Surgical management without resection of the oesophagus for aorto-oesophageal fistula secondary to aortic arch aneurysm rupture.

A 79-year-old moderately frail man with a history of graft replacement for descending thoracic aortic aneurysm and chronic kidney disease presented with the onset of haemoptysis. Computed tomography demonstrated aorto-oesophageal fistula secondary to aortic arch aneurysm rupture. Emergency surgery was performed through a median sternotomy. Cardiopulmonary bypass was established via femoral artery inflow and bicaval venous drainage. After establishing circulatory arrest, the aortic arch was excised. Resection of the aortic aneurysm and debridement were performed during antegrade cerebral perfusion and lower body perfusion from femoral artery inflow using balloon occlusion of the previous graft. Aortic arch graft replacement with concomitant debridement of mediastinal tissue and direct repair of oesophageal perforation comprised a first-stage operation. Forty hours later, abundant irrigation of warm normal saline around the mediastinal cavity and the omental flap covering the graft and the repair site of the oesophagus comprised the second-stage operation. Although the postoperative course was complicated, the patient resumed oral intake within 2 months after the initial operation. Serial computed tomography and oesophageal endoscopy showed good healing of the aorto-oesophageal fistula. There were no clinical manifestations or imaging findings of deep mediastinal infection throughout the postoperative course.