# Treatment of Aorto-Oesophageal Fistula in a Tertiary German Aortic and Oesophageal Centre A Multidisciplinary Effort

## TL;DR

This paper presents a multidisciplinary approach to treating aorto-oesophageal fistula, a rare and deadly condition, with findings suggesting that surgical treatment of the oesophagus improves survival.

## Contribution

The study provides insights into treatment strategies and outcomes for aorto-oesophageal fistula based on a single-center retrospective analysis and literature review.

## Key findings

- TEVAR is effective in stabilizing initial haemorrhage in aorto-oesophageal fistula patients.
- Short-interval oesophagectomy is associated with improved survival in these patients.
- Surgical treatment of the oesophagus significantly impacts survival rates.

## Abstract

Although rare, aorto-oesophageal fistula remains one of the most critical diseases in cardiovascular surgery. The lack of prospective studies or large case series leads to an absence of evidence-based therapeutic concepts.

We conducted a retrospective analysis of patients treated for aorto-oesophageal fistula between 2014 and 2023. Primary endpoints of analysis were 30-day mortality and median survival; subgroup analysis was performed for aetiology as well as treatment strategy. Additionally, a systematic search was conducted for all studies researching treatment of the disease, including ≥5 patients and published within the last 10 years.

In the collective of 10 patients, 4 manifested as primary fistula, while in 6 patients the fistula occurred secondary to previous thoracic endovascular aortic repair. Median duration to manifestation post-TEVAR was 20.1 months (34.1). Initial treatment consisted of TEVAR or TEVAR-relining in 7 cases, followed by bovine open aortic replacement (n = 1) or partial bovine patch repair (n = 2) when viable. Treatment of the oesophagus consisted of primary suture (n = 1) or oesophagectomy (n = 5) with gastric pull-up or colon interposition. Overall 30-day mortality was 40%, and overall median survival was 7.5 months (12.8). Patients receiving surgical treatment of the oesophagus exhibited longer survival than patients who did not (12.8 months [4.7] vs 0.35 months [0.4]). Across the reviewed literature, the strongest effect on survival originates from surgical treatment of the oesophagus. Specific surgical strategies as well as patient characteristics vary widely.

We found TEVAR effective in stabilizing the initial haemorrhage. Short-interval oesophagectomy seems to improve survival and should be considered in most patients. Open aortic replacement with bovine pericardium is a viable option. Interventional treatment options alone do not appear to be sufficient.

Aorto-oesophageal fistula (AEF) is an orphan condition with a communicating fistulation between the aorta and oesophagus, with 100% mortality if left untreated.