Life-saving staged management of a secondary aortoesophageal fistula after arch replacement: a case report

BACKGROUND: Aortoesophageal fistula (AEF) after thoracic aortic repair is a rare and devastating complication with an extremely high mortality (33-100%). Although emergency thoracic endovascular aortic repair (TEVAR) can provide immediate hemostasis, it does not address the underlying infection and therefore is insufficient for long-term survival. A staged multidisciplinary strategy may improve outcomes in selected patients: initial hemodynamic stabilization, early source eradication (esophagectomy), and delayed reconstruction. CASE PRESENTATION: A 78-year-old woman, who had undergone total arch replacement 6 years prior, presented with sudden haematemesis. Endoscopy and CT confirmed secondary AEF. Emergency TEVAR successfully stabilized bleeding. Two days later, the patient underwent thoracoscopic oesophagectomy, cervical oesophagostomy, jejunostomy, and omental flap coverage. Parvimonas micra was isolated intraoperatively, and targeted antimicrobial therapy was continued for eight weeks. After achieving infection control and nutritional optimization, presternal ileocolonic reconstruction was performed on postoperative day 69. She was discharged home 94 days after the initial intervention and remains well, free of recurrence, at 7 months post-TEVAR. CONCLUSION: This case highlights the critical role of a well-executed staged strategy in contributing to favorable clinical outcomes from secondary AEF. Immediate TEVAR served effectively as a life-saving bridge. Crucially, the early multidisciplinary coordination allowed for the prompt removal of the oesophageal source within 48 h, an intervention essential to prevent uncontrolled mediastinal sepsis. This sequence-haemostasis, early source control, and delayed extra-anatomical reconstruction-may provide a reasonable strategy for survival in selected high-risk patients.