Innovative Multimodal Endoscopic Management of a Vascular Enteric Fistula. The disclosures of all contributing authors are listed here. This video case report will detail the multidisciplinary management of a patient with a life-threatening upper GI hemorrhage and discuss the innovative endoscopic techniques for diagnosis and management of this complex pathology. The patient was a 44-year-old female with a history of Marfan syndrome and resultant complex cardiac and vascular surgical history. The patient had previously undergone a mechanical aortic and mitral valve replacement with aortic root and ascending aorta replacement for severe aneurysmal disease. She also had a history of recurrent type B aortic dissections and a complex thoraco-abdominal aortic aneurysm repair with an aortic tube graft. Additionally, the patient had atrial fibrillation and was anticoagulated with warfarin. The patient presented to a referring institution with a complaint of hemoptysis and was found to have acute blood loss anemia with a hemoglobin of 5.9. There, a CT scan was obtained and demonstrated a large volume of gastric content suspicious for blood. She was transfused with packed red blood cells, fresh frozen plasma, and vitamin K and transferred to the medical intensive care unit at our facility. Upon arrival, the patient was hemodynamically normal and protecting her airway. A bedside upper endoscopy was performed. This revealed a clot adherent to the distal esophageal wall as well as a large volume of gastric blood clot, but no source of active bleeding was identified. Given her extensive aortic surgical history, a CTA was obtained which demonstrated no evidence of GI bleeding, aortoenteric fistula, or acute aortic abnormality. The following morning, the patient had recurrent hematemesis and hemodynamic instability and a repeat upper endoscopy was performed. This demonstrated pulling of blood throughout the upper GI tract and a lesion in the upper esophagus which was concerning for an aortoenteric fistula. The lesion was slowly bleeding at that time. A repeat stat CTA was performed which showed a mediastinal hematoma around the descending thoracic aorta and adjacent to the esophagus. Also noted were small locules of air adjacent to the aorta as well as active contrast extravasation within the hematoma. At this point, the patient had worsening hemodynamic instability requiring massive transfusion and pressor support. Cardiac vascular and thoracic surgery services were consulted and the decision was made to take the patient for thoracic endovascular aortic repair to cover what was presumed to be disruption of the proximal aortic anastomosis. In the OR, bilateral common femoral axis was obtained. An initial angiogram was performed which did not demonstrate aortic extravasation. However, the patient had profound hemodynamic instability and a thoracic endovascular graft was placed under fluoroscopic guidance. A repeat angiogram again showed no extravasation. The patient had persistent hemodynamic instability and ongoing bleeding out of her mouth totaling greater than four liters. At this point, an interventional gastroenterologist, trauma surgeon, and a minimally invasive surgeon with fellowship training in advanced endoluminal surgery were called into the OR. A diagnostic scope was advanced into the esophagus. At 28 centimeters from the incisors on the left anterior lateral wall of the esophagus, a large mass-like lesion with severe active pulsatile bleeding was identified. There was no clearly identifiable source of bleeding within the lesion. The endoscope was initially placed against the lesion to tampon on the bleeding while a sclerotherapy needle and epinephrine injection were prepared. Epinephrine was injected into the lesion which did not slow the hemorrhage. Next, a Minnesota tube was requested but was not immediately available. Therefore, a large vessel vascular occlusion balloon was requested and inflated under direct endoscopic visualization over the lesion. This stopped the bleeding. After several minutes, the balloon was deflated and the bleeding was noted to have substantially slowed. The primary concern at this point remained the possibility of an aortoenteric fistula not detected by the vascular angiogram. Therefore, the idea of performing an angiogram endoscopically was suggested. Half-strength iohexol contrast was injected directly into the bleeding lesion using an injection needle and an angiogram was performed. The angiogram demonstrated a small peri-esophageal vessel which wrapped from the left side of the esophagus around to the right side. This maneuver proved that there was not an aortoenteric fistula but rather a vascular enteric fistula from a smaller, unnamed vessel. The vascular occlusive balloon was redeployed while a multidisciplinary discussion was held regarding management of this lesion. Because of her complex surgical history and ongoing inflammatory condition, it was determined that thoracic surgery would be too hazardous. Ultimately, the decision was made to address the lesion with an over-the-scope clip. A therapeutic scope was then advanced with a 12-6 T-type over-the-scope clip in place. An anchor grasper was then used to pull as much of the esophageal wall into the clip as possible and the clip was fired. There was no evidence of active ongoing bleeding. Friable tissue was noted around the lesion and so an endoscopic hemostatic agent was sprayed over the lesion. Final inspection revealed no evidence of bleeding. An NG tube was placed under direct visualization and the patient was returned to the ICU. The final diagnosis was felt to be erosion of the aortic graft margin into the esophagus with subsequent infection and bleeding from an unnamed mediastinal vessel. She was started on antibiotics. The patient had no evidence of ongoing bleeding and a heparin drip was resumed on postoperative day 4 without complication. The patient slowly progressed and was extubated on postoperative day 9. However, she developed worsening respiratory failure, renal failure, and neurologic decline and was made comfort care per the patient's wishes. She died on postoperative day 15. While this patient ultimately succumbed to her severe disease process due to underlying comorbidities, several important learning points are illustrated by the successful endoscopic evaluation and management of this dramatic GI hemorrhage and life-threatening situation. First, the case highlights the importance of gaining initial vascular control, even if only by temporary means. Temporary vascular control, in this case achieved by direct compression with the endoscope followed by balloon occlusion, allowed time for the anesthesia team to catch up with blood product resuscitation and for the multidisciplinary interventional team to thoughtfully determine the appropriate next diagnostic and therapeutic steps. Next, the case highlights the importance of situational awareness and knowledge of available equipment during critical moments. When a Minnesota tube was not immediately available, the endoscopist, recognizing their presence in a vascular hybrid OR, requested a large vessel vascular occlusive balloon to achieve urgent control. This balloon, typically used for temporary aortic occlusion and endograft dilation, has been used to prevent small bowel distension during the study of natural orifice transluminal endoscopic surgery in animal models. Interestingly, this device proved superior to a Minnesota tube or through-the-scope endoscopy balloons because its small size allowed it to be passed in parallel to the scope, while keeping the endoscope free for direct visualization and possible additional intervention. Thirdly, this case highlights the importance of relying on surgical principles while performing endoscopy. In this case, the endoscopist was able to think like a vascular surgeon and devise the novel plan of performing an angiogram endoscopically. This real-time decision making rolled out an aortoenteric fistula and ultimately may have prevented a hazardous, unnecessary operative intervention. This technique could easily be replicated in the future to assist in management of complex GI hemorrhage. Finally, this case illustrates the superior patient care that can be achieved when a multidisciplinary care team is assembled, particularly in critical moments. In conclusion, this case demonstrates the innovative multimodal endoscopic management of a vascular enteric fistula in a critically ill patient and highlights the importance of reliance on situational awareness, endoscopic and surgical principles, and multidisciplinary expertise for real-time decision making in a critical situation.

endoscopic techniques

upper GI hemorrhage

vascular enteric fistula

thoracic endovascular aortic repair

over-the-scope clip