Temporary stent placement in 2 cases of aortoesophageal fistula

Brief Reports

REFERENCES 1. Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339:659-66. 2. Pappone C, Rosanio S, Oreto G, et al. Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation. Circulation 2000;102:2619-28. 3. Oral H, Scharf C, Chugh A, et al. Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation 2003;108:2355-60. 4. Pappone C, Oral H, Santinelli V, et al. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation 2004;109:2724-6. 5. Scanavacca MI, D’avila A, Parga J, et al. Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2004;15:960-2. 6. Cummings JE, Schweikert RA, Saliba WI, et al. Brief communication: atrial-esophageal fistulas after radiofrequency ablation. Ann Int Med 2006;144:572-4. 7. Doll N, Borger MA, Fabricius A, et al. Esophageal perforation during left atrial radiofrequency ablation: is the risk too high? J Thorac Cardiovasc Surg 2003;125:836-42. 8. Sonmez B, Demirsoy E, Yagan N, et al. A fatal complication due to radiofrequency ablation for atrial fibrillation: atrio-esophageal fistula. Ann Thorac Surg 2003;76:281-3. 9. Gillinov MA, Pettersson G, Rice TW. Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg 2001; 122:1239-40. 10. Mohr FW, Fabicius AM, Falk V, et al. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results. J Thorac Cardiovasc Surg 2002;123:919-27. 11. Marrouche NF, Guenther J, Segerson NM, et al. Randomized comparison between open irrigation technology and intracardiac-echo-guided energy delivery for pulmonary vein antrum isolation: procedural parameters, outcomes, and the effect on esophageal injury. J Cardiovasc Electrophysiol 2007;18:583-8. 12. Schmidt B, Chun KRJ, Kuck KH, et al. Pulmonary vein isolation by highintensity focused ultrasound. Indian Pacing Electrophysiol J 2007;7: 126-33.

13. Schmidt B, Antz M, Ernst S, et al. Pulmonary vein isolation by highintensity focused ultrasound: first-in-man study with a steerable balloon catheter. Heart Rhythm 2007;4:575-84. 14. Natale A, Pisano E, Shewchik J, et al. First human experience with pulmonary vein isolation using a through-the-balloon circumferential ultrasound ablation system for recurrent atrial fibrillation. Circulation 2000; 102:1879-82. 15. Nakagawa H, Antz M, Wong T, et al. Initial experience using a forward directed, high-intensity focused ultrasound balloon catheter for pulmonary vein antrum isolation in patients with atrial fibrillation. J Cardiovasc Electrophysiol 2007;18:136-44. 16. Cummings JE, Schweikert RA, Saliba WI, et al. Assessment of temperature, proximity, and course of the esophagus during radiofrequency ablation within the left atrium. Circulation 2005;112:459-64. 17. Tsuchiya T, Ashikaga K, Nakagawa S, et al. Atrial fibrillation ablation with esophageal cooling with a cooled water-irrigated intraesophageal balloon: a pilot study. J Cardiovasc Electrophysiol 2007;18:145-50. 18. Oral H, Chugh A, Good E, et al. Randomized comparison of encircling and non-encircling left atrial ablation for chronic atrial fibrillation. Heart Rhythm 2005;2:1165-72. 19. Verma A, Marrouche NF, Natale A. Pulmonary vein antrum isolation: intracardiac echocardiography-guided technique. J Cardiovasc Electrophysiol 2004;15:1335-40. 20. Dixit S, Gerstenfeld EP, Callans DJ, et al. Comparison of cool tip versus 8-mm tip catheter in achieving electrical isolation of pulmonary veins for long-term control of atrial fibrillation: a prospective randomized pilot study. J Cardiovasc Electrophysiol 2006;17:1074-9. 21. Bunch JJ, Nelson J, Foley T, et al. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2007;17:435-9.

Division of Gastroenterology (A.K., M.S.C., L.D.), Division of Cardiology (D.E.H.), William Beaumont Hospital, Royal Oak, Michigan, USA. Reprint Requests: Amulya Konda, MD, Division of Gastroenterology, William Beaumont Hospital, 3601 W Thirteen Mile Rd, Royal Oak, MI 48073. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.12.011

Temporary stent placement in 2 cases of aortoesophageal fistula Ina Zuber-Jerger, MD, Ursula Hempel, MD, Felix Rockmann, MD, Frank Klebl, MD Regensburg, Germany

The aortoesophageal fistula is a life-threatening disorder with a nearly always fatal outcome. Proper management requires expedient endoscopic and radiographic evaluation for diagnosis, bridging stent therapy, and definitive surgery with grafts. We present 2 typical cases and discuss the role of endoscopy in the diagnosis and the use of an esophageal prosthesis as a new therapeutic tool for bridging therapy in the light of the therapeutic strategies described so far.

CASE REPORT

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Case 1 A 70-year-old man vomiting blood was admitted to a hospital of primary care. Upper endoscopy revealed masses of coagulated and fresh blood in the esophagus. CT demonstrated a covered perforation of a thoracic aneurysm. The patient was transported to our hospital of tertiary care. An aortal stent was placed immediately. Afterwards, upper endoscopy

Brief Reports

Figure 1. Plastic esophageal stent in a 70-year-old man with aortoesophageal fistula.

was repeated and showed a 3-cm perforation of the esophagus. A plastic stent (12-cm length, 2.5-cm diameter) was inserted (Fig. 1). The patient remained stable, and 13 days later, surgery was performed. An aortal graft was implanted, and the plastic stent was removed. The esophageal perforation was primarily stitched, but resection had to be performed one week later after reoccurrence of leakage.

Case 2 A 75-year-old man was admitted to our emergency unit in shock and vomiting blood. Upper endoscopy revealed a mass of coagulated and fresh blood, and a small unspectacular lesion in the esophagus suddenly began pulsatile bleeding. A Blakemore tube (Fig. 2, white arrow) was inserted. CTrevealed an aortoesophageal fistula (Fig. 2, black arrow), and an aortal stent was placed. Afterward a covered esophageal metal stent (8-cm length, 2.7-cm diameter) was inserted, covering the lesion (Fig. 3, white arrow) marked with lipiodol (Fig. 3, black arrow). The patient remained stable, and 7 days later the stent was removed and partial esophagus resection was performed.

Figure 2. Aortoesophageal fistula (black arrow) in a 75-year-old man. Blakemore tube (white arrow) in the esophagus to control esophageal bleeding.

The current incidence of aortoesophageal fistula is not known. The entity was first described in 1818.1 About 100 case reports describing this nearly-always-fatal entity have been collected in PubMed since 1969, suggesting that the condition is not that rare.

Most aortoesophageal fistulas arise from thoracic aneurysm, foreign-body ingestion, or esophageal malignancy.2 Other causes described in the literature are surgical complications, esophagitis, tuberculosis, and congenital malformations. The description of initial symptoms published is quite unique. Pain in the chest may be present, but GI bleeding is nearly always the first symptom of an aortoesophageal fistula. It is usually severe and intermittent. Considering this, the responsibility for the diagnosis remains with the endoscopist, who is likely to see the patient first after stabilization.

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DISCUSSION

Brief Reports

Figure 3. Covered metal esophageal stent covering the aortoesophageal fistula (white arrow). The lesion was marked fluoroscopically with lipiodol (black arrow).

There are only minor typical endoscopic findings: primarily, masses of coagulated and fresh blood are found in the esophagus and the upper parts of the stomach. The lesion itself is usually small and may be overlooked. Pulsatile bleeding can only be expected in a minority of cases because bleeding is intermittent, but the most important differential diagnosis in severe esophageal hemorrhage is varices, which can be detected quite easily even in severe bleeding. So if all facts are put together, this diagnosis should be considered in any patient with clinically severe GI bleeding in which the distribution of blood points to an esophageal bleeding source in the absence of varices. Multislice CT with arterial contrast should be performed immediately in these patients. Hemostasis cannot be achieved by endoscopic means, because high-pressure blood is pumped into the lowpressure GI tract. If the diagnosis is suspected, no time should be wasted with attempts to stop the bleeding by application of clips or injection therapy, which would only tend to enlarge the injury. A Blakemore tube should be inserted, and immediate endovascular stenting is required, either as bridging to definitive therapy with vascular grafts or as a permanent solution. Restoration of the esophagus may be difficult. In these critically ill patients the goal is to keep the surgical procedure as simple and swift as possible.3 On one hand, primary suturing of the esophageal defect has a high recurrence rate.4 On the other hand, resection of the esophagus should be delayed or avoided, because all forms of esophageal sub-

stitution are inferior to the native esophagus.3,5 An esophageal prosthesis may be a valuable therapeutic tool to protect the injured esophagus until surgery. There is very limited experience with the esophageal prosthesis in this entity. One of the first esophageal stentsdthe Gianturco-Z stentdwas even accused of inducing an aortoesophageal fistula6 by the wires anchoring the prosthesis. But in recent years, covered metal stents and plastic stents have been developed that induce less tissue injury. The use of an esophageal prosthesis in an aortoesophageal fistula has been reported once so far.7 In our patients the lesion was easily detected, and its location allowed the stable implantation of a stent. The application of both stents was easy to perform. Neither of the 2 stents migrated. Both stents were finally explanted during surgery.

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CONCLUSION Upper endoscopy is valuable in the diagnosis and therapy of an aortoesophageal fistula. The first aim of the endoscopist must be to consider the differential diagnosis in patients with severe nonvariceal esophageal bleeding. After having established the diagnosis with contrast-enhanced CT, and after implantation of an aortal prosthesis, depending on the location and the diameter of the lesion, an esophageal prosthesis can be put in to stabilize the injured esophagus to delay or avoid surgical procedures.

Brief Reports

DISCLOSURE The authors report that there are no disclosures relevant to this publication. REFERENCES 1. Dubreuil NN. Observation sur la perforation d l’oesophage et de l’aorte thoracique par une potion d’os avale: avec des re´flexions [French]. J Univ Sci Med 1818;9:357-65. 2. Podbielski FJ, Rodriguez HE, Zhu RY, et al. Aortoesophageal fistula secondary to reflux esophagitis. Dig Surg 2007;24:66-7. 3. Reardon MJ, Brewer RJ, LeMaire SA, et al. Surgical management of primary aortoesophageal fistula secondary to thoracic aneurysm. Ann Thorac Surg 2000;69:967-70. 4. Flores J, Shiiya N, Kunihara T, et al. Aortoesophageal fistula: alternatives of treatment case report and literature review. Ann Thorac Cardiovasc Surg 2004;10:241-6. 5. Chandrashekar G, Kumar VM, Kumar AK. Repair of aortoesophageal fistula due to a penetrating atherosclerotic ulcer of the descending

thoracic aorta and literature review. J Cardiothorac Surg 2007; 14:12. 6. Siersema PD, Tan TG, Sutorius FF. Massive hemorrhage caused by a perforating Gianturco-Z stent resulting in an aortoesophageal fistula. Endoscopy 1997;29:416-20. 7. Park DH, Park JH, Lee SH. Temporary placement of a covered metal stent for the management of a bleeding aortoesophageal fistula. Endoscopy 2007 Feb 26 [Epub ahead of print].

Department of Internal Medicine I, University of Regensburg, Regensburg, Germany. Reprint requests: I. Zuber-Jerger, Department of Internal Medicine I, University of Regensburg, 93042 Regensburg, Germany. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.12.010

Tissue ingrowth in a fully covered self-expandable metallic stent (with videos) Sathya Jaganmohan, MD, Gottumukkala S. Raju, MD, FASGE Galveston, Texas, USA

Self-expandable stents have revolutionized the management of benign and malignant esophageal obstruction and esophageal leaks. Since the first successful deployment of a self-expandable metal stent (SEMS) by Domschke et al1 in 1990, SEMS have evolved steadily over the past decade. The indications for esophageal stent use have expanded from its initial use in palliation of malignant esophageal obstruction to its current use in many benign and malignant conditions. The addition of a polyurethane layer to the spine of the stent providing a covering to the stent has effectively reduced the tissue ingrowth that plagued the initial wire mesh metal stents with obstruction. Partial or fully covered self-expandable stents have become a popular noninvasive endoscopic management option for esophageal leaks, fistulas, perforations, and recalcitrant strictures. Although improvements in stent material, design, and technology have made stents safer and more reliable, complications, albeit rare, do occur. Recently, a fully covered self-expandable stent FC-SEMS (ALIMAXX-E, Alveolus, Charlotte, NC) delivered through a smaller flexible delivery system was introduced for easy insertion and the fully covered stent design for easy removal of the stent, if necessary. However, fully covered SEMS may not be foolproof in preventing tissue ingrowth as observed in 2 patients at our center. Our aim is to present 2 cases with extensive tissue ingrowth

through a fully covered SEMS and discuss strategies for successful stent extraction when ingrowth occurs.

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CASE 1 A 29-year old woman with achalasia and epiphrenic diverticulum had a postoperative esophageal leak after a combined thoracotomy, esophageal myotomy, and epiphrenic diverticulectomy. Initially, a Polyflex stent (Boston Scientific, Natick, Mass) was inserted with successful sealing of the leakage. Seven days later, the stent migrated down with recurrence of leakage. Repeat thoracotomy and surgical closure reinforced with diaphragmatic muscle and repositioning of the stent was undertaken. Because of persistent leakage, an FC-SEMS (23  120 mm, Alimaxx-E stent) was inserted. The leak sealed off. Two weeks later, EGD revealed extensive tissue ingrowth in the distal third of the stent with luminal narrowing (Fig. 1, Video 1, available online at www.giejournal. org). On endoscopy, pulling the spine of the stent with an alligator forceps (Olympus, Tokyo, Japan) fractured the stent, leaving the stent portion with tissue ingrowth in situ. The portion of the stent with the ingrowth could not be separated from the esophageal wall despite pulling the stent forcibly with an alligator forceps. Argon plasma coagulation at a