Endoluminal Stenting of the Aorta

Abstract

A 78-year-old woman with severe chronic obstructive pulmonary disease was admitted to the emergency room with hematemesis. With use of esophagoscopy, chest computed tomographic scanning, and aortography, we found a large descending aortic aneurysm and a penetrating ulcer of the proximal descending aorta. We determined that the patient had an aortoesophageal fistula and pseudoaneurysm that had originated from a ruptured penetrating ulcer of the mid-descending aorta.

We deployed two 100-mm stent grafts to seal the ruptured thoracic aorta. Six months later, the pseudoaneurysm was almost completely resolved, with no infection or endoleak. We advocate the use of endoluminal aortic stenting for aortoesophageal fistulas of aortic origin, particularly in patients with severe concomitant disease. (Tex Heart Inst J 2002;29:216–7)

Aortoesophageal fistula is rare and is typically caused by esophageal or primary aortic disease. In most instances, the condition requires extensive surgery to replace a portion of the aorta and repair the esophagus. The deleterious complications of such extensive intervention are often unavoidable, especially when the patients involved are severely debilitated. In a few patients, the use of endoluminal aortic stenting has been reported as a valuable alternative in the treatment of aortoesophageal fistulas secondary to esophageal neoplasms. ^1,2 We recently used an endovascular approach to treat a fistula, the primary origin of which was a penetrating ulcer of the aorta.

A 78-year-old woman with known, severe, chronic obstructive pulmonary disease (COPD) was admitted to the emergency room because of hematemesis. An immediate esophagoscopy revealed an ulcer of the mid-esophagus with signs of extrinsic compression. A computed tomographic (CT) scan of the chest documented a large descending aortic pseudoaneurysm that surrounded the mid-esophagus (Fig. 1). An aortogram confirmed the presence of a 6- × 8-cm pseudoaneurysm of the mid-descending aorta associated with a penetrating ulcer of the proximal descending aorta (Fig. 2). These findings suggested that the fistula and the pseudoaneurysm had originated from a ruptured penetrating ulcer of the mid-descending aorta. Considering the patient's severe COPD, we chose an endoluminal approach and implantation of a Talent™ stent graft (Medtronic, Inc.; Minneapolis, Minn).

Fig. 1 Chest computed tomographic scan shows a pseudoaneurysm of the aorta that is invading the posterior mediastinum (long arrows). The esophagus is compressed within the pseudoaneurysm and is not recognizable in the picture. The short arrow indicates the descending aortic lumen.

Fig. 2 Descending thoracic aortography documents a 6- × 8-cm contained rupture of the mid-descending aorta (black arrow) and an ulcerated area in the proximal descending aorta (white arrow).

The Talent stent graft is composed of a skeleton of self-expanding nitinol stents connected by stabilizing bars to which graft material is annealed, thereby completing the aortic segment. The stent graft is preloaded in a vascular sheath and inserted through a surgical cut-down of the common femoral artery. Deployment within the aorta is achieved by withdrawal of the outer sheath, which enables the self-expanding stent skeleton to oppose itself against the vessel wall. The graft is tamped into place by the inflation of a separate balloon catheter.

In our patient, we surgically exposed the right common femoral artery and then deployed two 100-mm Talent Medtronic endoprostheses to seal the ruptured aorta (Fig. 3). The procedure and the perioperative course were uneventful. The patient underwent intravenous antibiotic treatment for 1 month after the operation. A chest CT scan on 6-month follow-up documented almost complete resolution of the pseudoaneurysm with no sign of mediastinal infection or endoleak (Fig. 4). We advocate endoluminal aortic stenting as a safe alternative for the treatment of aortoesophageal fistulas of aortic origin, particularly in patients with severe concomitant disease.

Fig. 3 Aortography shows the aortic stent graft insertion and the exclusion of the aortic ulcer and pseudoaneurysm (arrows).

Fig. 4 At the 6-month follow-up visit, a chest computed tomographic scan shows almost complete resolution of the periaortic hematoma, resolution of the aortoesophageal fistula, and absence of mediastinal infection. The esophageal lumen is indicated by the white arrow and the descending aortic lumen with the endoprosthesis is indicated by the black arrow.