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We describe the case of a 75-year-old man who had undergone total laryngectomy with neck dissection and major pectoralis flap for recurrent squamous cell carcinoma after chemoradiation treatment. Post-operatively he developed a recurrent pharyngocutaneous fistula, managed with placement of a partially covered self-expandable metal stent (SEMS) (23×105-mmWallflex; Boston Scientific Inc., Marlborough, Massachusetts, USA). The patient missed a scheduled follow-up for stent retrieval. After several months he was admitted to our emergency department for hematemesis and severe anemia. Following hemodynamic resuscitation, an upper gastrointestinal (GI) endoscopy was performed. A spurting bleed at the distal end of the esophageal stent was observed (▶Fig. 1, ▶Video 1). First the stent was removed to expose the source of the bleed, followed by injection of 5ml of cyanoacrylate glue (Glubran; GEM srl, Viareggio, Italy). Because of persistent active bleeding, a fully covered SEMS (24×180-mm Niti-S Beta; TaeWoong Medical, Gyeonggi-do, South Korea) was placed. After few seconds, abrupt bleeding recurred with rupture of the silicone covering of the stent (▶Fig. 2). Further injection of 3ml of cyanoacrylate glue was repeated into the mesh, thereby controlling the bleeding almost completely (▶Fig. 3). An urgent CT angiography revealed an aortoesophageal fistula originating from an anomalous right-sided aortic arch. The cyanoacrylate tamponade effect on the fistula was sufficient to stabilize the patient and, after emergent multidisciplinary consultation, an endovascular bailout was planned. The patient was referred to our cath lab where he immediately received a percutaneous aortic stent graft to stop the leak (▶Fig. 4). Of note, the aberrant origin of the supraortic trunks allowed for a successful arch covering without brain ischemic sequelae. The patient recovered uneventfully, and no further bleeding occurred. The esophageal SEMS was removed 1 month later and there was no evidence of a mucosal defect (▶Fig. 5). An aortoesophageal fistula has been reported as a dramatic adverse event of aortic disease, thoracic aortic surgery, foreign body ingestion, esophageal stent placement and esophageal malignancy with a high mortality rate [1]. To date there is no standardized treatment for this condition [2, 3]. Furthermore, the E-Videos

The worst adverse event for an endoscopist after esophageal stent placement: an aortoesophageal fistula