Endoscopic Closure Combined With the Endoscopic Submucosal Dissection Technique and Over-the-scope Clip for Chronic Aortoesophageal Fistula: A Case Report

Abstract

Aortoesophageal fistula (AEF) is a rare but life-threatening condition. Initial management typically includes thoracic endovascular aortic repair (TEVAR) or aortic graft replacement to achieve hemostasis, followed by esophagectomy with aortic graft replacement and greater omentum wrapping to eliminate the source of infection. We report a case of successful endoscopic closure of a chronic esophageal fistula secondary to AEF. A 63-year-old man presented with hematemesis. He had a history of two ascending aortic replacements and one descending aortic replacement for aortic dissection. Computed tomography revealed a pseudoaneurysm at the graft anastomosis site and perforation into the esophagus. He was diagnosed with AEF and underwent TEVAR for hemostasis. Although the bleeding was stopped, follow-up imaging confirmed a residual fistula. Because of his poor general condition, surgery was contraindicated, and endoscopic closure was attempted. Initial treatment with hemostasis clips was ineffective. A second attempt using polyglycolic acid sheets, fibrin glue, and hemostasis clips with endoscopic submucosal dissection (ESD) achieved closure, but the fistula reopened after 5 months. Finally, the combination of ESD and over-the-scope clip (OTSC) achieved complete and sustained closure. The patient was discharged after 3 months but died 8 months postoperatively owing to idiopathic splenic rupture. This case demonstrates that the combination of ESD and OTSC may be an effective treatment option for chronic esophageal fistulas caused by AEF.