Aortoesophageal fistulas due to thoracic aorta aneurysm: surgical versus endovascular repair. Is there a role for combined aortic management?

Aortoesophageal fistula (AEF) is a rare cause of gastrointestinal bleeding with high mortality. Thoracic aorta aneurysms represent the leading cause of aortoesophageal fistula. Surgery offers the only chance for cure in these patients. So far there are no clear indications on the optimal management of these patients. A review of the literature was undertaken focusing on the surgical management of thoracic aorta aneurysm-related AEFs in an attempt to clarify the indications for the surgical or endovascular treatment of this entity. Only 37 successfully treated patients were identified. Most of them underwent open surgical repair with the intent to control both hemorrhage and mediastinal contamination. Thoracic aorta replacement with a synthetic graft was used in most cases. Cryopreserved homografts, extranatomic bypass, and endovascular stent grafting were used in a small number of patients. Esophageal manipulation using various techniques was undertaken in all patients with open surgical repair of their AEF. Based on the reported results and identified limitations of each approach, the present authors advocate open surgical repair of both aneurysm and esophageal defect as the treatment of choice in all patients with AEF and signs of infection in relatively good general condition. Stent grafting is considered a valid approach only for patients who cannot tolerate open repair. A combined technique of stent grafting for immediate bleeding control followed by open surgical repair of both aneurysm, preferably using homografts, and esophageal defect are extremely promising and may represent a more valid alternative to the classical open approach in the future.