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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