title: New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications.
abstract: OBJECTIVE
  To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR).
  
  
  METHODS
  International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres).
  
  
  RESULTS
  Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33).
  
  
  CONCLUSIONS
  The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients.
authors.affiliation: Department of Cardiovascular Surgery, Inselspital, University Hospital Berne, Berne, Switzerland.
authors.forename: Martin
authors.initials: M
authors.lastname: Czerny
authors.forename: Holger
authors.initials: H
authors.lastname: Eggebrecht
authors.forename: Gottfried
authors.initials: G
authors.lastname: Sodeck
authors.forename: Ernst
authors.initials: E
authors.lastname: Weigang
authors.forename: Ugolino
authors.initials: U
authors.lastname: Livi
authors.forename: Fabio
authors.initials: F
authors.lastname: Verzini
authors.forename: Jürg
authors.initials: J
authors.lastname: Schmidli
authors.forename: Roberto
authors.initials: R
authors.lastname: Chiesa
authors.forename: Germano
authors.initials: G
authors.lastname: Melissano
authors.forename: Andrea
authors.initials: A
authors.lastname: Kahlberg
authors.forename: Philippe
authors.initials: P
authors.lastname: Amabile
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Harringer
authors.forename: Michael
authors.initials: M
authors.lastname: Horacek
authors.forename: Raimund
authors.initials: R
authors.lastname: Erbel
authors.forename: Kay-Hyun
authors.initials: KH
authors.lastname: Park
authors.forename: Friedhelm
authors.initials: F
authors.lastname: Beyersdorf
authors.forename: Bartosz
authors.initials: B
authors.lastname: Rylski
authors.forename: Philipp
authors.initials: P
authors.lastname: Blanke
authors.forename: Ludovic
authors.initials: L
authors.lastname: Canaud
authors.forename: Ali
authors.initials: A
authors.lastname: Khoynezhad
authors.forename: Lars
authors.initials: L
authors.lastname: Lonn
authors.forename: Hervè
authors.initials: H
authors.lastname: Rousseau
authors.forename: Santi
authors.initials: S
authors.lastname: Trimarchi
authors.forename: Jan
authors.initials: J
authors.lastname: Brunkwall
authors.forename: Michael
authors.initials: M
authors.lastname: Gawenda
authors.forename: Zhihui
authors.initials: Z
authors.lastname: Dong
authors.forename: Weiguo
authors.initials: W
authors.lastname: Fu
authors.forename: Ingrid
authors.initials: I
authors.lastname: Schuster
authors.forename: Michael
authors.initials: M
authors.lastname: Grimm
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D015331:Cohort Studies; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000379:methods; D004937:Esophageal Fistula / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D005060:Europe; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012042:Registries
keywords: Aorto-oesophageal fistulation; Complications; Thoracic endovascular aortic repair; Treatment