ELECTRONIC IMAGE OF THE MONTH Emergency Double-Stenting and Surgery for the Successful Management of Massive Upper Gastrointestinal Bleeding Caused by Mycotic Aortic Aneurysm Gerald Hackl,* Rupert H. Portugaller,‡ and Peter Fickert§ *Division of Angiology, §Division of Gastroenterology and Hepatology, Department of Internal Medicine, ‡Division of Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
57-year-old man with known osteomyelofibrosis and a 2-month history of pulmonary aspergilloma of the right lung (Figure A) presented to our emergency unit with hematemesis and clinical signs of severe hemorrhagic shock caused by massive upper gastrointestinal bleeding. After hemodynamic stabilization, protective intubation, and controlled ventilation, immediate upper gastrointestinal endoscopy showed severe arterial bleeding from an esophageal rupture in the lower third of the esophagus (Figure B). After attempts to stop the bleeding with local adrenalin injections failed, placement of a totally covered SX-ELLA Stent Danis (ELLA-CS, s.r.o., Hradec Kralove, Czech Republic) (relaxed diameter of stent body, 25 mm; stent length, 135 mm) succeeded
A
in doing so (Figure C). This type of stent was chosen because of the massive uncontrolled bleeding, its immediate availability in our emergency room, its well-known effects in controlling severe variceal bleeding through direct compression, and because it is easily removable. A subsequent contrast-enhanced computed tomography scan of the chest and abdomen showed contrast medium extravasation from the aorta at the thoracoabdominal transition that was suggestive of an aorto-esophageal fistula (Figure D). Because the medical history of pulmonary aspergilloma clearly indicated mycotic aneurysm, emergency endovascular stenting of the aortic lesion was indicated1 (Figure E). After the patient had been stabilized and put on antifungal treatment in our intensive
Clinical Gastroenterology and Hepatology 2015;13:e171–e172
ELECTRONIC IMAGE OF THE MONTH, continued care unit, the esophageal stent was removed 2 days after the initial bleeding, immediately before the definitive surgical procedure. There were no hints of sustained bleeding after stent removal. The subsequent surgical treatment consisted of suturing the ruptured esophagus, followed by a modified fundoplication with a 300 gastric fundus wrap and a 360 omental flap for further stabilization. The procedure was combined with resection of the pulmonary aspergilloma. The patient recovered quickly and was discharged in good general condition 2 weeks later. Data on the management of upper gastrointestinal bleeding from mycotic aortic aneurysms leading to aortoesophageal fistulas are very scarce and the prognosis typically is dismal.2 Consequently, conventional surgery for the treatment of mycotic aortic aneurysm has rather high surgical morbidity and mortality rates, especially in nonelective patients.3 We showed successful use of combined esophageal and endovascular aortic stenting to achieve hemostasis and patient stabilization before definitive surgical treatment, and present it as a novel and promising approach to manage such life-threatening events. Based on our experience, double emergency stenting of the esophagus and aorta may be a feasible way to
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stabilize such critically ill patients for definitive surgical treatment and antifungal therapy.
References 1.
Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg 2007;46:906–912.
2.
Kieffer E, Chiche L, Gomes D. Aortoesophageal fistula: value of in situ aortic allograft replacement. Ann Surg 2003; 238:283–290.
3.
Hsu RB, Chen RJ, Wang SS, et al. Infected aortic aneurysms: clinical outcome and risk factor analysis. J Vasc Surg 2004; 40:30–35.
Acknowledgments This article is dedicated to the brilliant surgeon Dr Jan Danis† (1952–2010). The authors gratefully acknowledge Eugenia Lamont for critical reading of the manuscript and Drs Andreas Lueger and Alfred Maier for their essential clinical input. Conflicts of interest The authors disclose no conflicts. Most current article © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.04.016
57-year-old man with known osteomyelofibrosis and a 2-month history of pulmonary aspergilloma of the right lung (Figure A) presented to our emergency unit with hematemesis and clinical signs of severe hemorrhagic shock caused by massive upper gastrointestinal bleeding. After hemodynamic stabilization, protective intubation, and controlled ventilation, immediate upper gastrointestinal endoscopy showed severe arterial bleeding from an esophageal rupture in the lower third of the esophagus (Figure B). After attempts to stop the bleeding with local adrenalin injections failed, placement of a totally covered SX-ELLA Stent Danis (ELLA-CS, s.r.o., Hradec Kralove, Czech Republic) (relaxed diameter of stent body, 25 mm; stent length, 135 mm) succeeded
A
in doing so (Figure C). This type of stent was chosen because of the massive uncontrolled bleeding, its immediate availability in our emergency room, its well-known effects in controlling severe variceal bleeding through direct compression, and because it is easily removable. A subsequent contrast-enhanced computed tomography scan of the chest and abdomen showed contrast medium extravasation from the aorta at the thoracoabdominal transition that was suggestive of an aorto-esophageal fistula (Figure D). Because the medical history of pulmonary aspergilloma clearly indicated mycotic aneurysm, emergency endovascular stenting of the aortic lesion was indicated1 (Figure E). After the patient had been stabilized and put on antifungal treatment in our intensive
Clinical Gastroenterology and Hepatology 2015;13:e171–e172
ELECTRONIC IMAGE OF THE MONTH, continued care unit, the esophageal stent was removed 2 days after the initial bleeding, immediately before the definitive surgical procedure. There were no hints of sustained bleeding after stent removal. The subsequent surgical treatment consisted of suturing the ruptured esophagus, followed by a modified fundoplication with a 300 gastric fundus wrap and a 360 omental flap for further stabilization. The procedure was combined with resection of the pulmonary aspergilloma. The patient recovered quickly and was discharged in good general condition 2 weeks later. Data on the management of upper gastrointestinal bleeding from mycotic aortic aneurysms leading to aortoesophageal fistulas are very scarce and the prognosis typically is dismal.2 Consequently, conventional surgery for the treatment of mycotic aortic aneurysm has rather high surgical morbidity and mortality rates, especially in nonelective patients.3 We showed successful use of combined esophageal and endovascular aortic stenting to achieve hemostasis and patient stabilization before definitive surgical treatment, and present it as a novel and promising approach to manage such life-threatening events. Based on our experience, double emergency stenting of the esophagus and aorta may be a feasible way to
e172
stabilize such critically ill patients for definitive surgical treatment and antifungal therapy.
References 1.
Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg 2007;46:906–912.
2.
Kieffer E, Chiche L, Gomes D. Aortoesophageal fistula: value of in situ aortic allograft replacement. Ann Surg 2003; 238:283–290.
3.
Hsu RB, Chen RJ, Wang SS, et al. Infected aortic aneurysms: clinical outcome and risk factor analysis. J Vasc Surg 2004; 40:30–35.
Acknowledgments This article is dedicated to the brilliant surgeon Dr Jan Danis† (1952–2010). The authors gratefully acknowledge Eugenia Lamont for critical reading of the manuscript and Drs Andreas Lueger and Alfred Maier for their essential clinical input. Conflicts of interest The authors disclose no conflicts. Most current article © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.04.016
