Abstract Introduction Tracheoesophageal fistula (TEF) is a rare but life-threatening complication of esophageal stenting, typically arising in the context of advanced malignancy, radiation therapy, or direct tumor invasion. While TEF is well described in the literature, bronchial erosion by esophageal stents remains exceedingly uncommon and diagnostically challenging. Hemoptysis in this setting may be misattributed to infection, thrombocytopenia, or anticoagulation, delaying definitive airway evaluation. Case Presentation A 61-year-old male with newly diagnosed mid-esophageal cancer undergoing neoadjuvant chemoradiation presented with atrial fibrillation with rapid ventricular response, pneumonia, and pancytopenia. He had a mid-esophageal covered stent placed one month prior for malignant dysphagia. During hospitalization, he developed large-volume hemoptysis initially attributed to pneumonia and anticoagulation. Despite holding heparin and initiating conservative measures—including nebulized tranexamic acid and racemic epinephrine—hemoptysis persisted. Bronchoscopy revealed erosion of the esophageal stent into the left mainstem bronchus, with active gastrointestinal spillage into the airway, confirming a bronchoesophageal fistula. The patient underwent endoscopic stent revision and fistula repair, followed by placement of a PEG tube for feeding. Repeat bronchoscopy showed bronchial erosions without residual fistula. He was safely restarted on anticoagulation for atrial fibrillation and a new left upper extremity deep vein thrombosis, without recurrence of bleeding. Discussion This case highlights a rare presentation of TEF due to esophageal stent erosion into the bronchial tree, manifesting as hemoptysis in a patient with no prior pulmonary history. Overlapping infectious and hematologic factors compounded the diagnostic complexity. Bronchoscopy proved critical for diagnosis and therapeutic planning. While TEF is typically associated with tracheal involvement, bronchial invasion is less commonly reported and may carry unique procedural and airway management implications. This case underscores the importance of early airway inspection in patients with esophageal instrumentation and unexplained hemoptysis—multidisciplinary coordination, including pulmonology and gastroenterology, enabled successful intervention and reinitiation of anticoagulation. Conclusion Bronchial erosion by esophageal stents is a rare but serious cause of hemoptysis in patients with esophageal cancer and palliative stenting. Early bronchoscopy and endoscopic management can restore airway integrity and prevent further complications. This case adds to the limited literature on malignant TEF involving the bronchial tree and reinforces the need for vigilance in oncologic airway care. This abstract is funded by: None
Mills-Annoh et al. (Fri,) studied this question.