S4818 Fatal Aortoesophageal Fistula Caused by Malecot Drain Erosion: A Rare Iatrogenic Complication

Introduction: Aortoesophageal fistula (AEF) is a rare but often fatal cause of upper gastrointestinal bleeding. Although classically associated with thoracic aortic aneurysms or esophageal malignancy, iatrogenic causes—including surgical interventions and foreign body erosion—are increasingly recognized. Case Description/Methods: A 30-year-old woman with a history of alcohol use disorder, prior hiatal hernia repair, and partial gastrectomy complicated by esophageal necrosis presented with sudden, massive hematemesis. A Malecot drain had been placed postoperatively within a blind esophageal pouch. On arrival, she was tachycardic and hypotensive (BP 64/37 mmHg; MAP 43) with ongoing hematemesis, necessitating intubation and vasopressor support. Laboratory data revealed a hemoglobin of 7.5 g/dL and lactate of 5.7 mmol/L. Computed tomography angiography revealed the Malecot drain terminating in the blind esophageal pouch with contrast extravasation suggesting communication with the descending thoracic aorta. Despite urgent vascular surgery consultation and preparations for thoracic endovascular aortic repair (TEVAR), the patient experienced refractory shock and died from cardiac arrest. Discussion: AEF is exceedingly rare (<0.007% in autopsy series), with most cases due to aneurysms (54%), malignancy (19%), or foreign body ingestion (17%). Iatrogenic cases remain a minority but are increasing. This case highlights a unique mechanism—erosion from a chronically placed Malecot drain leading to fatal fistula formation. Clinicians must maintain high suspicion for AEF in any patient with prior upper GI surgery and massive hematemesis, especially in the setting of indwelling esophageal devices.