Esophago-pericardial fistula and gastric perforation after esophageal stenting during ramucirumab treatment.

Esophageal stent migration is a known complication in malignant obstructions, but its severity can be critically exacerbated by antiangiogenic therapies like ramucirumab, which significantly increases the risk of gastrointestinal perforation (RR 3.2 (95% CI: 1.5-7.0).). We report the case of a 52-year-old male with unresectable distal esophageal adenocarcinoma under treatment with paclitaxel and ramucirumab, who presented with dyspnea, dysphagia, and constitutional syndrome due to caudal stent migration complicated by an esophago-pericardial fistula and a contained gastric perforation. Given the clinical deterioration and the lack of viable endoscopic or surgical alternatives, palliative sedation was initiated, and the patient passed away. This case underscores the lethal synergistic risk of combining mechanical stenting with antiangiogenic agents, highlighting the critical need for active surveillance and multidisciplinary evaluation in patients where these high-risk factors coexist to optimize patient selection and prevent catastrophic adverse events.