Ann Thorac Surg 1997;63:1158-1160
© 1997 The Society of Thoracic Surgeons
Case Report
Repair of Aortobronchial Fistula Using Extraanatomic Grafts and Hypothermic Arrest
W. Andrew Lawrence, BS,
John A. Kern, MD,
Curtis G. Tribble, MD
Division of Thoracic Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
Accepted for publication November 2, 1996.
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Abstract
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Aortobronchial fistula is a rare complication of thoracic aortic operations that is fatal if not promptly diagnosed and repaired. The case of a 23-year-old woman who presented with an aortobronchial fistula after three previous left thoracotomies for thoracic aortic procedures is described.
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Introduction
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Aortobronchial fistula is a rarely encountered complication after thoracic aortic operations [1–4]. Untreated, this lesion has a mortality approaching 100% secondary to exsanguinating hemoptysis [1, 3–5]. The surgical management of aortobronchial fistula is by no means well defined. However, early diagnosis and operative intervention are essential for survival. We report a case of an aortobronchial fistula 8 years after a third repair of an aortic coarctation, which we repaired through a median sternotomy using an extraanatomic aortic bypass graft, cardiopulmonary bypass, and hypothermic total circulatory arrest.
A 23-year-old woman with a history of three previous left thoracotomies and aortic coarctation repairs presented with massive hemoptysis. Her most recent repair was 8 years before this admission and involved the placement of a 16-mm knitted Dacron interposition graft. Admission chest radiographs revealed infiltrates of the left lung. A rapidly conducted computed tomographic scan demonstrated a pseudoaneurysm of the distal aortic arch and proximal descending thoracic aorta (Fig 1
), as well as massive amounts of blood in the mediastinum, left lung, and pleural space. An aortobronchial-pleural fistula was suspected, and the patient was taken directly to the operating room.
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Fig 1. . Computer regeneration of a computed tomogram demonstrating a pseudoaneurysm of the distal aortic arch and proximal descending thoracic aorta.
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After selective endobronchial intubation with a double-lumen endotracheal tube, a median sternotomy incision was made. Exploration of the mediastinum revealed significant displacement of the heart by blood in the left hemithorax. The midline incision was extended to include an upper midline laparotomy, and a 14-mm Dacron Hemashield (Meadox Medicals Inc, Oakland, NJ) extraanatomic bypass graft was placed from the ascending aorta to the intraabdominal supraceliac aorta using a partial occlusion clamp for both proximal and distal anastomoses.
The patient was then cannulated in the standard fashion and placed on cardiopulmonary bypass. On bypass, the left pleural space was entered, revealing dense adhesions and a massive amount of old and fresh blood. Dissection revealed a pseudoaneurysm of the distal aortic arch and takeoff of the left subclavian artery, which was noted to be in communication with the apex of the lung and the left main bronchus. With the heart decompressed and the lung not ventilated, we easily visualized the entire descending thoracic aorta. To gain proximal control and exclude the aneurysm, we needed to divide and oversew the aorta between the left common carotid and subclavian arteries. Because of the proximity of the aneurysm to the left carotid artery, we were unable to clamp distal to this vessel. Thus, we placed a superior vena caval cannula for retrograde cerebral perfusion and an aortic root cannula for cardioplegia, cooled the patient to 16°C, and instituted a period of circulatory arrest. During 11 minutes of circulatory arrest, the aorta was divided and oversewn just distal to the left common carotid artery. Retrograde cerebral perfusion and antegrade blood cardioplegia were used during this brief period. Back on bypass, the pseudoaneurysm and old interposition graft were removed and the distal left subclavian artery and distal midthoracic aorta oversewn. The aortic and subclavian stumps were not covered due to a lack of adequate tissue.
To revascularize the left upper extremity, a 6-mm Dacron Hemashield graft was placed between the 14-mm extraanatomic aortic graft and left axillary artery. This graft exited the chest through the second intercostal space, passed beneath the pectoralis major muscle, and was anastomosed to the left axillary artery via an infraclavicular incision. The trachea and left bronchus were carefully examined, and no discrete defect was identified.
The patient was weaned from bypass and taken to the postoperative unit, where she was extubated 3 days later. She recovered without complication and was discharged 10 days later, neurologically intact.
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Comment
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Pseudoaneurysm formation as a consequence of thoracic aortic aneurysm repair is being increasingly reported [6]. Fistulous communication between the pseudoaneurysm and the tracheobronchial tree or pulmonary parenchyma can result in exsanguinating hemoptysis and is a condition that carries nearly uniform mortality if diagnosis and surgical intervention is delayed [1, 3–5, 7]. In a recent review of 63 cases, the correct preoperative diagnosis was made in only 54% of cases [3]. As the diagnosis of this lesion is challenging, it is essential that a high index of suspicion be maintained for patients who present with hemoptysis and have a past history of thoracic vascular operations [5–7].
Appropriate management of aortobronchial fistula includes early diagnosis and immediate repair. Various surgical approaches have been implemented, but constant features include control of the airway, maintenance of distal perfusion, aortic repair or replacement, and repair of the pulmonary defect usually through a left thoracotomy [2, 8]. Although repair has been performed with simple aortic cross-clamping only, partial or complete cardiopulmonary bypass and extraanatomic bypass have also been used [3, 8].
Several aspects of the management of our patient are unusual. Anticipating the need for total cardiopulmonary bypass, we approached the lesion through a median sternotomy as opposed to the almost uniformly reported left thoracotomy. We thought a fourth thoracotomy incision in this setting would result in fatal exsanguination before we could achieve proximal and distal aortic control. Through a sternotomy we were able to perform an extraanatomic aortic bypass and maintain both cerebral and distal perfusion while we dissected out the left side of the chest. Continuing hemorrhage during our left chest dissection was simply aspirated into the cardiopulmonary bypass circuit. The use of an extraanatomic bypass from ascending aorta to supraceliac abdominal aorta prior to exploration of the pleural cavity ensured adequate distal perfusion despite subsequent transection and oversewing of the distal aortic arch and descending aorta (Fig 2). The brief period of hypothermic circulatory arrest was also facilitated through a sternotomy because retrograde cerebral perfusion and optimal cardiac protection were easily carried out. The implementation of cold circulatory arrest with retrograde cerebral perfusion enabled us to cross-clamp the aorta proximally such that the aortic resection could be completed without compromising neurologic or cardiac function. We feared that dissection of the descending thoracic aortic graft and left pulmonary hilum would be limited through a sternotomy, but with the heart decompressed on bypass these areas were very easily seen. Revascularization of the left upper extremity by grafting from the extraanatomic aortic graft provided adequate perfusion and required no proximal anastomosis to a native vessel.
In summary, we present an alternative surgical approach to the repair of an unusual aortobronchial fistula. This method involved a median sternotomy as opposed to the conventional left thoracotomy, extraanatomic grafts for distal aortic and left upper extremity perfusion, total cardiopulmonary bypass, and hypothermic circulatory arrest.
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Footnotes
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Address reprint requests to Dr Tribble, Division of Thoracic Cardiovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Box 181, Charlottesville, VA 22908.
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References
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- Ishizaki Y, Tada Y, Takagi A, et al. Aortobronchial fistula after an aortic operation. Ann Thorac Surg 1990;50:975–7.[Abstract/Free Full Text]
- Paull DE, Keagy BA. Management of aortobronchial fistula with graft replacement and omentopexy. Ann Thorac Surg 1990;50:972–4.[Abstract/Free Full Text]
- MacIntosh EL, Parrott JCW, Unruh HW. Fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg 1991;51:515–9.[Abstract/Free Full Text]
- Garniek A, Morag B, Schmahmann S, Rubinstein ZJ. Aortobronchial fistula as a complication of surgery for correction of congenital aortic anomalies. Radiology 1990;175:347–8.[Abstract/Free Full Text]
- Demeter SL, Cordasco EM. Aortobronchial fistula: keys to successful management. Angiology 1980;31:431–5.
- Miller JP, Cammarata SK. Massive hemoptysis 17 years after repair of aortic coarctation. Chest 1994;105:1249–50.[Medline]
- Caes F, Taeymans Y, Van Nooten G. Aortobronchial fistula: a late complication of coarctation repair by patch angioplasty. Thorac Cardiovasc Surg 1993;41:80–2.[Medline]
- Graeber GM, Farrell BG, Neville JF, Parker FB. Successful diagnosis and management of fistulas between the aorta and the tracheobronchial tree. Ann Thorac Surg 1980;29:555–61.[Abstract/Free Full Text]
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Abstract
Introduction
