Multidisciplinary Management of a Thoracic Aortic-Penetrating Esophageal Foreign Body: A Case Report

Multidisciplinary Management of a Thoracic Aortic-Penetrating Esophageal Foreign Body: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Multidisciplinary Management of a Thoracic Aortic-Penetrating Esophageal Foreign Body: A Case Report Songbo Xue, Wanru Zheng, Xu Tian, Jiajing Tong, Yu Chen, Zhiqiang Gao, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7111916/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 19 You are reading this latest preprint version Abstract Background Thoracic aortic penetration by an esophageal foreign body (EFB) is a rare, fatal emergency (> 80% mortality). This case demonstrates a standardized multidisciplinary approach emphasizing prophylactic thoracic endovascular aortic repair (TEVAR) for hemorrhage prevention. Case presentation A 57-year-old woman developed retrosternal pain after fish ingestion. Computed tomography confirmed a fish bone penetrating the esophagus into the aortic arch lumen. Under multidisciplinary coordination: a covered stent was pre-positioned endovascularly; rigid esophagoscopy extracted the barbed bone; immediate TEVAR sealed aortic leakage post-removal. Postoperative management included dual antibiotics and antiplatelet therapy. Three-month follow-up showed intact stent without complications. Conclusions Prophylactic TEVAR prior to EFB removal is lifesaving in aortic-penetrating injuries, preventing catastrophic hemorrhage in stable patients. This integrated cardiothoracic-otolaryngology protocol offers a replicable model for managing this lethal condition. Figures Figure 1 Figure 2 Figure 3 Introduction Esophageal foreign bodies (EFBs) represent a prevalent clinical emergency, compromising approximately 85% of upper gastrointestinal foreign body cases in China [1] , with fish bones predominating among sharp-object incidents [2] . Given esophagus’ intimate anatomical proximity to the aorta , transmural EFB penetration of the esophageal wall can life-threatening complications. When direct aortic lumen penetration occurs, an aorto-esophageal fistula (AEF) can develop, carrying an untreated mortality rate exceeding 80% attributed primarily to hemorrhagic shock or sepsis [3] . The management of AEF poses three major challenges. First, diagnostic criteria lack standardization. Although CT imaging effectively detects esophageal perforation, the assessment of aortic penetration depth remains contentious [4] . While Wei et al. proposed that an EFB-aortic distance < 2 mm suggests probable or confirmed AEF [5] , this threshold lacks universal validation [6] . Second, there is no consensus on the optimal treatment approach. Conventional thoracotomy permits complete debridement but entails high substantial morbidity and mortality [7] . For suspected AEF cases, the hybrid approach-combining thoracic endovascular aortic repair (TEVAR) for aortic defect closure with endoscopic EFB removal-has emerged as a preferred strategy due to reduced operative risk and accelerated recovery compared to open surgery [6] . Nevertheless, TEVAR carries inherent risks, including stent-related infections and thrombosis with potentially fatal consequences [7] . Third, perioperative management demands meticulous coordination given the complex interplay of retained foreign bodies, infection, and vascular injury, necessitating a multidisciplinary team (MDT) approach. Drawing on previous successes and our institutional experience, optimal management should encompass hemorrhage control, EFB extraction, and prolonged antibiotic therapy. This report presents a critical case of thoracic aorta penetration by a fish bone, successfully managed through concerted efforts of cardiovascular surgery, interventional radiology, and otolaryngology. This case highlights three key elements: 1) the imperative for rapid multidisciplinary coordination, 2) strategic of TEVAR application, and 3) imaging’s decisive role in therapeutic decision-making. By detailing key diagnostic and therapeutic decisions, this case contributes to defining an optimal management strategy for this rare yet lethal complication. Case Report A 57-year-old woman presented with 4-day progressive retrosternal and cervical pain following fish consumption, accompanied by a peak febrile episode of 38.5°C. Physical examination revealed no oral or pharyngeal lesions, cervical tenderness, or palpable masses. The patient had no fever, no bloody vomiting, no bloody stools, or other related symptoms. without visible swelling or palpable foreign bodies. Cervical-thoracic contrast-enhanced CT demonstrated a linear foreign body traversing the esophagus wall with penetration into the thoracic aorta lumen (Figure.1). Intervention Given the critical nature of the injury, an urgent multidisciplinary consultation was convened with specialists from Cardiology, Thoracic Surgery, Gastroenterology, Interventional medicine, and Diagnostic Imaging. MDT consensus was reached that urgent intervention was imperative to prevent life-threatening complications including pseudoaneurysm formation and mediastinitis secondary to arterial rupture. The patient demonstrated no evidence of mediastinal infection, supporting the rationale for endovascular management with a coated stent to achieve hemostasis, while rigid esophagoscope provided an optimal visualization for foreign body removal. The TEVAR combined with rigid esophagoscopy foreign body removal protocol was selected. In the hybrid operating room, a DSA-guided arterial access was performed through the right femoral artery, and a stent was positioned in the thoracic aortic arch. Following gradual extraction of the fishbone under rigid esophagoscopy guidance (Figure.2. A), a small amount of contrast spillage was observed at the penetration site, allowing precise localization of the aortic injury (Figure.2. B). Subsequent stent deployment resulted in complete seal confirmed by post-procedural DSA, with no endoleak detected. Final endoscopic re-evaluation of the traumatized region revealed no residual no residual hemorrhage. Postoperatively, the patient was managed with a comprehensive regimen comprising: dual antibiotic therapy (ceftazidime and metronidazole), gastric acid suppression therapy, enteral nutritional via nasogastric tube for two weeks, with vigilant monitoring for hemorrhagic and thrombotic complications. Long-term antiplatelet prophylaxis (aspirin, 100mg daily) was initiated two weeks postoperatively. Follow-up A follow-up CTA and upper gastrointestinal imaging at three months post-surgery demonstrated excellent stent positioning without complications (Figure.3.). Discussion This case underscores the critical risk of EFBs penetration into the aortic lumen. CT imaging conclusively demonstrated a sharp, pin-shaped object breaching the aortic wall, a life-threatening condition associated with a high mortality rate without prompt intervention [ 8 , 9 ] . Immediate surgical management is imperative to mitigate catastrophic complications [ 7 ] , requiring urgent MDT coordination for optimal outcomes. Our institutional approach emphasized on three pivotal factors: (1) infection status evaluation to determine the need for thoracotomy; (2) aortic penetration to guide vascular repair, and (3) foreign body location and characteristics to inform removal technique. Based on this case, we established a standardized management algorithm that reduced decision-to-intervention intervals to under two hours. Infection and Surgical Decision-Making Infection remains the leading cause of mortality in AEF [ 8 ] . Accurate assessment of mediastinal infection is essential for determining the treatment strategy. Despite the patient’s fever, laboratory tests revealed no significant signs of inflammation, and CT revealed no infection indicators, such as periesophageal gas, fluid collections, mediastinal widening, or pneumoperitoneum [ 4 ] . Based on these findings, endoscopic intervention was considered appropriate, while open surgery was reserved for cases with severe contamination. Hemorrhage and the Role of TEVAR Massive hemorrhage is another major mortality factor in AEF management [ 9 ] . Preoperative CT imaging confirmed direct contact (0 mm distance) between the fish bone and the aorta but did not establish full-thickness penetration. In cases where aortic wall breach is confirmed, foreign body removal can lead to catastrophic bleeding. Delayed-onset AEF has been reported following simple endoscopic removal [ 10 , 11 ] , underscoring the need for prophylactic TEVAR in suspected aortic injuries. Therefore, preparation for massive hemorrhage is essential. In hemodynamically stable patients without infection, preemptive TEVAR can prevent fatal hemorrhage, aligning with the recommendations of Zeng et al. [ 12 ] . However, TEVAR carries inherent risks including infection, high costs, and the need for long-term anticoagulation [ 11 ] . While stent grafting is imperative for active leakage, consensus is lacking on whether to place a stent if no leakage is observed, as the risk of delayed AEF remains [ 7 , 9 , 10 ] . Selection of Removal Technique The optimal approach to EFB management depends on patient factors (age, clinical condition, American Society of Anesthesiologists [ASA] score), EFB characteristics (type, size, and location), impaction duration, and physician expertise [ 13 ] . Rigid endoscopy provides superior exposure of the upper esophagus, while flexible endoscopy offers greater patient comfort and lower complication rates [ 14 ] . At our institution, rigid endoscopy is preferred for objects above the aortic arch, while flexible endoscopy is used for those below. If one method fails, the alternative is considered. Surgery is indicated in cases with significant esophageal perforation or when endoscopic removal proves unsuccessful [ 15 ] . In this case, given the sharp, barbed features of the fish bone and its location above the aortic, rigid endoscopy was chosen over flexible endoscopy. Intraoperative Technical Considerations Technical precision during TEVAR is paramount. Stent graft selection and placement should be guided by digital subtraction angiography (DSA) to ensure adequate sealing while avoiding subclavian artery occlusion. Prepositioning the stent allows for immediate deployment if leakage occurs post-extraction. In this case, after prepositioning a covered stent graft, DSA confirmed intra-aortic leakage following foreign body removal, prompting immediate stent deployment to prevent hemorrhage. Additionally, adequate blood product preparation and the availability of a cardiothoracic surgical team for emergency thoracotomy conversion are essential. Ruan et al. reported an 8% conversion rate in their series [ 6 ] . Postoperative Management and Long-Term Follow-Up Stent graft infection represents the most serious postoperative complication, with a reported mortality rate of up to 33% in AEF patients treated with TEVAR [ 8 ] . To mitigate this risk, oral intake should be restricted, a nasogastric tube placed, and broad-spectrum parenteral antibiotics should be administered. Long-term complications include stent thrombosis, necessitating prolonged antiplatelet therapy. Regular follow-up with computed tomography angiography is required to monitor stent position, morphology and aortic wall healing. Conclusion This case highlights the necessity for standardized multidisciplinary approach in managing EFBs penetrating the aorta. While TEVAR serves as a lifesaving bridge, its application requires careful risk-benefit analysis in potential infectious contexts, emphasizing individualized risk assessment. Subsequent investigations should focus on optimizing therapeutic algorithms and long-term outcome stratification. Abbreviations Abbreviation Full Term EFB Esophageal Foreign Body AEF Aortoesophageal Fistula TEVAR Thoracic Endovascular Aortic Repair MDT Multidisciplinary Team CT Computed Tomography CTA Computed Tomography Angiography DSA Digital Subtraction Angiography VRT Volume Rendering Technology ASA American Society of Anesthesiologists Declarations Ethics approval and consent to participate The study was conducted after obtaining ethical clearance from the Internal Ethics & Research Committee of Peking Union Medical College Hospital. (Approval Reference No: I-25PJ0826) Consent for publication: Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials: The datasets used and/or analysed during the current case report are available from the corresponding author on reasonable request. Competing interests The authors report no competing interests to declare. Funding: This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: SX, YZ, and XT conceived the study and designed the management protocol. SX and WZ drafted the initial manuscript. SX, JT, and YC performed data analysis, validation, and critical revisions. ZG, YZhu, and GF supervised the clinical management and provided expert guidance. All authors reviewed the final manuscript and approved its submission. Acknowledgements: The authors acknowledge the collaborative efforts of the cardiovascular surgery, interventional radiology, and diagnostic imaging teams involved in this patient's care. References Geng C, et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: a retrospective study of 1294 cases[J]. Scand J Gastroenterol, 2017, 52(11):1286-1291 Zhong Q, et al. Esophageal foreign body ingestion in adults on weekdays and holidays: A retrospective study of 1058 patients[J]. Medicine (Baltimore), 2017, 96(43):e8409 Akinkugbe O, et al. Vascular Complications in Children Following Button Battery Ingestions: A Systematic Review[J]. Pediatrics, 2022, 150(3) Liu Y C, Zhou S H and Ling L. Value of helical computed tomography in the early diagnosis of esophageal foreign bodies in adults[J]. Am J Emerg Med, 2013, 31(9):1328-1332 Wei Y, et al. Proposed management protocol for ingested esophageal foreign body and aortoesophageal fistula: a single-center experience[J]. Int J Clin Exp Med, 2015, 8(1):607-615 Ruan W S and Lu Y Q. The life-saving emergency thoracic endovascular aorta repair management on suspected aortoesophageal foreign body injury[J]. World J Emerg Med, 2020, 11(3):152-156 Rey Chaves C E, et al. Aortoesophageal fistulae following TEVAR: Case report and literature review[J]. Int J Surg Case Rep, 2023, 106:108126 Wang C, et al. Thoracic Endovascular Aortic Repair For The Management of Aorto-Esophageal Fistulae: A Systematic Review[J]. J Endovasc Ther, 2024:15266028241300403 Nana Sede Mbakop R, et al. Chicken Bone Ingestion Leads to Aortoesophageal Fistula With Catastrophic Bleeding[J]. J Investig Med High Impact Case Rep, 2023, 11:23247096231192818 Chen J. Vascular covered stent and video-assisted thoracoscopic surgery for Aortoesophageal fistula caused by esophageal fishbone: a case report[J]. J Cardiothorac Surg, 2024, 19(1):112 Reddy S M, et al. Esophago-Vascular Fistulae in Children: Five Survivors, Literature Review, and Proposal for Management[J]. J Pediatr Surg, 2023, 58(10):1969-1975 Zeng L, et al. Aortic injury caused by esophageal foreign body-case reports of 3 patients and literature review[J]. Medicine (Baltimore), 2020, 99(26):e20849 Birk M, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline[J]. Endoscopy, 2016, 48(5):489-496 Ikenberry S O, et al. Management of ingested foreign bodies and food impactions[J]. Gastrointest Endosc, 2011, 73(6):1085-1091 Gmeiner D, et al. Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus[J]. Surg Endosc, 2007, 21(11):2026-2029 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 22 Dec, 2025 Reviews received at journal 30 Aug, 2025 Reviews received at journal 29 Aug, 2025 Reviews received at journal 24 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviews received at journal 20 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 18 Aug, 2025 Reviews received at journal 18 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 14 Aug, 2025 Editor assigned by journal 14 Jul, 2025 Submission checks completed at journal 14 Jul, 2025 First submitted to journal 13 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7111916","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":502961976,"identity":"3c8116dc-3730-40af-89da-f669c6578006","order_by":0,"name":"Songbo Xue","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences \u0026 Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Songbo","middleName":"","lastName":"Xue","suffix":""},{"id":502961977,"identity":"7255c75c-273e-40c4-be1d-119aa1ccdf26","order_by":1,"name":"Wanru Zheng","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences \u0026 Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Wanru","middleName":"","lastName":"Zheng","suffix":""},{"id":502961978,"identity":"250bc070-76d9-45cb-aee8-0285ac0fe224","order_by":2,"name":"Xu Tian","email":"","orcid":"","institution":"Peking Union Medical College Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Tian","suffix":""},{"id":502961979,"identity":"efeeaa1b-2398-4fcd-bc0c-891c57c54523","order_by":3,"name":"Jiajing Tong","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences \u0026 Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jiajing","middleName":"","lastName":"Tong","suffix":""},{"id":502961980,"identity":"09b49b35-2562-4d46-a359-8841c0136c73","order_by":4,"name":"Yu Chen","email":"","orcid":"","institution":"Peking Union Medical College Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Chen","suffix":""},{"id":502961981,"identity":"2a9d0caa-c939-40d2-9aef-ab2599b58956","order_by":5,"name":"Zhiqiang Gao","email":"","orcid":"","institution":"Peking Union Medical College Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhiqiang","middleName":"","lastName":"Gao","suffix":""},{"id":502961982,"identity":"b6236625-3771-4bd1-a558-3dcd78b91c52","order_by":6,"name":"Yingying Zhu","email":"","orcid":"","institution":"Peking Union Medical College Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yingying","middleName":"","lastName":"Zhu","suffix":""},{"id":502961983,"identity":"f62ef2d9-e344-483d-a29a-b979db6a9172","order_by":7,"name":"Yang Zhao","email":"","orcid":"","institution":"Peking Union Medical College Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Zhao","suffix":""},{"id":502961984,"identity":"9a9df54d-5bcf-4bc0-b1b2-5c4aff20aa3b","order_by":8,"name":"Guodong Feng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYBAC9gYGAyBlw8PP30CkFp4DIC0JaTKSMw6QpuWwjUFDArFa+BdvfFz44zyPAcMBxg8fc4jRIvGs2HhGwm0ec+YGZsmZ24jQYi9xxkyaB6jFsuEAGzMvMVp4JM6Y/+ZJOMdjcCCBWC38PWbMPAkHSNEiwVYszZOWzCM542AzcX7h4T+88TOPjZ09P3/zwQ8fidHCIJEAYzE2EKMeCPgPEKlwFIyCUTAKRi4AAAUyMqK4ISbRAAAAAElFTkSuQmCC","orcid":"","institution":"Peking Union Medical College Hospital","correspondingAuthor":true,"prefix":"","firstName":"Guodong","middleName":"","lastName":"Feng","suffix":""}],"badges":[],"createdAt":"2025-07-13 07:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7111916/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7111916/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-026-03949-6","type":"published","date":"2026-04-08T15:59:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89660376,"identity":"e5c015db-e0df-4fff-bc9f-6cae98a2b781","added_by":"auto","created_at":"2025-08-22 11:05:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":508060,"visible":true,"origin":"","legend":"\u003cp\u003eCervical-thoracic contrast-enhanced CT. Coronal reconstructed CT image (A) and Volume Rendering Technology (VRT) image (B) showed a foreign body (red arrow) in the upper part of the esophagus penetrating the left esophageal wall and aortic arch.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7111916/v1/55315af3951daf753cf4b6ac.png"},{"id":89660381,"identity":"8e4c9255-e045-4c1d-b6b8-1d69103a7df7","added_by":"auto","created_at":"2025-08-22 11:05:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":834682,"visible":true,"origin":"","legend":"\u003cp\u003eForeign body and reaction after removal. (A) Foreign body: A fish bone shows barbs (red arrow); (B) Arterial leakage (red arrow) can be seen after pulling out the fish bone.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7111916/v1/7931f5211cd3730ff43cc25d.png"},{"id":89661522,"identity":"9dc4e437-345e-4e9b-a19b-87478b7d1b85","added_by":"auto","created_at":"2025-08-22 11:13:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":279454,"visible":true,"origin":"","legend":"\u003cp\u003eAxial reconstructed image (A) and VRT image (B) of CTA after the follow-up.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7111916/v1/5f5b85978d15363f77bb0ea8.png"},{"id":106809349,"identity":"a16a2513-40b2-4ada-a0d9-68579e92b069","added_by":"auto","created_at":"2026-04-13 16:09:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2941811,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7111916/v1/111b6040-d8bf-4947-90a7-1db3afa88ce4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multidisciplinary Management of a Thoracic Aortic-Penetrating Esophageal Foreign Body: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEsophageal foreign bodies (EFBs) represent a prevalent clinical emergency, compromising approximately 85% of upper gastrointestinal foreign body cases in China\u003csup\u003e[1]\u003c/sup\u003e, with fish bones predominating among sharp-object incidents\u003csup\u003e[2]\u003c/sup\u003e. Given \u003cstrong\u003eesophagus\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eintimate anatomical \u003cstrong\u003eproximity to the aorta\u003c/strong\u003e, transmural EFB penetration of the esophageal wall can life-threatening complications. When direct aortic lumen penetration occurs, an aorto-esophageal fistula (AEF) can develop, carrying an untreated mortality rate exceeding 80% attributed primarily to hemorrhagic shock or sepsis\u003csup\u003e[3]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe management of AEF poses three major challenges. First, diagnostic criteria lack standardization. Although CT imaging effectively detects esophageal perforation, the assessment of aortic penetration depth remains contentious \u003csup\u003e[4]\u003c/sup\u003e. While Wei et al. proposed that an EFB-aortic distance \u0026lt; 2 mm suggests probable or confirmed AEF\u003csup\u003e[5]\u003c/sup\u003e, this threshold lacks universal validation\u003csup\u003e[6]\u003c/sup\u003e. Second, there is no consensus on the optimal treatment approach. Conventional thoracotomy permits complete debridement but entails high substantial morbidity and mortality\u003csup\u003e[7]\u003c/sup\u003e. For suspected AEF cases, the hybrid approach-combining thoracic endovascular aortic repair (TEVAR) for aortic defect closure with endoscopic EFB removal-has emerged as a preferred strategy due to reduced operative risk and accelerated recovery compared to open surgery\u003csup\u003e[6]\u003c/sup\u003e. Nevertheless, TEVAR carries inherent risks, including stent-related infections and thrombosis with potentially fatal consequences\u003csup\u003e[7]\u003c/sup\u003e. Third, perioperative management demands meticulous coordination given the complex interplay of retained foreign bodies, infection, and vascular injury, necessitating a multidisciplinary team (MDT) approach. Drawing on previous successes and our institutional experience, optimal management should encompass hemorrhage control, EFB extraction, and prolonged antibiotic therapy.\u003c/p\u003e\n\u003cp\u003eThis report presents a critical case of thoracic aorta penetration by a fish bone, successfully managed through concerted efforts of cardiovascular surgery, interventional radiology, and otolaryngology. This case highlights three key elements: 1) the imperative for rapid multidisciplinary coordination, 2) strategic of TEVAR application, and 3) imaging\u0026rsquo;s decisive role in therapeutic decision-making. By detailing key diagnostic and therapeutic decisions, this case contributes to defining an optimal management strategy for this rare yet lethal complication.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 57-year-old woman presented with 4-day progressive retrosternal and cervical pain following fish consumption, accompanied by a peak febrile episode of 38.5\u0026deg;C. Physical examination revealed no oral or pharyngeal lesions, cervical tenderness, or palpable masses. The patient had no fever, no bloody vomiting, no bloody stools, or other related symptoms. without visible swelling or palpable foreign bodies. Cervical-thoracic contrast-enhanced CT demonstrated a linear foreign body traversing the esophagus wall with penetration into the thoracic aorta lumen (Figure.1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the critical nature of the injury, an urgent multidisciplinary consultation was convened with specialists from Cardiology, Thoracic Surgery, Gastroenterology, Interventional medicine, and Diagnostic Imaging. MDT consensus was reached that urgent intervention was imperative to prevent life-threatening complications including pseudoaneurysm formation and mediastinitis secondary to arterial rupture. The patient demonstrated no evidence of mediastinal infection, supporting the rationale for endovascular management with a coated stent to achieve hemostasis, while rigid esophagoscope provided an optimal visualization for foreign body removal. The TEVAR combined with rigid esophagoscopy foreign body removal protocol was selected. In the hybrid operating room, a DSA-guided arterial access was performed through the right femoral artery, and a stent was positioned in the thoracic aortic arch. Following gradual extraction of the fishbone under rigid esophagoscopy guidance (Figure.2. A), a small amount of contrast spillage was observed at the penetration site, allowing precise localization of the aortic injury (Figure.2. B). Subsequent stent deployment resulted in complete seal confirmed by post-procedural DSA, with no endoleak detected. Final endoscopic re-evaluation of the traumatized region revealed no residual no residual hemorrhage.\u003c/p\u003e\n\u003cp\u003ePostoperatively, the patient was managed with a comprehensive regimen comprising: dual antibiotic therapy (ceftazidime and metronidazole), gastric acid suppression therapy, enteral nutritional via nasogastric tube for two weeks, with vigilant monitoring for hemorrhagic and thrombotic complications. Long-term antiplatelet prophylaxis (aspirin, 100mg daily) was initiated two weeks postoperatively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA follow-up CTA and upper gastrointestinal imaging at three months post-surgery demonstrated excellent stent positioning without complications (Figure.3.).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case underscores the critical risk of EFBs penetration into the aortic lumen. CT imaging conclusively demonstrated a sharp, pin-shaped object breaching the aortic wall, a life-threatening condition associated with a high mortality rate without prompt intervention\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Immediate surgical management is imperative to mitigate catastrophic complications\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, requiring urgent MDT coordination for optimal outcomes. Our institutional approach emphasized on three pivotal factors: (1) infection status evaluation to determine the need for thoracotomy; (2) aortic penetration to guide vascular repair, and (3) foreign body location and characteristics to inform removal technique. Based on this case, we established a standardized management algorithm that reduced decision-to-intervention intervals to under two hours.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInfection and Surgical Decision-Making\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInfection remains the leading cause of mortality in AEF\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Accurate assessment of mediastinal infection is essential for determining the treatment strategy. Despite the patient\u0026rsquo;s fever, laboratory tests revealed no significant signs of inflammation, and CT revealed no infection indicators, such as periesophageal gas, fluid collections, mediastinal widening, or pneumoperitoneum\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Based on these findings, endoscopic intervention was considered appropriate, while open surgery was reserved for cases with severe contamination.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHemorrhage and the Role of TEVAR\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMassive hemorrhage is another major mortality factor in AEF management\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Preoperative CT imaging confirmed direct contact (0 mm distance) between the fish bone and the aorta but did not establish full-thickness penetration. In cases where aortic wall breach is confirmed, foreign body removal can lead to catastrophic bleeding. Delayed-onset AEF has been reported following simple endoscopic removal \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, underscoring the need for prophylactic TEVAR in suspected aortic injuries. Therefore, preparation for massive hemorrhage is essential. In hemodynamically stable patients without infection, preemptive TEVAR can prevent fatal hemorrhage, aligning with the recommendations of Zeng et al.\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. However, TEVAR carries inherent risks including infection, high costs, and the need for long-term anticoagulation\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. While stent grafting is imperative for active leakage, consensus is lacking on whether to place a stent if no leakage is observed, as the risk of delayed AEF remains\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSelection of Removal Technique\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe optimal approach to EFB management depends on patient factors (age, clinical condition, American Society of Anesthesiologists [ASA] score), EFB characteristics (type, size, and location), impaction duration, and physician expertise\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Rigid endoscopy provides superior exposure of the upper esophagus, while flexible endoscopy offers greater patient comfort and lower complication rates \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. At our institution, rigid endoscopy is preferred for objects above the aortic arch, while flexible endoscopy is used for those below. If one method fails, the alternative is considered. Surgery is indicated in cases with significant esophageal perforation or when endoscopic removal proves unsuccessful\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. In this case, given the sharp, barbed features of the fish bone and its location above the aortic, rigid endoscopy was chosen over flexible endoscopy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntraoperative Technical Considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTechnical precision during TEVAR is paramount. Stent graft selection and placement should be guided by digital subtraction angiography (DSA) to ensure adequate sealing while avoiding subclavian artery occlusion. Prepositioning the stent allows for immediate deployment if leakage occurs post-extraction. In this case, after prepositioning a covered stent graft, DSA confirmed intra-aortic leakage following foreign body removal, prompting immediate stent deployment to prevent hemorrhage. Additionally, adequate blood product preparation and the availability of a cardiothoracic surgical team for emergency thoracotomy conversion are essential. Ruan et al. reported an 8% conversion rate in their series\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePostoperative Management and Long-Term Follow-Up\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStent graft infection represents the most serious postoperative complication, with a reported mortality rate of up to 33% in AEF patients treated with TEVAR\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. To mitigate this risk, oral intake should be restricted, a nasogastric tube placed, and broad-spectrum parenteral antibiotics should be administered. Long-term complications include stent thrombosis, necessitating prolonged antiplatelet therapy. Regular follow-up with computed tomography angiography is required to monitor stent position, morphology and aortic wall healing.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights the necessity for standardized multidisciplinary approach in managing EFBs penetrating the aorta. While TEVAR serves as a lifesaving bridge, its application requires careful risk-benefit analysis in potential infectious contexts, emphasizing individualized risk assessment. Subsequent investigations should focus on optimizing therapeutic algorithms and long-term outcome stratification.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFull Term\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEFB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEsophageal Foreign Body\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAEF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAortoesophageal Fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTEVAR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic Endovascular Aortic Repair\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMDT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMultidisciplinary Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eComputed Tomography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCTA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eComputed Tomography Angiography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDSA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDigital Subtraction Angiography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVRT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eVolume Rendering Technology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted after obtaining ethical clearance from the Internal Ethics \u0026amp; Research Committee of Peking Union Medical College Hospital. (Approval Reference No: I-25PJ0826)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current case report are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSX, YZ, and XT conceived the study and designed the management protocol. SX and WZ drafted the initial manuscript. SX, JT, and YC performed data analysis, validation, and critical revisions. ZG, YZhu, and GF supervised the clinical management and provided expert guidance. All authors reviewed the final manuscript and approved its submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the collaborative efforts of the cardiovascular surgery, interventional radiology, and diagnostic imaging teams involved in this patient\u0026apos;s care.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGeng C, et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: a retrospective study of 1294 cases[J]. Scand J Gastroenterol, 2017, 52(11):1286-1291\u003c/li\u003e\n\u003cli\u003eZhong Q, et al. Esophageal foreign body ingestion in adults on weekdays and holidays: A retrospective study of 1058 patients[J]. Medicine (Baltimore), 2017, 96(43):e8409\u003c/li\u003e\n\u003cli\u003eAkinkugbe O, et al. Vascular Complications in Children Following Button Battery Ingestions: A Systematic Review[J]. Pediatrics, 2022, 150(3)\u003c/li\u003e\n\u003cli\u003eLiu Y C, Zhou S H and Ling L. Value of helical computed tomography in the early diagnosis of esophageal foreign bodies in adults[J]. Am J Emerg Med, 2013, 31(9):1328-1332\u003c/li\u003e\n\u003cli\u003eWei Y, et al. Proposed management protocol for ingested esophageal foreign body and aortoesophageal fistula: a single-center experience[J]. Int J Clin Exp Med, 2015, 8(1):607-615\u003c/li\u003e\n\u003cli\u003eRuan W S and Lu Y Q. The life-saving emergency thoracic endovascular aorta repair management on suspected aortoesophageal foreign body injury[J]. World J Emerg Med, 2020, 11(3):152-156\u003c/li\u003e\n\u003cli\u003eRey Chaves C E, et al. Aortoesophageal fistulae following TEVAR: Case report and literature review[J]. Int J Surg Case Rep, 2023, 106:108126\u003c/li\u003e\n\u003cli\u003eWang C, et al. Thoracic Endovascular Aortic Repair For The Management of Aorto-Esophageal Fistulae: A Systematic Review[J]. J Endovasc Ther, 2024:15266028241300403\u003c/li\u003e\n\u003cli\u003eNana Sede Mbakop R, et al. Chicken Bone Ingestion Leads to Aortoesophageal Fistula With Catastrophic Bleeding[J]. J Investig Med High Impact Case Rep, 2023, 11:23247096231192818\u003c/li\u003e\n\u003cli\u003eChen J. Vascular covered stent and video-assisted thoracoscopic surgery for Aortoesophageal fistula caused by esophageal fishbone: a case report[J]. J Cardiothorac Surg, 2024, 19(1):112\u003c/li\u003e\n\u003cli\u003eReddy S M, et al. Esophago-Vascular Fistulae in Children: Five Survivors, Literature Review, and Proposal for Management[J]. J Pediatr Surg, 2023, 58(10):1969-1975\u003c/li\u003e\n\u003cli\u003eZeng L, et al. Aortic injury caused by esophageal foreign body-case reports of 3 patients and literature review[J]. Medicine (Baltimore), 2020, 99(26):e20849\u003c/li\u003e\n\u003cli\u003eBirk M, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline[J]. Endoscopy, 2016, 48(5):489-496\u003c/li\u003e\n\u003cli\u003eIkenberry S O, et al. Management of ingested foreign bodies and food impactions[J]. Gastrointest Endosc, 2011, 73(6):1085-1091\u003c/li\u003e\n\u003cli\u003eGmeiner D, et al. Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus[J]. Surg Endosc, 2007, 21(11):2026-2029\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7111916/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7111916/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThoracic aortic penetration by an esophageal foreign body (EFB) is a rare, fatal emergency (\u0026gt;\u0026thinsp;80% mortality). This case demonstrates a standardized multidisciplinary approach emphasizing prophylactic thoracic endovascular aortic repair (TEVAR) for hemorrhage prevention.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e\u003cp\u003eA 57-year-old woman developed retrosternal pain after fish ingestion. Computed tomography confirmed a fish bone penetrating the esophagus into the aortic arch lumen. Under multidisciplinary coordination: a covered stent was pre-positioned endovascularly; rigid esophagoscopy extracted the barbed bone; immediate TEVAR sealed aortic leakage post-removal. Postoperative management included dual antibiotics and antiplatelet therapy. Three-month follow-up showed intact stent without complications.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eProphylactic TEVAR prior to EFB removal is lifesaving in aortic-penetrating injuries, preventing catastrophic hemorrhage in stable patients. This integrated cardiothoracic-otolaryngology protocol offers a replicable model for managing this lethal condition.\u003c/p\u003e","manuscriptTitle":"Multidisciplinary Management of a Thoracic Aortic-Penetrating Esophageal Foreign Body: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 11:05:41","doi":"10.21203/rs.3.rs-7111916/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-22T19:19:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-30T13:31:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T17:55:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-24T20:30:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T14:17:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T07:54:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T07:40:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178198559155257238525920378977468991181","date":"2025-08-19T17:42:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99290506797752330427991878759697844841","date":"2025-08-18T16:30:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T15:35:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8616135370408228491364027030488999306","date":"2025-08-17T11:52:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208527575813467147234153320283314091416","date":"2025-08-16T14:19:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63530075530596785950784575379970648504","date":"2025-08-16T11:42:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35623054061176973094098562174691208655","date":"2025-08-16T01:38:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223499517495004568610691882681012534841","date":"2025-08-14T13:33:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T11:07:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-14T11:16:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-14T11:13:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-07-13T07:50:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3a6e4ef-798b-46a3-9bf9-12929e01f095","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:06:17+00:00","versionOfRecord":{"articleIdentity":"rs-7111916","link":"https://doi.org/10.1186/s13019-026-03949-6","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-08 15:59:10","publishedOnDateReadable":"April 8th, 2026"},"versionCreatedAt":"2025-08-22 11:05:41","video":"","vorDoi":"10.1186/s13019-026-03949-6","vorDoiUrl":"https://doi.org/10.1186/s13019-026-03949-6","workflowStages":[]},"version":"v1","identity":"rs-7111916","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7111916","identity":"rs-7111916","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}