S4825 Aortoesophageal Fistula Secondary to Infected TEVAR Graft: A Fatal Complication Following UTI Bacteremia

Introduction: Aortoesophageal fistula (AEF) is a rare but acutely life-threatening condition. In a study involving 123 surgically treated cases, 61% were secondary AEFs—most commonly due to aortic grafting (32.5%), followed by thoracic endovascular aortic repair (TEVAR) (24.4%). Other reports have identified esophageal cancer as a cause. We present a case of AEF secondary to an infected TEVAR graft in a patient with recent type B thoracoabdominal aortic dissection and aneurysm. Case Description/Methods: A 68-year-old Asian man with a remote history of type A aortic dissection status post surgical repair, recent hx of type B thoracoabdominal dissection and aneurysm status post 2 TEVARs, and chronic urinary obstruction managed with a suprapubic catheter (SPC), was admitted for evaluation of a urinary tract infection (UTI). He had been well until 1 week prior, when he developed fever, chills, and dysuria. His SPC was exchanged, and a 5-day course of oral ciprofloxacin resolved the fever, though urinary symptoms persisted. On admission, he was started on intravenous cefepime and vancomycin. Blood cultures grew Gemella haemolysans. Two days later, he had hematemesis with a hemoglobin drop from 9.9 to 6.9 g/dL. esophagogastroduodenoscopy showed an esophageal ulcer with recent bleeding in the mid-esophagus. CTA revealed multifocal gas within the aneurysm sac and false lumen around the stent graft, consistent with an aorto-esophageal fistula (AEF). Vascular surgery was consulted, but due to his frailty, graft explantation was deferred. He was transitioned to comfort care and passed away the following day. Discussion: AEF is an extremely rare but critically life-threatening condition. Reported outcomes in a series of 10 patients with TEVAR graft infections complicated by AEF had a perioperative mortality rate of 70%. Seven of the 10 patients died from hemorrhage and infection, and only 3 survived to hospital discharge. In our case, the patient developed bacteremia from a urinary tract infection, which led to graft infection and subsequently resulted in an AEF. Clinicians should maintain a high index of suspicion for AEF in patients presenting with hematemesis, particularly those with a history of aortic surgery, thoracic aortic aneurysm, TEVAR, or thoracic and gastrointestinal malignancies.