Fatal complications of aortoesophageal fistula caused by pseudoaneurysm following esophageal stent placement: A case report

Rationale: Aortoesophageal fistula (AEF) is an exceedingly rare yet critically life-threatening condition, with mortality rates nearing 100% if not addressed promptly. AEF often develops in the context of thoracic aortic aneurysms, esophageal malignancies, or as a complication of foreign body ingestion and prior thoracic aortic surgeries. This study reports an exceptionally severe and clinically rare case of AEF associated with a pseudaneurysm induced by esophageal stenting. By disseminating this case, we aim to heighten awareness of AEF and emphasize the necessity for meticulous decision-making during esophageal stent placement, along with the importance of vigilant postoperative monitoring to enable early intervention.

Patient concerns: A 70-year-old male presented with "food obstruction" and was subsequently diagnosed with esophageal malignancy. To alleviate the obstruction, he underwent esophageal stenting. Fifty-five days postprocedure, he experienced a sudden onset of "chest pain, vomiting of dark red blood, and melena," prompting hospitalization for "gastrointestinal bleeding."

Diagnoses: Urgent computed tomography angiography revealed the emergence of a new pseudaneurysm at the lateral aspect of the esophageal stent, with direct communication between the aneurysm and the adjacent esophagus, raising the suspicion of AEF.

Interventions: An urgent multidisciplinary emergency team was convened to execute critical interventions, including endoluminal stenting of the esophagus and thoracic endovascular aortic repair.

Outcomes: The patient suffered a sudden and massive hematemesis, estimated at approximately 3000 mL, leading to his subsequent demise.

Lessons: AEF is a rare cause of upper gastrointestinal bleeding. For patients suspected of AEF, it is imperative to conduct prompt and thorough computed tomography angiography while initiating an emergency surgical alert. The proximity of esophageal stents to the aorta may significantly elevate the risk of AEF; thus, a comprehensive risk assessment should precede stent placement in cases involving tumors adjacent to the aorta. Furthermore, postoperative surveillance is crucial to monitor potential aortic invasion by the tumor or the development of an aneurysm near the esophagus, facilitating timely intervention.