Management of aortobronchial fistula developing 27 years after open aortic surgery by means of endovascular stent grafting.

Fistulous connections between the thoracic aorta and the bronchial systems are rare but potentially fatal complications. However, reports are limited and guidelines for diagnosis and treatment are not available. Most often, patients have a history of reconstructive vascular surgery followed by anastomotic aneurysm or dissection. Aortobronchial fistulas (ABFs) regularly present with mild to massive hemoptysis and chest pain.1Nishizawa J. Matsumoto M. Sugita T. Matsuyama K. Tokuda Y. Yoshida K. et al.Surgical treatment of five patients with aortobronchial fistula in the aortic arch.Ann Thorac Surg. 2004; 77: 1821-1823Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Given the high mortality of untreated patients, immediate patient management with either open surgery or endovascular repair is essential. We present the case of an ABF occurring 27 years after open surgical repair because of a false aortic aneurysm. A 52-year-old female patient reported to the emergency department with increasing volumes of hemoptysis. The patient had been experiencing increasing episodes of coughing followed by production of bloody sputum for the previous 10 days. During the last 48 hours, a significant aggravation of symptoms was noted by the patient. At the age of 16 years, the patient had sustained multiple injuries after a traumatic car accident and was treated for ruptured diaphragm and spleen, as well as pelvic and maxillary fractures. The diaphragmatic defect was unsatisfactorily repaired. In addition, a false aneurysm of the descending aorta was diagnosed and observed. Growth of the aneurysm was slow, and elective vascular surgery with resection of the false aneurysm and implantation of a prosthesis with end-to-end anastomosis was performed in 1981. Proximal to the anastomosis, a dissection of the aortic wall was diagnosed at a routine follow-up examination in 2006, but the patient remained without clinical symptoms until 2008, 27 years after the initial surgical repair. Arterial blood pressure at the day of admission was 140/80 mm Hg. Initial chest computed tomography (CT) showed a perforating ulcus of the descending aorta in close proximity to the preexisting anastomosis with connection to the bronchial system, leading to the diagnosis of a secondary ABF (Figure 1, A, B). A smaller second lesion was identified at the inner curve of the aortic arch. Immediate endovascular treatment with implantation of a stent graft was initiated. After surgical exposure of the left common femoral artery and insertion of a 4F pigtail catheter via the right brachial artery, a stiff 0.035-inch Back-up Meier guidewire (Boston Scientific, Natick, MA) was placed into the ascending aorta using a retrograde endovascular route. After baseline angiography (Figure 1, C), the patient received a Valiant Thoracic Stent Graft 28/28 × 100 mm (Medtronic, Minneapolis, MN), and the covered part was placed distal of the left subclavian artery. Control angiography of the aortic arch disclosed successful exclusion of both ulcers (Figure 2, A). During the procedure, antibiotic prophylaxis with cefuroxime was commenced. After the intervention, the patient remained in the intensive care unit for another day and was transferred to the Department of Pneumology for further monitoring. Recurring minor episodes of bloody expectorations ceased after 5 days. Administration of corticosteroids to prevent inflammation of the left lung was started. The postoperative course was uneventful with stable levels of hemoglobin and no other signs of bleeding. Follow-up CT showed optimal situation of the stent graft and complete thrombosis of the false lumen (Figure 2, B, C). ABFs are a rare event with potentially fatal outcome. Early diagnosis and treatment are essential for survival. Patients with a history of aortic repair or aneurysms are considered to be at increased risk. In most cases, ABFs are localized between the descending aorta and the left bronchial tree.2Pirrelli S. Bozzani A. Arici V. Odero A. Endovascular treatment of acute haemoptysis secondary to aortobronchial fistula.Eur J Vasc Endovasc Surg. 2006; 32: 366-368Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Acute or massive hemoptyses are the leading symptom and should lead to urgent radiologic assessment using contrast-enhanced CT. More invasive methods (eg, bronchoscopy or diagnostic angiography) may lead to clot instability and substantial blood loss. Until recently, open surgical repair was deemed the only treatment option for patients with ABFs. Yet, mortality rates of 15.3%, mainly because of the complexity of procedures and emergency conditions, were reported.3Piciche M. De Paulis R. Fabbri A. Chiariello L. Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management.Ann Thorac Surg. 2003; 75: 1998-2006Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar During the past years, endovascular repair of postoperative ABFs was considered to be a safe and less-invasive alternative.4Kokotsakis J. Misthos P. Athanasiou T. Romana C. Skouteli E. Lioulias A. et al.Endovascular stenting for primary aortobronchial fistula in association with massive hemoptysis.Tex Heart Inst J. 2007; 34: 369-372PubMed Google Scholar, 5Quintana A.L. Aguilar E.M. Heredero A.F. Riambau V. Paul L. Acin F. Aortobronchial fistula after aortic coartactation.J Thorac Cardiovasc Surg. 2006; 131: 240-243Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar We report the case of an ABF occurring 27 years after open aortic surgery. Replacement of the descending aorta was necessary because of multiple trauma 9 years earlier that led to the development of a false aneurysm. ABFs may develop even many years after surgery for aortic repair. Patients with hemoptysis and positive history for thoracic surgery require emergency diagnosis and immediate repair because untreated ABFs are uniformly fatal.3Piciche M. De Paulis R. Fabbri A. Chiariello L. Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management.Ann Thorac Surg. 2003; 75: 1998-2006Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar Endovascular intervention and stent grafting are feasible and should be the first option in the treatment of ABFs.