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We report a case of the repair of an acquired benign tracheoesophageal fistula (TEF) after prolonged mechanical invasive ventilation. Patient had an unknown double incomplete aortic arch determining a vascular ring above trachea and esophagus. External tracheobronchial compression, caused by the vascular ring, increasing the internal tracheoesophageal walls pressure determined by endotracheal and nasogastric tubes favored an early TEF development. The fistula was repaired through an unusual left thoracotomy and vascular ring dissection. TEFs are a heterogeneous group of diseases affecting critically ill patients. Operative closure is necessary to avoid further complications related to this condition. Pre-operative study is mandatory to plan an adequate surgical approach.