S4221 Sentinel Upper Gastrointestinal Bleeding From Aorto-Esophageal Fistula Due to Infected Aneurysmal Graft: A Rare but Fatal Complication of Post-Endovascular Aortic Aneurysm Repair

Introduction: Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure and is an alternative to open repair for aortic aneurysm (AA) especially in complex patients. Aorto-esophageal fistula (AEF) is a rare (1.5% to 1.9%) but fatal complication of TEVAR associated with high mortality rate of 75% which usually occurs early after the procedure. The delayed presentation of AEF is extremely rare. Here, we present a case of a woman who presented 8 years after endovascular graft repair with sentinel upper gastrointestinal bleeding and concomitant graft infection. Case Description/Methods: Sixty-six-year-old woman with medical history of descending thoracic aortic AA s/p TEVAR, ovarian, vulvar and colon cancer s/p TAH-BSO, chemo and radiation presented with epigastric abdominal pain and hematemesis, admitted for hypovolemic shock. Labs revealed Hb of 6.8 mg/dl. Computed tomography abdomen with no abnormality. Emergent upper endoscopy revealed small nonbleeding ulcer in proximal esophagus treated with hemostatic clips. The obvious fistulous opening was not seen, and no active bleeding was witnessed. Due to presence of persistent epigastric pain and worsening leukocytosis the alternative etiology was evaluated using computed tomography chest showing stable AA but extensive gas foci with stranding around aneurysm sac and fistulous tract concerning for AEF. Patient was deemed not a surgical candidate and managed medically. Subsequently, she improved and discharged home on antibiotics. She was re-admitted after 2 days with hematemesis and severe sepsis. Repeat imaging were concerning for pneumonia and aneurysmal graft infection and diagnosed to have contained aneurysm rupture evident by presence of dense material in growing aneurysmal sac. Numerous foci of gas within the aneurysmal sac were suggestive of persistent aorto-esophageal fistula. Due to poor candidacy for surgical intervention, family opted for comfort measure. Discussion: AEF is a catastrophic complication of endovascular stent-graft placement. Abdominal pain and hematemesis in lieu of previous history of aortic aneurysm or aneurysmal repair should ring the bell for possibility of AEF. Majority of the AEF cases present within first year after aneurysmal repair however this case highlights a rare, delayed presentation after 8 years of the graft placement. The definitive treatment is surgical repair with high risk of peri-operative complication and mortality. The medical management is always fatal. The key to prevent mortality is having high clinical suspicion and immediate surgical repair.