[Early type I Endoleak after Endovascular Management of an Aorto-esophageal Fistula].

Objective: Presentation of a clinical case of an aorto-esophageal fistula secondary to thoracic aorta pseudoaneurysm, complicated by early type Ia endoleak after endovascular repair.

Clinical Case: A 64 years old male patient, with a history of arterial hypertension, smoking, alcohol abuse and ischemic heart disease with previous coronary revascularization was observed because of chest pain and abundant hematemesis, with Angio-CT revealing a 77mm pseudoaneurysm of the descending thoracic aorta, close to the left subclavian artery, with mass effect on the esophagus and trachea and signs of fistulization. He was proposed to endovascular repair with sealing in zone 2 of the aortic arch after building a left carotid-subclavian bypass. In the first 24 hours there were two episodes of massive hematemesis, with new Angio-CT revealing a early distal migration of the prosthesis, conditioning a type Ia endoleak. A carotid-carotid right-left bypass with left carotid ligation was performed and a new endoprosthesis was implanted in the origin of the brachycephalic trunk (zone 1). The final angiography showed aneurysm exclusion with permeability of the supra-aortic trunks. Later contrasted esophageal examination and endoscopy revealed an ulcer of the posterior left lateral wall with clot suggestive of fistula, and an esophageal prosthesis was successfully implanted. It held seven days of antibiotic therapy with ceftriaxone and metronidazole with no evidence of mediastinal infection and with aneurysm exclusion in the CT follow-up.

Conclusion: The recognized biomechanical and anatomical complexity of the aneurysmatic thoracic aorta represents a considerable challenge to the endovascular treatment of aorto-esophageal fistulas, especially in aneurysmatic sealing of the aortic arch, with significant rates of type Ia and III endoleaks.