Czerny Martin, Eggebrecht Holger, Sodeck Gottfried, Weigang Ernst, Livi Ugolino, Verzini Fabio, Schmidli Jürg, Chiesa Roberto, Melissano Germano, Kahlberg Andrea, Amabile Philippe, Harringer Wolfgang, Horacek Michael, Erbel Raimund, Park Kay-Hyun, Beyersdorf Friedhelm, Rylski Bartosz, Blanke Philipp, Canaud Ludovic, Khoynezhad Ali, Lonn Lars, Rousseau Hervè, Trimarchi Santi, Brunkwall Jan, Gawenda Michael, Dong Zhihui, Fu Weiguo, Schuster Ingrid, Grimm Michael
Department of Cardiovascular Surgery, Inselspital, University Hospital Berne, Berne, Switzerland.
Eur J Cardiothorac Surg. 2014 Mar;45(3):452-7. doi: 10.1093/ejcts/ezt393. Epub 2013 Jul 31.
To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR).
International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres).
Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33).
The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients.
回顾经胸腔内血管主动脉修复术（TEVAR）后发生主动脉-食管瘘（AOF）患者的发病率、临床表现、确切治疗方法及1年预后情况。
2001年至2011年的国际多中心注册研究（欧洲血管内主动脉修复并发症注册研究），共纳入2387例TEVAR手术病例（17个中心）。
共识别出36例患者，中位年龄69岁（四分位间距56 - 75岁），女性占25%，9例（19%）曾接受过主动脉手术。研究期间，TEVAR术后整个队列中AOF的发生率为1.5%。TEVAR的主要潜在主动脉病变为53%的患者存在动脉粥样硬化性动脉瘤形成，AOF发生的中位时间为90天（四分位间距30 - 150天）。主要临床症状为不明原因发热29例（81%）、呕血19例（53%）、休克8例（22%）。92%的病例可通过计算机断层扫描确诊，28例（78%）患者的主要征象为新出现的纵隔肿块。保守治疗导致1年死亡率为100%，仅行食管支架置入术的1年生存率为17%。单纯食管切除术后的生存率为43%。通过包括根治性食管切除术和主动脉置换在内的积极治疗可实现最高的1年生存率（46%）[相对风险增加1.73，95%置信区间（CI）1.03 - 2.92]。在自抽样分析中可证实这种积极治疗方式的生存优势（95% CI 1.11 - 3.33）。
AOF的发生是TEVAR术后一种罕见但致命的并发症，与急诊TEVAR需求以及纵隔血肿形成有关。治愈该疾病唯一持久且成功的方法是根治性食管切除术和广泛的主动脉重建。这些发现可作为治疗这些复杂患者的医生的决策工具。
