Management of secondary aorto-oesophageal fistula after aortic arch replacement: a case report without aortic reconstruction

Background Secondary aorto-oesophageal fistula (AEF) after aortic aneurysm repair is a rare but clinically catastrophic complication. Conservative management is associated with an unacceptably high risk of mortality, primarily due to severe infections. Although definitive in situ aortic reconstruction may be curative, it is highly invasive and carries substantial perioperative morbidity and mortality, particularly in frail patients or those with established infection. This case report describes the successful treatment of a secondary AEF without aortic arch reconstruction, achieving durable long-term infection control. Case summary A 74-year-old man was referred to our hospital with haematemesis, and a pseudoaneurysm was identified at the distal anastomosis site following total aortic arch replacement. Emergency thoracic-endovascular-aortic-repair (TEVAR) was performed as a life-saving measure to achieve rapid haemostasis and stabilisation. One month later, persistent fever and a residual oesophageal perforation prompted oesophagectomy with omental flap placement, without aortic arch reconstruction. Gastric conduit reconstruction was performed 4 months after TEVAR. The patient has remained event-free for more than 1 year after the initial presentation and intervention. Discussion This case highlights the importance of an individualised treatment strategy for secondary AEF. In selected patients, infection control may be achieved without aortic arch reconstruction.