AEF secondary to thoracic aortic aneurysm repair is a rare and fatal condition [1]. Furthermore, the optimal treatment for AEF remains controversial between intraluminal stent graft and open surgery, including extra-anatomical bypass and thoracic aortic replacement [2,3,4,5].

Stent graft for the treatment of AEF has been used especially in patients with acute aortic syndrome, but without follow-up treatment, the long-term mortality rate remains high without subsequent therapy. Conservative treatment is not a viable option according to other report [6]. Definite aortic treatment and esophageal reconstruction is crucial to prevent secondary infection of the aortic prosthesis but is usually accompanied by high morbidity and mortality.

Several case series have discussed the feasibility of extra-anatomical bypass to prevent secondary infection and local debridement. However, some reports have reported risking lower body malperfusion by bilateral axillofemoral bypass [3].

The omental flap has been used in deep sternal infection such as post-operative mediastinitis for several decades. Some case reports have discussed using omental flap to treat aortoesophageal fistula. Most of them were treated with aortoesophageal fistula directly repaired and omental flap was harvested thereafter to cover between aortic stent graft and esophagus. And this gave us ideas about using omental flap after total reconstruction surgery to. In our opinion, we thought that total reconstruction surgery remained the gold standard treatment for active in.

Our standardized protocol was as follows: (1) infected stent graft removal followed by thoracic aortic replacement; (2) total esophagectomy and gastric tube reconstruction; and (3) omental flap to cover the new aortic graft. We suggest that young patients whose ECOG performance status scale is less than two may need further aggressive treatments. We believe that the omental flap to cover the new aortic graft that has the advantage that can be isolated from primary infection site.

For aortic graft replacement, we chose left posterolateral thoracotomy approach using CPB under deep hypothermia circulatory arrest (DHCA) to prevent proximal aortic clamping. According to our previous thoracoabdominal aortic replacement result, DHCA demonstrates favorable protective effect on the spinal cord, with low stroke rate [7]. Extra-anatomical bypass is not considered for cases involving high morbidity and risk of further aortic rupture. After protamine reversal, meticulous hemostasis was performed for the next esophageal reconstruction surgery. Through the same wound, we freed the esophagus from the cervical esophagus to esophagogastric junction. Thereafter, we consulted a general surgeon for further gastric tube reconstruction and omental flap coverage via the posterior mediastinal approach.

In this case, the patient underwent TEVAR surgery for AEF, but the efficacy remains unclear. We suggested direct total reconstruction, including thoracic aortic replacement and esophageal reconstruction after 2 weeks of antibiotic treatment. In AEF cases presenting with acute aortic syndrome, TEVAR stent is a viable option, but we suggest that all patients need to undergo second-stage operation. Herein, we reported a case of postoperative AEF treated using one-stage total repair, including (1) stent graft removal and thoracic aortic graft replacement, (2) total esophagectomy, (3) esophagus reconstruction with gastric tube, and (4) omental flap coverage of the aortic graft to prevent secondary infection. Due to effective results in our hospital, definite aortic treatment and debridement must be aggressive in these patients.