Aorto-oesophageal fistula treated with emergent thoracic endovascular repair.

To cite: Andrade LC, FelixMorais R, Gil-Agostinho A, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204254 DESCRIPTION A 85-year-old woman was admitted to the emergency room with haematemesis and epigastric pain. The patient had a past history of diabetes mellitus and right lower limb amputation. At initial examination the patient was haemodynamically stable. Laboratory findings included a haemoglobin level of 9.6 g/dL and platelet count of 116 000/mL. During her stay in the emergency room, the patient developed another severe episode of haematemesis and went into hypovolemic shock. Upper gastrointestinal endoscopy revealed external compression of the mid-oesophagus as well as mucosal ulceration and erosion with an adherent clot. CTangiography revealed contrast extravasation from the descending aorta into the mid-oesophagus and confirmed the aorto-oesophageal fistula due to a ruptured saccular aortic aneurysm (figure 1). 2 The patient underwent emergent thoracic endovascular aortic repair with deployment of a stent graft. The fistula was excluded and the patient remained stable. One month after medical discharge, the patient return to the hospital with back pain and fever. Laboratory findings revealed leucocytosis (leucocyte count of 15 300/mL, 76.1% neutrophils), anaemia (haemoglobin of 8.7 g/dL), platelet count of 271 000/mL and elevation of C-reactive protein (27.63 mg/dL). A repeat CT that showed the aortic prosthesis surrounded by soft tissue and gas bubbles, findings that were interpreted as peri-stent graft infection (figure 2). Empiric intravenous vancomycin, metronidazol and imipenem (cilastatin) was initiated after blood cultures were obtained. The blood cultures yield no growth. Despite appropriate intensive care, the patient died of sepsis 5 days after readmission.