Kahlberg Andrea, Tshomba Yamume, Marone Enrico M, Castellano Renata, Melissano Germano, Chiesa Roberto
Department of Vascular Surgery, Vita-Salute University, San Raffaele Scientific Institute, Milano, Italy.
Department of Vascular Surgery, Vita-Salute University, San Raffaele Scientific Institute, Milano, Italy.
Ann Vasc Surg. 2014 Oct;28(7):1782-8. doi: 10.1016/j.avsg.2014.06.003. Epub 2014 Jun 12.
Aortoesophageal (AEF) and aortobronchial (ABF) fistulae are uncommon but invariably fatal if left untreated. Mortality rates of open surgery remain prohibitive. Thoracic endovascular aortic repair (TEVAR) was shown to be a valid alternative to control bleeding in emergency, allowing a reduction of perioperative mortality. However, it entails a significant risk of late sequelae, namely endograft contamination and sepsis, related to the untreated esophageal leak. The aim of this study is to present initial results of a combined "hybrid" (endovascular and open) strategy to treat AEF and ABF.
From 2006 to 2013, 8 patients (6 men, mean age 63 ± 13 years) were operated at our institution for primary and secondary AEF (7 patients) or ABF (1 patient) by means of a combined approach: emergent endovascular exclusion of the aortic rupture, followed by staged open surgical repair of the esophageal or bronchial lesion with associated intercostal muscle flap interposition. Follow-up was available in all patients (mean 34 ± 26 months).
TEVAR was successfully performed in all cases in emergency because of active bleeding or hemodynamic instability. Stabilization of hemodynamic parameters was obtained in all patients. Open surgical stage was performed either directly after TEVAR (n = 1) or after a mean delay of 6.9 ± 3.5 days (n = 7). No perioperative sepsis, bleeding, or death was observed. At follow-up, 7 patients were alive (87.5%). One patient died 1 year after the procedure because of sudden cardiocirculatory arrest of unknown origin. Another patient experienced 2 hospitalizations, at 3 and 8 months after the procedure, for recurrent fever requiring prolonged intravenous antibiotic therapy. No conversion or aortic bleeding was recorded during follow-up.
Immediate TEVAR followed by staged open repair of the esophageal or bronchial defect with intercostal muscle flap interposition appears to be a feasible treatment of AEF and ABF. Despite the fact that initial results are encouraging, further data on wider cohorts with longer follow-up are necessary to confirm the efficacy and durability of this strategy.
主动脉食管瘘（AEF）和主动脉支气管瘘（ABF）较为罕见，但如果不治疗，必然会导致死亡。开放手术的死亡率仍然很高。胸主动脉腔内修复术（TEVAR）已被证明是在紧急情况下控制出血的有效替代方法，可降低围手术期死亡率。然而，它存在后期后遗症的重大风险，即与未治疗的食管瘘相关的移植物污染和败血症。本研究的目的是展示一种联合“杂交”（血管内和开放）策略治疗AEF和ABF的初步结果。
2006年至2013年，8例患者（6例男性，平均年龄63±13岁）在我院接受手术，采用联合方法治疗原发性和继发性AEF（7例患者）或ABF（1例患者）：紧急血管内封堵主动脉破裂，随后分期进行开放手术修复食管或支气管病变，并置入肋间肌瓣。所有患者均获得随访（平均34±26个月）。
由于活动性出血或血流动力学不稳定，所有病例均成功进行了紧急TEVAR。所有患者的血流动力学参数均得到稳定。开放手术阶段在TEVAR后直接进行（n = 1）或平均延迟6.9±3.5天（n = 7）后进行。未观察到围手术期败血症、出血或死亡。随访时，7例患者存活（87.5%）。1例患者在术后1年因不明原因的心脏循环骤停死亡。另1例患者在术后3个月和8个月因反复发热需要长期静脉抗生素治疗而住院2次。随访期间未记录到转换或主动脉出血。
立即进行TEVAR，随后分期开放修复食管或支气管缺损并置入肋间肌瓣似乎是治疗AEF和ABF的可行方法。尽管初步结果令人鼓舞，但仍需要更多关于更大队列、更长随访时间的数据来证实该策略的疗效和持久性。
