Clinical experience and long-term survival of aorto-esophageal fistula following descending aortic repair

Objective To compare the outcomes between surgical and conservative treatment of aorto-esophageal fistula after descending aortic repair. Methods Between January 2019 and January 2024, we treated 35 patients with aorto-esophageal fistula after descending aortic repair. Patients were assigned to conservative (n = 14) or surgical (n = 21) management. Surgical strategies included in situ descending thoracic aortic replacement (n = 2); two-stage aortic surgery with (n = 12) or without (n = 4) esophageal repair—first stage: combined median sternotomy and upper midline laparotomy with a four-branch Dacron graft interposition between the ascending and abdominal aortas, debranching of the supra-aortic trunks, and aortic arch transection proximal to the innominate artery; second stage: left intercostal thoracotomy with excision of the infected descending aorta, stent graft, and surrounding mediastinal tissue; single-stage aortic surgery (n = 1); and isolated esophageal repair (n = 2). Results Mean age was 54.5 ± 10.2 years, and 31 (88.6%) patients were male. Prior aortic repair included thoracic endovascular aortic repair in 27 (77.1%), total arch repair in 2 (5.7%) and combined total arch repair with thoracic endovascular aortic repair in 6 (17.1%). Early mortality was 50.0% (7/14) in the conservative group versus 14.3% (3/21) in the surgical group ( P = 0.053). Causes of early death primarily included aortic rupture and sepsis with multiorgan failure. follow-up was 100% complete at median 30 months (interquartile range 3.3–74). All conservatively managed patients died within 1.5 years. Late death occurred in 6 patients of the surgical group (28.6%), and all survivors successfully resuming normal oral feeding. The 1-, 3-, and 5-year survival rates were significantly higher in the surgical group (71.4%, 58.4%, and 48.7%) compared to the conservative group (14.3%, 0%, and 0%; P < 0.001). Notably, patients undergoing two-stage aortic surgery achieved a favorable 5-year survival of 65.6%. Conclusions The two-stage aortic surgery with esophageal repair yielded favorable outcomes in the management of aorto-esophageal fistula secondary to descending aortic repair.