1. Management Algorithm for Aortoesophageal Fistulas  Joseph D Whitlark MD FACS, Lydia Rotondo DNP RN, Alex Su  THORACIC AND VASCULAR ASSOCIATES OF KINSTON, KINSTON, NC

2. Aortoesophageal fistulas  RARE, BUT BECOMING MORE COMMON WITH THORACIC ENDOVASCULAR AORTIC REPAIR (TeVAR)  EXTREMELY HIGH MORTALITY WITH PRIMARY SURGICAL REPAIR (80% IN SOME SERIES)  TeVAR ALONE IS NOT SUFFICIENT, BUT DOES BUY TIME FOR DEFINITIVE REPAIR  MINIMALLY INVASIVE ESOPHAGEAL SURGERY RESULTS IN LOWER MORTALITY FOR ESOPHAGEAL RESECTIONS IN GENERAL

3.  52 yo male with obstructing midesophageal cancer had a covered esophageal stent inserted, with a laparoscopic j-tube  After two months of chemoradiation, developed massive upper gastrointestinal bleeding from an aortoesophageal fistula (AEF)  TeVAR performed emergently, and bleeding controlled  Three weeks later, a thoracoscopic esophagectomy with a cervical esophagostomy, lapascopic gastrostomy tube and left gastric artery ligation performed (pathology – Complete Responder)  Two months later, a substernal gastric pull-up with cervical esophagogastrostomy performed.  Discharged home on POD #9  Six months later, swallowing normally with no evidence of disease, normal CT scan, on no antibiotics

4. ALGORITHM FOR AEF’s  EMERGENT TeVAR (EVEN WITH EXISTING THORACIC AORTIC STENT GRAFT IN PLACE) TO CONTROL BLEEDING  RESUSCITATE, SUPPORT NUTRITIONALLY, AND TREAT WITH ANTIBIOTICS (2 TO 6 WEEKS)  MINIMALLY INVASIVE THORACOSCOPIC ESOPHAGECTOMY, CERVICAL ESOPHAGOSTOMY, LAPAROSCOPY WITH LEFT GASTRIC ARTERY LIGATION TO PREPARE GASTRIC TUBE AND GASTROSTOMY TUBE TO KEEP GASTRIC MUCOSA STIMULATED

5. ALGORITHM FOR AEF’S  WHEN ADEQUATELY RECOVERED (4-8 WEEKS), RE-ESTABLISH ENTERIC CONTINUITY WITH A SUBSTERNAL GASTRIC PULL UP AND CERVICAL ESOPHAGOGASTROSTOMY (LAPAROSCOPIC PREPARATION OF GASTRIC TUBE)

6. ALGORITHM FOR AEF’S  THE COMBINATION OF MINIMALLY INVASIVE AORTIC CONTROL ALONG WITH STAGED MINIMALLY INVASIVE ESOPHAGEAL RESECTION AND RECONSTRUCTION MAY LOWER THE OVERALL MORTALITY AND MORBIDITY FROM THIS LETHAL PROBLEM  SPECIAL THANKS TO DR OMAR AWAIS FROM THE UNIVERSITY OF PITTSBURGH FOR HIS TIMELY ADVICE AND GUIDANCE