diseased tissue and perform in-situ aortic reconstruction surgery. This method is more traumatic to patients, and most patients suffer from long-term infections, poor general conditions and poor coagulation function, and relatively severe problems such as intraoperative bleeding. At the same time, in situ reconstruction of the aorta also has a higher possibility of infection recurrence. [23, 24]Related reports used aortic bypass and removal of artificial stents to successfully treat patients with AEF after TEVAR. For this reason, according to the patient’s condition, we adopt contemporaneous and staged surgical methods. First, the ascending aorta is transplanted to the innominate artery, left common carotid artery, left subclavian artery, and abdominal aorta bypass to reconstruct the aortic vascular channel. After that, both ends of the infected aorta are sealed and severed, which is convenient for exposure, does not require the assistance of cardiopulmonary bypass, has less bleeding, and is easy to control. The aorta was dissected at 1 to 2 cm distal to the arterial stent, without considering the reconstruction of intercostal vessels, and no patients had spinal cord ischemia or paraplegia after the operation. This operation does not require the assistance of cardiopulmonary bypass, and it is more beneficial for high-risk patients, especially those with involvement of the branches of the arch (needing hypothermic circulatory arrest).
After the operation, it is very important to give regular antimicrobial treatment according to the results of drug sensitivity culture. The treatment cycle is generally 4-6 weeks, which is mainly determined according to the patient’s infection control status. No fever, no abnormal blood routine and C-reactive protein indicators, chest tube drainage fluid had normal traits, negative blood culture, and no obvious abnormal encapsulated empyema on chest CT, so the antibacterial treatment was gradually stopped. We believe that ascending aorta-abdominal aortic artificial blood vessel bypass grafting combined with the removal of infected vessels and stents, and local exclusion and drainage for the treatment of stent infections after TEVAR can achieve better clinical results; the timing of surgery and The treatment cycle of antibacterial drugs in the later period needs to be determined according to the specific conditions of the patient. In summary, raising awareness and individualized diagnosis and treatment measures are the key to improving the survival rate of AEF after TEVAR.
CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.
ETHICS STATEMENT
This Clinical retrospective study was approved by the ethical commission of DeltaHealth Hospital, Shanghai, People’s Republic of China.
Written consent was obtained from all patients.
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