TEVAR后移植物感染合并主动脉食管瘘的外科治疗

Surgical treatment for graft infection with aortoesophageal fistula after TEVAR

背景与目的:主动脉食管瘘(AEF)是一种相对罕见的疾病,通常危及生命。尽管胸主动脉腔内修复术(TEVAR)已成为治疗胸主动脉瘤、胸主动脉夹层的一种成熟手术策略,但TEVAR后继发性AEF更为棘手。笔者报告7例该疾病的治疗方式和结果。方法:回顾性分析2018—2021年间收治的7例TEVAR后继发性AEF合并移植物感染患者的临床资料。所有7例患者均接受了介入或手术治疗,其中4例患者施行了开放手术治疗,即:非体外循环下升主动脉-腹主动脉解剖外人工血管旁路术、感染移植物及感染灶切除术、食管瘘口旷置引流术;2例患者施行了TEVAR;1例患者分期施行了TEVAR和开放手术。结果:一期和分期施行开放手术治疗的5例患者,2例痊愈出院,3例死亡。单纯施行TEVAR的2例患者,计划待抗感染、营养支持后限期施行开放手术,治疗期间死亡。结论:因感染移植物及感染灶的存在,保守治疗或单纯行TEVAR往往无法使患者获得救治。虽然开放手术病死率较高,但在条件允许时,清除感染灶及移植物,并进行解剖外主动脉重建及食管瘘旷置引流,是治疗TEVAR术后移植物感染合并主动脉食管瘘的合理策略。

Background and Aims: Aortoesophageal fistula(AEF) is a relatively rare but often life-threatening condition. Although thoracic endovascular aortic repair(TEVAR) has been established as an alternative surgical strategy for thoracic aortic aneurysms and thoracic aortic dissections, the secondary AEF after TEVAR becomes more challenging. Here, the authors report the treatment modalities and outcomes of 7 cases with this disease.Methods: The clinical data of 7 patients with secondary AEF complicated with graft infection after TEVAR treated between 2018 and 2021 were retrospectively analyzed. All patients underwent interventional or surgical treatment, including open surgery in 4 cases, that was off-pump extraanatomical bypass from ascending aorta to abdominal aorta, excision of infected graft and infection lesion, and esophageal fistula drainage;TEVAR in 2 cases;staged TEVAR and open surgery in one case.Results: Of the 5 patients who underwent primary and staged open surgery, 2 cases recovered and discharged, and 3 cases died. The 2 patients who underwent TEVAR alone and originally planned to perform open surgery after anti-infection and nutritional support treatment died during the treatment.Conclusion: Conservative management or TEVAR alone often fails to save patients due to infected grafts and infection lesions. Although open surgery is associated with high mortality, complete removal of the infected lesions and grafts, extra-anatomical bypass from ascending aorta to abdominal aorta, and adequate drainage of the infected lesions are reasonable strategies for the treatment of graft infection complicated with aortoesophageal fistula after TEVAR under feasible conditions.