Unexpectedly large aortoesophageal fistula inconsistent with CT imaging due to the thrombus working as the tamponade

SummaryA 69-year-old woman with a history of graft replacement of descending aortic aneurysm was referred to our hospital due to massive hematemesis with shock status. Additionally, the deterioration of respiratory status made us start the management under mechanical ventilation. The emergent gastrointestinal endoscopy by a general practitioner showed ulcer-like lesion of the upper esophagus and arterial bleeding. A contrast-enhanced computed tomography showed thoracic aortic aneurysm surrounded by low density mass and contrast medium protruding from the aneurysm. The findings suggested that thoracic aortic aneurysm perforated into esophagus and made an aortoesophageal fistula. Hemodynamic deterioration rapidly progressed and she passed away 4 days after her hospitalization.Autopsy showed that a new thoracic aortic aneurysm arose from the proximal site of the graft. The aneurysm ruptured to esophagus with 6.0 cm × 5.0 cm sized fistula. The fistula was filled with a large thrombus. The large thrombus filling with the fistula worked as the tamponade and prevented her from the fatal exsanguinations and sudden death. The mechanism of the sentinel bleeding and the fatal exsanguinations known as Chiari's triad was revealed in our report.