aortoesophageal fistula is a rare , devastating and usually fatal condition which has multiple aetiological factors . the first report , in 1818 , described the death of a 28-year - old soldier who exsanguinated after ingesting a beef bone fragment . a comprehensive review , published by hollander and quick , which included 500 cases of fistula , identified three major causes of aortoesophageal fistula , the main aetiologic factor being aortic disease with 54.2% of cases secondary to rupture of a descending thoracic aorta aneurysm into the oesophagus . foreign body ingestion ( 19.2% ) and advanced esophageal carcinoma ( 17.0% ) were the next commonest causes . regardless of cause , the optimal management of the fistula remains controversial , and recent literature has focused on the role of endovascular techniques and open thoracic surgery . however , high mortality from the condition usually results from massive uncontrolled haemorrhage prior to these interventions being possible . although non - surgical measures to control the initial haemodynamic insult caused by haemorrhage have been described , this remains a relatively unexplored area of management . a 47-year - old caucasian man with recently diagnosed advanced esophageal cancer attended the imaging department for an ultrasound scan . in the waiting area , the patient had a massive haematemesis and proceeded into a peri - arrest state . tech , seoul , distributed by mtw , wesel , germany ) was inserted across the lesion . ct confirmed an esophageal tumour in continuity with the right main bronchus with an associated right lung abscess . an overlapping fully covered 12  18 alveolus aero stent ( alveolus , charlotte , n.c . , 1 ) , presumably because the bronchial fistula had been adequately sealed with the stents , creating an undrained collection in the lung which subsequently fistulated through to the pleural cavity . while awaiting a video - assisted thoracoscopic surgical procedure to drain and seal the abscess and empyema , he spontaneously drained the abscess by coughing up nearly 1 litre of pus in 24 h ; this led to a dramatic improvement in his clinical state and resolution of his chest x - ray changes . a week before the ultrasound scan he experienced mid - thoracic pain and small episodes of haematemesis . when he collapsed , he was tachycardic ( heart rate 128 bpm ) with unrecordable blood pressure . its clearance identified a large arterial bleeding point , just above the proximal end of the stent in the mid - esophagus ( fig . a further 28 mm diameter niti - s covered esophageal stent ( taewong medical , seoul , korea ) was inserted to tamponade the bleeding point ( fig . despite aggressive resuscitation with fluids and 8 units of blood , there was no improvement in his haemodynamic status until after stent deployment . the patient was transferred to the intensive care unit where fresh bleeding continued to be aspirated from his nasogastric tube overnight . a further 8 units of blood and 6 units of fresh frozen plasma were transfused to maintain his haemoglobin between 7 and 7.7 g / dl . with this ct angiography was performed and demonstrated an aortoesophageal fistula at the level of the carina with ongoing bleeding into the mediastinum ( fig . was inserted into the thoracic aorta distal to the origin of the left subclavian artery sealing the fistula . he survived for 2 months at home , during which he was able to attend to his personal affairs , before dying of disseminated malignancy . this case highlights the successful non - surgical management of a massive bleed caused by aortoesophageal fistula . the esophageal stent acted as a means to tamponade and provided partial initial control of the bleeding point . this allowed time for appropriate endovascular intervention in the form of a thoracic endoluminal stent device to further stabilise the haemodynamic status of the patient . the challenge to recognise and treat successfully before the patient exsanguinates is probably why success stories for closure of aortoesophageal fistulas are few . high clinical suspicion and recognition of warning symptoms such as mid - thoracic pain and sentinel arterial upper gastrointestinal haemorrhage is crucial . transient self - limiting ' herald ' bleeds may precede fatal exsanguination by more than 24 h . this ' window of opportunity ' allows early transfer to a specialist centre . high clinical suspicion and first reported using an endoluminal stent graft for repair of abdominal aortic aneurysms , thoracic endovascular aortic repair ( tevar ) has become more common in the management of aortoesophageal fistula , with much of the literature focusing on endovascular and open surgical management . a recently reported successful surgical approach   advocated open transthoracic esophageal resection , cervical esophagectomy and gastrostomy . the patient had developed a fistula secondary to previous tevar , so the authors could not decide the best approach to salvage the thoracic aorta . although successful in stabilising the patient , this highly invasive approach may not be suitable for patients with advanced esophageal malignancy . less invasive successful endovascular management of fistulas in patients with esophageal malignancy has been reported . one report   describes the use of a dacron prosthesis interposed into the descending thoracic aorta to restore aortic flow as successful endovascular intervention ; the same patient later underwent an esophagectomy for definitive treatment . a separate report   describes successful endovascular intervention to stabilise bleeding , although again this patient also went on to require further definitive gastrointestinal surgical management . further reports [ 9 , 10 , 11 ] appear to suggest that although tevar is a useful method for achieving hemodynamic stability , for definitive long - term management the patient will require some form of open surgical intervention . of course with advanced esophageal malignancy , patients may simply not be suitable for surgery , leaving tevar as their only option . the problem with tevar remains that it does not prevent immediate exsanguination in patients admitted with fistula . it was found in patients who underwent tevar that early esophageal repair appeared to improve survival . literature on the successful esophageal management of the initial exsanguination remains limited , with the successful use of a sengstaken - blakemore tube prior to tevar being reported . newer techniques have been emerging , such as the use of cyanoacrylate embolisation of the fistula followed by tevar . the use of esophageal stenting as a means of controlling initial exsanguination remains a relatively unexplored area of management . in conclusion , with early recognition , esophageal stenting may have a role in the initial emergency control of bleeding due to aortoesophageal fistula , but clearly , immediate access to anaesthetic , interventional endoscopic and radiological services is mandatory .