Introduction to a Rare Clinical Emergency

Foreign body ingestion usually results in minor complications; however, it can occasionally lead to fatal vascular injuries. Recent clinical reports highlight that aortic pseudoaneurysm management becomes a life-saving priority when a fish bone penetrates the esophageal wall. A 43-year-old male recently presented with chest pain one week after such an ingestion. His symptoms included fever, tachycardia, and anemia, which pointed toward a severe inflammatory process and internal hemorrhage.

Computed tomography angiography (CTA) plays a pivotal role in these scenarios. In this specific case, imaging revealed a fish bone lodged adjacent to a 27\u00d717 mm thoracic aortic pseudoaneurysm. This finding, coupled with hemodynamic instability, necessitated immediate intervention to prevent exsanguination from a potential aortoesophageal fistula (AEF).

Challenges in Aortic Pseudoaneurysm Management

Traditional open surgery for AEF carries an extremely high mortality rate. Consequently, clinicians are increasingly turning to thoracic endovascular aortic repair (TEVAR) as the primary bridge to stabilization. In the reported case, surgeons performed an emergent zone 2 TEVAR to control the hemorrhage. This minimally invasive approach allowed the medical team to stabilize the patient before addressing the source of infection.

Following the aortic repair, the multidisciplinary team focused on source control. They performed an endoscopic removal of the fish bone and placed a nasogastric tube for nutrition. Furthermore, they used a mini-thoracotomy for mediastinal drainage. This staged approach ensures that the vascular repair is protected from the contaminated environment of the esophagus. Therefore, successful aortic pseudoaneurysm management requires rapid diagnostic imaging and a coordinated surgical strategy.

Clinical Outcomes and Lessons

The use of TEVAR provides immediate life-saving hemorrhage control in unstable patients. Moreover, it creates a window of opportunity for definitive management of the esophageal defect and mediastinal infection. Clinicians must maintain a high index of suspicion in patients presenting with chest pain or "sentinel" hematemesis after foreign body ingestion. Early diagnosis and aggressive multidisciplinary care remain the cornerstones of survival for these rare but devastating injuries.

Frequently Asked Questions

What are the classic symptoms of an aortoesophageal fistula?

Patients often present with Chiari's triad, which includes mid-sternal chest pain, a sentinel arterial hemorrhage (initial minor bleeding), and a subsequent period of symptom-free stability before massive exsanguination.

Why is TEVAR preferred over open surgery in emergencies?

TEVAR is preferred because it is minimally invasive and allows for rapid control of life-threatening bleeding. This is especially crucial for patients who are hemodynamically unstable or have severe mediastinal sepsis.

What is the role of mediastinal drainage in these cases?

Drainage is essential to treat or prevent mediastinitis. Since the esophagus is contaminated, the area surrounding the aortic stent must be cleared of infection to prevent graft failure or recurrent fistula formation.

Disclaimer: This content is for informational and educational purposes only and does not constitute medical advice. Always seek the advice of a qualified healthcare provider regarding any medical condition. Refer to the latest local and national guidelines for clinical practice.

References

G\u00fcler S et al. Life-threatening aortic pseudoaneurysm secondary to fish bone ingestion: A case report. Turk Gogus Kalp Damar Cerrahisi Derg. 2026 Feb 17. doi: 10.4274/tjtcs.2025.28623. PMID: 41700462.

Kelly SL, Peters P, Ogg M, et al. Successful management of an aortoesophageal fistula caused by a fish bone - case report and review of literature. J Cardiothorac Surg. 2009;4:21.

Li Y, et al. Aorto-esophageal fistula caused by fishbone ingestion: a case report on staged endovascular and endoscopic treatment. BMC Gastroenterol. 2021;21(1):50.