title: Thoracic Aortic Pseudoaneurysm after Esophageal Perforation and Mediastinitis Caused by Accidental Ingestion of a Mutton Bone: A Case Report on Staged Endoscopic and Endovascular Treatments.
abstract: BACKGROUND
  Esophageal perforation involving the thoracic aorta is a rare but potentially life-threatening event. Esophageal wall dehiscence, aortoesophageal fistula, mycotic aneurysms, or mediastinitis may complicate this challenging condition, and a multidisciplinary approach is mandatory. Aggressive endoscopic and medical therapy followed by thoracic endovascular aneurysm repair (TEVAR) may be a valuable approach to reduce the mortality rate of this catastrophic event.
  
  
  METHODS
  A 79-year-old man presented at the emergency department with a 2-day history of worsening dysphagia and fever, suddenly appeared after consuming mutton meat. Esophagogastroduodenoscopy and computed tomography (CT) scan at admission showed a bone fragment penetrating the esophagus very close to the thoracic aorta, associated with signs of mild mediastinitis. After endoscopic removal of the bone, an esophageal fistula occurred. A conservative approach by means of endoscopic clipping of the esophageal perforation, nasojejunal tube for enteral nutrition and broad spectrum antibiotic therapy was preferred at this stage. Control chest X-ray with oral water-soluble contrast (Gastrografin) and repeat CT at 10- and 20-day follow-up showed a complete resolution of the esophageal fistula and mediastinitis. On the other hand, an increase of the aortic pseudoaneurysm was noted. This was treated by means of TEVAR. Subsequent clinical evolution was uneventful, and the patient was discharged in optimal clinical conditions with a 4-week course of home antibiotic therapy. The 6-month follow-up was uneventful.
  
  
  CONCLUSIONS
  Foreign body esophageal perforation causing mediastinitis and aortic pseudoaneurysm is a very rare and challenging situation that requires a strict follow-up and an intensive multidisciplinary approach. A staged approach, first by endoscopy followed by endovascular treatment, may be safe and effective in selected patients.
authors.affiliation: Department of Vascular and Endovascular Surgery, University Hospital of Verona, Verona, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Mezzetto
authors.affiliation: Department of Upper Gastrointestinal Surgery, University Hospital of Verona, Verona, Italy.
authors.forename: Elio
authors.initials: E
authors.lastname: Treppiedi
authors.affiliation: Department of Vascular and Endovascular Surgery, University Hospital of Verona, Verona, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Scorsone
authors.affiliation: Department of Upper Gastrointestinal Surgery, University Hospital of Verona, Verona, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Giacopuzzi
authors.affiliation: Department of Radiology, University Hospital of Verona, Verona, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Perandini
authors.affiliation: Department of Vascular and Endovascular Surgery, University Hospital of Verona, Verona, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Macrì
authors.affiliation: Department of Vascular and Endovascular Surgery, University Hospital of Verona, Verona, Italy. Electronic address: gianfranco.veraldi@ospedaleuniverona.it.
authors.forename: Gian Franco
authors.initials: GF
authors.lastname: Veraldi
mesh_terms: D000368:Aged; D017541:Aneurysm, False / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000209:etiology / Q000601:surgery; D004724:Endoscopy; D057510:Endovascular Procedures; D004939:Esophageal Perforation / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D005547:Foreign Bodies / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000175:diagnosis / Q000209:etiology / Q000601:surgery