Late Bronchoesophageal-Arterial Fistula After Surgery of an Aberrant Sublcavian Artery

Abstract

INTRODUCTION: Aortic arch abnormalities are rare, but right-retroesophageal-subclavian-artery is the most common of them. It is usually asymptomatic. Dysphagia lusoria and fistulas, associated with hematemesis have been reported, with a very high mortality rate. There is no standard therapeutic approach for them. CASE PRESENTATION: A 67 year old man came with hematemesis and dysphagia. A retrotracheal, right subclavian artery, with a 68mm aneurysm was found on a CT-scan. Oesophageal endoscopy was performed, but it didn't find the bleeding's origin. Emergency endovascular prosthesis was placed on the aortic arch covering the supraortic branches to stop the bleeding, and an open arterial by-pass surgery was required to recover their normal flow. A second esophageal endoscopy found an aneurismal-esophageal fistula forty-eight hours after the surgery. Conservative treatment was decided, and the patient stayed at the intensive care unit during four weeks. Ventilation difficulties motivated a new CT-scan, and a late broncho-esophageal-arterial fistula on the right main bronchus was suspected and then confirmed with a bronchoscopy. The bronchoscope was able to pass from the trachea to the esophagus and the isolated aneurismal remaining cavity. A tracheal- Y-stent was placed in order to seal the air leakage unsuccessfully, and progressive worsening led the patient to death on the tenth week. DISCUSSION: Right-retroesophageal-subclavian-arteries can produce a pulsatile compression that can lead to tissue necrosis and fistulas. It has been associated specially with long term semirigid-catheter placement. CONCLUSIONS: The initial management of vascular malformations associated to bleeding must be focused on damage control and survival of the patient. Nevertheless, we always have to take into consideration the damage that we can produce with each of our decissions. Teamwork is very important in the therapeutical approach of patients, with diseases that overlap on the limits of different medical specialities.