Novel use of thoracic endovascular aortic repair in mediastinitis-induced aortic erosion: a case series

The presence of pathogenic microorganisms within the mediastinum can lead to severe tissue damage with resultant necrosis, often necessitating surgical intervention. We describe three patients who developed erosion of the thoracic aorta secondary to acute mediastinitis of presumed infectious etiology. The three patients initially presented with distinct pathologies, although all eventually developed mediastinitis and aortic necrosis. The first patient underwent emergent thoracic endovascular aortic repair (TEVAR) to control active bleeding into the esophagus. Following control of bleeding and definitive treatment of his mediastinitis, the patient survived for 10 months with the stent graft in place. The second patient underwent TEVAR for a non-transmural adventitial aortic erosion, secondary to severe necrotic pneumonia, to prevent complete vessel perforation. Mediastinitis was never controlled, and transmural erosion of the thoracic aorta necessitated extra-anatomic aortic bypass and removal of the infected stent graft one month after placement. The third patient was treated emergently with TEVar following development of an aorto-esophageal fistula in the region of ulcerated and necrotic esophageal tissue. The mediastinitis was controlled with an esophageal stent. The patient succumbed to peritonitis four months after TEVAR. For the very rare occurrence of mediastinitis-induced aortic erosion, we suggest that thoracic endovascular aortic repair can be a temporizing measure prior to definitive aortic reconstruction or bypass.