Aortoesophageal fistula: Long-term survival with aggressive multidisciplinary management

Objective: Aortoesophageal fistula (AoEF) is a rare but complex problem that carries high mortality. This study describes our institutional experience with the management of AoEF. Methods: There were 17 patients with AoEF who were managed in our center (2005-2023). Medical records were reviewed for baseline characteristics, history of esophageal or aortic disease, diagnostic evaluation, surgical treatment, and follow-up. Overall survival (OS) was analyzed using the Kaplan-Meier method and log rank tests. Results: Most patients had previous aortic operations (12/17, 71%)—7 thoracic endovascular aortic repair (TEVAR), 3 open/TEVAR, and 2 open repairs. The etiology of AoEF was aortic disease in 13 (76%) and anastomotic leak after esophagectomy in 4 (24%). Upon presentation, 2 (12%) patients were not offered intervention, whereas 6 (35%) had emergency TEVAR to control bleeding. Twelve (67%) patients were treated with curative intent, 1 patient did not survive an initial aortic operation. Of the remaining 11 patients, esophageal operations happened before aortic repair in 7 (64%), concurrently in 3 (27%), and after in 1 (9%). This included diversion esophagectomy in 7 (64%) and primary repair in 3 (27%). Definitive aortic surgery included aorta replacement with rifampin-soaked grafts in 8 (67%) and homografts in 4 (33%). In-hospital mortality occurred in 1 of 12 (8%) cases. One- and 2-year OS was 83% and 74%. OS was lower in patients not receiving curative-intent treatment (P < .001). Conclusions: Management of AoEF is complex. However, aggressive multidisciplinary intervention with definitive esophageal and aortic repairs can result in good long-term survival in selected patients.