title: Emergency open surgery for aorto-oesophageal and aorto-bronchial fistulae after thoracic endovascular aortic repair: a single-centre experience†.
abstract: OBJECTIVE
  Severe complications after thoracic endovascular aortic repair (TEVAR), such as secondary aorto-oesophageal (AOF) or aorto-bronchial fistulae (ABF), are most likely under-reported; however, once detected, emergent surgery becomes necessary.
  
  
  METHODS
  Between June 2002 and September 2013, 10 (2.6%) of 374 patients (8 males; mean age 68 years, range: 49-77) were admitted with AOF (n = 8) or ABF (n = 2) post-TEVAR during follow-up (mean 12.9 months, range 0.2-48.1). The respective Ishimaru landing zones were 0 (n = 1), 2 (n = 3), 3 (n = 4) and 4 (n = 2). Median interval between TEVAR and AOF/ABF formation was 18.1 months (range 0.1-65.1). Symptoms on admission included haematemesis (n = 4), haemoptysis (n = 2), melena (n = 1), elevated C-reactive protein (n = 10), new-onset fever (n = 3), positive blood cultures (n = 8), dysphagia (n = 1), chest pain (n = 4), previous syncope (n = 1) and vertigo (n = 1). In 6 patients with AOF, stent graft removal required ascending aortic (n = 1), aortic arch (n = 1), left hemiarch (n = 2) and descending aortic (n = 6) replacement with concomitant oesophagectomy (n = 4) and cervical oesophagostomy (n = 1) or oesophageal repair (n = 2); another patient with AOF underwent oesophagectomy and cervical oesophagostomy via posterolateral thoracotomy without stent graft removal as a first-stage operation. One patient with ABF was treated by stent graft removal, aortic arch and descending aortic replacement in combination with bronchial repair. Two patients were deemed inoperable and treated conservatively.
  
  
  RESULTS
  All patients survived the operation. Reoperation due to postoperative mediastinitis, haemorrhage, pericardial tamponade and wound infection was required in 4 (50%, 95% confidence interval [CI] [22, 78]) patients. In-hospital mortality was 25% (n = 2; 95% CI [7, 59]) due to mediastinitis with resulting multiorgan failure (n = 1) and aortic rupture with haemorrhagic shock (n = 1). One patient died due to unknown cause on postoperative day 158. No neurological complications occurred postoperatively. Postoperative complications comprised acute renal failure with temporary dependence on haemodialysis (n = 2) and respiratory insufficiency (n = 4) requiring percutaneous tracheostomy (n = 2). Both patients treated conservatively died after 4 and 81 days due to pulmonary haemorrhage and fulminant mediastinitis, respectively.
  
  
  CONCLUSIONS
  AOF and ABF represent uncommon but fatal complications-if treated conservatively-after TEVAR that may occur during short- and mid-term follow-up. Surgery for AOF/ABF requires early diagnosis and should be performed promptly and in a radical fashion to totally excise all infected tissues in these high-risk patients.
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany mail@dr-luehr.net.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Luehr
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Christian D
authors.initials: CD
authors.lastname: Etz
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Michal
authors.initials: M
authors.lastname: Nozdrzykowski
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Garbade
authors.affiliation: Department of Radiology, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Lukas
authors.initials: L
authors.lastname: Lehmkuhl
authors.affiliation: Department of Angiology, Centre of Vascular Medicine, Park Hospital, Leipzig, Germany.
authors.forename: Andrej
authors.initials: A
authors.lastname: Schmidt
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Misfeld
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Borger
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Friedrich-Wilhelm
authors.initials: FW
authors.lastname: Mohr
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000601:surgery*; D001983:Bronchial Fistula / Q000401:mortality / Q000601:surgery*; D004630:Emergencies; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D004937:Esophageal Fistula / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D012189:Retrospective Studies; D019616:Thoracic Surgical Procedures / Q000009:adverse effects* / Q000401:mortality
keywords: Aortic erosion; Aorto-bronchial fistula; Aorto-oesophageal fistula; Postinterventional complication; Stent graft infection; Thoracic endovascular aortic repair