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Ann Thorac Surg 1995;60:1797-1798
© 1995 The Society of Thoracic Surgeons

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Case Report

Giant Bronchoesophageal Fistula: A Rare Complication of Bronchial Artery Embolization

Division of Thoracic Surgery, Veterans General Hospital-Kaohsiung, Kaohsiung, Taiwan

Accepted for publication June 9, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Bronchoesophageal fistulas after bronchial artery embolization are rare. In the previous literature only 2 cases were recorded. Here we report treatment of a giant bronchoesophageal fistula on both the left and right bronchus. Our surgical treatment included fistula exclusion by esophageal diversion, and esophageal reconstruction was made by retrosternal stomach. The result was good, and the patient made a satisfactory recovery.

	Introduction

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Bronchial artery embolization (BAE) is recommended as useful treatment for massive pulmonary hemoptysis [1–3]. It can be lifesaving for patients with poor pulmonary function. Yet the potential risks include spinal cord injuries, embolization of other vessels, and damage of bronchial tree and esophagus [4–9]. Broncho-esophageal fistula is a rare complication of BAE. Helenon and associates [6] reported 1 case in 1977, and Munk and colleagues [8] had another 1 in 1990.

A 35-year-old man was admitted to another hospital due to frequent hemoptysis. He had no remarkable medical history except chronic productive cough with bloody tinged sputum in recent years. Chest roentgenogram showed volume reduction in right lung with fibrothorax and fibrocalcified lesions over the right lower lung field. Sputum smear for tuberculosis bacilli was negative. Fiberbronchoscopy failed to demonstrate active bleeding or cause of bleeding. Bronchial angiogram could not show the abnormal vascularity. Nevertheless, BAE was performed with gelatin sponge (Ferrosan, Denmark) cut into fine pieces. Immediately after the procedure, severe precordial burning was noted. Odynophagia and hoarseness developed gradually. Two weeks after BAE, the patient suffered from sudden onset of choking, dyspnea, and spiking fever. Supportive treatment was given but in vain.

The patient was transferred to our hospital 3 weeks after BAE. On his arrival, he was in septic shock condition with bilateral pneumonia. Emergent computed tomographic scan of the chest was done at our hospital, and revealed fibrocalcified lesions over the right pleura with volume reduction of the right lung in favor of chronic inflammatory and fibrotic change. Diffuse alveolar patterns over the bilateral upper lung fields was noted. Ill-defined esophageal wall between the esophagus and left main bronchus was observed. Esophagoscopic examination discovered a giant fistula leading to the left main bronchus. Bronchoscopy revealed paralysis of the left vocal cord and a large bronchoesophageal fistula. The posterior wall of the left main bronchus directly communicated with the esophagus, and the distal end was almost obliterated by necrotic and swelling bronchial mucosa. There was a tiny fistula over the right main bronchus.

Emergent esophageal diversion as described by Utley and colleagues in 1978 [10] was performed. The operation included end-cervical esophagostomy, drainage gastrostomy, and feeding jejunostomy. After operation, the patient was admitted to the intensive care unit. With proper antibiotics, sepsis was under control. One month later, because of several episodes of gastric reflux, a right-sided thoracotomy was done to resect the distal esophagus. We did not approach the esophagus proximal to the fistula due to dense adhesion over the right upper pleural cavity. The esophagus below the fistula was resected. One intercostal muscle flap was sutured to the resection line to reinforce healing process.

Two months after admission, the patient received esophageal reconstruction using stomach through the retrosternal route. He underwent an uneventful postoperative course and subsequently regained his normal oral intake. At present the patient has been followed up for 2 years; the posterior wall of the left main bronchus, which formed the wall of esophagus, has not caused any complaint.

	Comment

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The true incidence of bronchial or esophageal injuries after BAE is unknown, because no systematic endoscopic evaluation has been done. This complication may occur more often than we think. Embolic agents such as Gelform, absolute alcohol, Ivalon, and isobutyl-2-cyanoacrylate have been reported to cause serious complications [6–9]. In this case, although the patient received BAE at another hospital and the initial post-BAE endoscopic change was not available, the direct relation between BAE and bronchoesophageal fistula is clear.

Several mechanisms of post-BAE ischemia have been advocated: embolization of the blood supply to proximal bronchus, occlusion of the capillary bed by small embolic particles, reflux of the embolic agent into adjacent vessels, and incorporation and agitation of the bleeding patient during BAE [5–8]. Bronchial artery embolization can be considered a relatively safe procedure only when it is handled by an experienced surgeon. Injuries to bronchus and esophagus are quite rare [6–9]. There have been reports of bronchial wall necrosis and stenosis [7, 9]. In the available literature only 2 cases of BEF have been reported as complications of BAE: Helenon and associates [6] first reported 1 case in 1977, followed by Munk and colleagues [8] in 1990 with another 1 case.

In our case, direct repair of the fistula was impossible due to massive necrosis of the bronchial wall. We followed the procedure of esophageal diversion for giant tracheoesophageal fistula reported by Utley and colleagues [10]. A conservative procedure with exclusion of the fistula stands a better chance of controlling infection. Esophageal reconstruction with stomach then can be performed accordingly.

We conclude that the radiologist should be aware of the possible bronchial and esophageal injuries after BAE. Post-BAE endoscopy may be considered as a routine examination. Bronchoesophageal fistulas will be seen more frequently as an increasing number of BAEs are performed. We hope our case report can serve as a reminder to others.

	Footnotes

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Address reprint requests to Dr Hsu, Division of Thoracic Surgery, Veterans General Hospital-Kaohsiung, 386 Tachung 1st Road, Kaohsiung, Taiwan 813.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977;122:33–7.[Abstract]
2. Uflacker R, Kaemmerer A, Neves C, Picon PD. Management of massive hemoptysis by bronchial artery embolization. Radiology 1983;146:627–34.[Abstract/Free Full Text]
3. Rabkin JE, Astafjev VI, Gothman LN, Grigorjev YG. Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 1987;163:361–5.[Abstract/Free Full Text]
4. DiChiro G. Unintentional spinal cord arteriography: a warning. Radiology 1974;112:231–3.[Medline]
5. Lemoigne F, Rampal P, Petersen R. Fatal ischemic colitis after bronchial artery embolization. Nouv Presse Med 1983;12:2056–7.
6. Helenon CH, Chatel A, Bigot JM, Brocard H. Left esophagobronchial fistula following bronchial artery embolization. Nouv Presse Med 1977;6:4209.[Medline]
7. Ivanick MJ, Thorwarth W, Donohue J, Mandell V, Delany D, Jaques PF. Infarction of the left main stem bronchus: a complication of bronchial artery embolization. AJR 1983;141:535–7.[Free Full Text]
8. Munk PL, Morris DC, Nelems B. Left main bronchial-esophageal fistula: a complication of bronchial artery embolization. Cardiovasc Intervent Radiol 1990;13:95–7.[Medline]
9. Girard P, Baldeyrou P, Lemoine G, Grunewald D. Left main-stem bronchial stenosis complicating bronchial embolization. Chest 1990;97:1246–8.[Abstract/Free Full Text]
10. Utley JE, Dillon ML, Todd EP, Griffen WO, Zeok JV. Giant tracheoesophageal fistula: management by esophageal diversion. J Thorac Cardiovasc Surg 1978;75:373–7.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hsu, H.-K. Articles by Su, J.-M. Search for Related Content PubMed PubMed Citation Articles by Hsu, H.-K. Articles by Su, J.-M.