[Case Report] Peking Union Medical College Hospital: A Two-Stage Surgical Strategy for Post-TEVAR Aortoesophageal Fistula (AEF)

A 35-year-old male presented with massive hematemesis and hemorrhagic shock 40 days post-TEVAR (Thoracic Endovascular Aortic Repair). The diagnosis was Aortoesophageal Fistula (AEF) complicated by stent graft infection. The case was managed by the multidisciplinary cardiothoracic surgical team at Peking Union Medical College Hospital (PUMCH).

📌 Clinical Decision-Making

AEF is a catastrophic cardiovascular emergency. For AEF with severe local sepsis, single-stage in-situ reconstruction of both the aorta and esophagus carries an unacceptably high risk of reinfection and secondary hemorrhage. To mitigate this, the PUMCH team adopted a "Damage Control + Two-Stage Reconstruction" strategy.

📌 Surgical Technique & Process

🔹 Stage 1 (Damage Control & Debridement):

• Aortic Bypass: Cardiac Surgery established an extra-anatomic bypass for the aortic arch branches in a clean, uninfected field to maintain organ perfusion.
• Source Debridement: The infected descending aorta was cross-clamped and resected, and the contaminated stent graft was completely extracted.
• Esophagectomy: Thoracic Surgery simultaneously resected the damaged esophagus to eliminate the infection source and performed a laparoscopic jejunostomy for early enteral nutrition.

🔹 Stage 2 (Digestive Tract Reconstruction):

• On post-op day 50, following complete infection clearance and systemic recovery, the second stage was initiated.
• Thoracic Surgery performed a gastric pull-up and esophagogastric anastomosis using a VATS + Laparoscopy + Cervical 3-incision approach.

💡 Clinical Outcome & Significance

The patient successfully resumed oral intake. Follow-up imaging showed a patent anastomosis with no stricture or recurrent fistula. This staged approach effectively decouples the compounded risks of acute hemorrhage and severe sepsis, providing a highly viable surgical pathway for complex AEF management globally.