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Ann Thorac Surg 1999;68:1833-1836
© 1999 The Society of Thoracic Surgeons

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Case Reports

A review of aortopulmonary fistulas in aortic dissection

^a Department of Cardiac Surgery, Tor Vergata University, Rome, Italy

Address reprint requests to Dr Chiariello, Department of Cardiac Surgery, Tor Vergata University, European Hospital, Via Portuense 700, 00149 Rome, Italy

	Abstract

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Aortopulmonary fistula is an exceedingly rare complication of aortic dissection. Only 4 cases in acute dissection and 8 cases in the chronic one have been published previously. We report the thirteenth case and a review of the literature. A man underwent an operation for type A aortic dissection. At surgery, a fistula was discovered between the false lumen and the main pulmonary artery, although the preoperative investigations did not suggest such a complication.

	Introduction

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Aortopulmonary fistula is an exceedingly rare evolution of aortic dissection, and is often a postmortem diagnosis. Conversely, chronic aneurysms and giant-cell arteritis of the aorta may develop a fistula into the pulmonary artery more easily because of the chronic nature of these lesions. In spite of that, only four cases of chronic dissecting aneurysms complicated by such fistulas have been reported in the literature, versus nine cases of acute dissections, including this report. The surgical technique is described together with a review of the literature.

A 60-year-old man, with a history of hypertension, experienced an at-rest, sudden onset of precordial pain radiating into the neck and syncope. A first diagnostic evaluation was inconclusive. Four days later, because of recurrence of thoracic pain, computed tomography was performed, disclosing type A (Stanford) acute aortic dissection with dilation of the ascending aorta, a left pleural effusion, and left lower lobe atelectasis (Fig 1). He was then transferred to our hospital. Upon admission, his blood pressure was 100/55 mm Hg and pulses of the lower extremities were weak. Electrocardiography revealed a sinus tachycardia of 130 bpm with no ST- or T-wave changes. Transesophageal echocardiography detected an intimal flap originating 3 cm from the competent aortic valve and extending to the middle arch. Swan-Ganz catheterization (Baxter Healthcare Corp, Irvine, CA) revealed a central venous pressure of 14 mm Hg and a pulmonary pressure of 35/15 mm Hg.

View larger version (118K): [in this window] [in a new window]   Fig 1. Computed tomography of the chest showing aortic dissection. The dissection flap (thin arrow) and the point in which the fistula was found at surgery (large arrow) are indicated. The ascending aorta is dilated. A left pleural effusion and left lower lobe atelectasis are also visible.

After the patient had been cooled down to 30°C, the distal ascending aorta was cross-clamped and the left ventricle vented. The dissecting aneurysm was opened by a longitudinal incision and a single dose of 1200 mL of blood cardioplegia was injected through the coronary ostia by direct cannulation. Many clots were present in the false lumen. This was found to be strictly adherent and to communicate with the distal main pulmonary artery stump through a 1-cm tear occluded by clots. The ruptured pulmonary wall was carefully dissected from the aorta and then repaired using a continuous 5-0 Prolene suture (Ethicon, Somerville, NJ). The ascending aorta was then totally transected and the proximal end was obliterated using the GRF (gelatin-resorcin-formaldehyde) tissue glue and reinforced with an external Teflon (Impra Inc, subsidiary of C.R. Bard, Tempe, AZ) felt circumferential strip. A 28-mm Dacron (C.R. Bard, Haverhill, PA) Hemashield graft (Meadox Medicals Inc, Oakland, NJ) was selected and the proximal anastomosis was performed in a continuous fashion with a 4-0 Prolene suture (Ethicon). Meanwhile, the patient was further cooled down, and at 18°C circulatory arrest was established. The aortic arch was partially replaced with a bevel anastomosis of the graft sewn along its inner curvature with a 4-0 continuous Prolene suture (Ethicon). The dissected aorta had been completely resected till no more false lumen was seen.

Cardiopulmonary bypass was then resumed and air removal performed on the heart with the patient in deep Trendelenburg position. Ventilation was resumed during rewarming. Total circulatory arrest time was 14 minutes; cardiopulmonary bypass time was 194 minutes. The heart returned to sinus rhythm following defibrillation. Weaning from cardiopulmonary bypass was accomplished with a low dose of inotropic support. Histopathology of the aortic wall revealed areas of primary medial degeneration.

The patient was discharged on the nineteenth postoperative day and was seen for follow-up after 2 months. He was found to be asymptomatic with no activity limitations; echocardiography showed a normally functioning vascular implant without any sign of aortopulmonary shunt.

	Comment

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In 1924, Boyd [1] reviewed 4,000 autopsy reports of thoracic aortic aneurysms and found a 4% occurrence of aortopulmonary fistulas; in 1958, Hirst and associates [2] reviewed 505 cases of aortic dissection without a single instance of aortopulmonary fistula. Such a discrepancy is explained by the acute nature of dissection, whereas most atherosclerotic, traumatic, and infectious aneurysms have an indolent time course and more easily predispose to a communication into the adjacent anatomic structures. Despite this, a review of the medical literature showed that more cases of aortopulmonary fistulas have been reported in the setting of acute aortic dissection (< 14 days) rather than in the chronic dissection setting (Table 1).

In most reports [3–13], diagnosis was performed by aortography, which disclosed both the dissection and the left-to-right shunt, often with direct passage of the catheter from the aorta to the pulmonary artery. Cardiac catheterization showed an oxygen saturation step-up from the right ventricle to the pulmonary artery [3, 10–12]. In two cases, this information was obtained simply using a Swan-Ganz catheter (Baxter Healthcare Corp) blood samples [5–8]. Doppler echocardiography [9, 11–14] was successful in diagnosing aortic dissection in 4 of 5 cases, but only Veerbeek and associates [9] and Coselli and associates [12] diagnosed the aortopulmonary fistula using this exam.

In our patient, many clots filled the false lumen, resulting in fistula occlusion, and no left-to-right shunt existed. Doppler echocardiography disclosed just the dissection, while the fistula was an intraoperative discovery. At surgery, a careful exploration of the main pulmonary artery should be performed in all cases of dissection of the ascending aorta, even when the preoperative diagnostic evaluation failed to reveal such a complication.

	References

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1. Boyd L.J. A study of four thousand reported cases of aneurysm of the thoracic aorta. Am J Med Sci 1924;168:654-663.
2. Hirst A.E., Johns V.J., Kime S.W. Dissecting aneurysm of the aorta; a review of 505 cases. Medicine 1958;37:217-279.[Medline]
3. Bory M., Donnarel G., Djiane P., Dor V., Serradimigni A. Dissection aortique rompue dans l’artère pulmunaire chez un malade atteint d’hypercolèsterolémie familiale. Arch Mal du Coeur 1970;8:1197-1204.
4. McCarthy C., Dickson G.H., Besterman E.M.M., Bromley L.L., Thompson A.E. Aortic dissection, with rupture through ductus arteriosus into pulmonary artery. Br Heart J 1972;34:428-430.[Free Full Text]
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8. Large S.R., English T.A.H. Aortopulmonary fistula. J Cardiovasc Surg 1988;29:403-405.[Medline]
9. Veerbeek A.G., van der Wieken L.R., Schuilenburg R.M., Bloemandaal K. Acquired aorto-pulmonary fistula in acute dissection. Eur Heart J 1992;3:713-715.
10. Tate D.A., Parker L.A., Starek P.J.K., Harper J.R. Aortic dissection with aortopulmonary artery fistula. Cathet Cardiovasc Diagn 1993;29:154-156.[Medline]
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13. Massetti M., Babatasi G., Rossi A., et al. Aortopulmonary fistula. Ann Thorac Surg 1995;59:1563-1564.[Abstract/Free Full Text]
14. Atay Y., Can L., Yagdi T., Buket S. Aortopulmonary artery fistula. Tex Heart Inst J 1998;25:72-74.[Medline]

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This Article Abstract Full Text (PDF) 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 Author home page(s): Ruggero De Paulis Luigi Chiariello Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Piciché, M. Articles by Chiariello, L. Search for Related Content PubMed PubMed Citation Articles by Piciché, M. Articles by Chiariello, L.