Ann Thorac Surg 2000;69:666-667
© 2000 The Society of Thoracic Surgeons
Correspondence
Aortobronchial fistula after coarctation repair
Alper Toker, MDa,
Vural Özcan, MDa,
Emin Tireli, MDa
a Department of Thoracic and Cardiovascular Surgery, University of Istanbul, Istanbul Medical School, Çapa Istanbul, Inonu Cad. Yildiz sok., STFA bloklari B/6 No 13 Kozyatagi 81090, Istanbul, Turkey
e-mail: aetoker{at}superonline.com
To the Editor
We read the case report about a 34-year-old man who had development of an aortobronchial fistula 17 years after patch aortoplasty for correction of aortic coarctation and 5 years afterblunt chest trauma, presented by Milano and colleagues [1]. The patient was successfully treated.
We operated on an aortobronchial fistula patient on December 30, 1997. The patient was a 17-year-old boy who had patch aortoplasty for correction of aortic coarctation 10 years earlier. He had episodes of hemoptysis lasting for 4 days. The patient was hemodynamically stable; routine laboratory findings revealed moderate anemia. Chest roentgenogram revealed enlargement of descending aorta, and the pseudoaneurysm of the descending aorta was confirmed by chest computed tomography (Fig 1). Digital substraction angiography (DSA) was unable to show the fistula, but the pseudoaneurysm could easily be recognized (Fig 2). Because the patient had no other pulmonary pathology to explain hemoptysis, he was evaluated as having an aortobronchial fistula. Bronchoscopic examination of the bronchial tree was done in the operating room before selective intubation to exclude an undiagnosed endobronchial lesion, and no other pathology was present in the main bronchial system. Resection of the sac and aorta, and graft interposition, was performed under simple aortic cross-clamping. The wedge resection of the left upper lobe superior segment was done after clamping the subclavian artery, arch of aorta distal to the left carotid artery, and descending aorta. The patient was discharged on postoperative day 11 with the complication of left recurrent nerve paralysis.
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Fig 1. Computerized tomographic scan of the chest revealing the pseudoaneurysm at the level of aortic patch.
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We would like to present our opinion about bronchoscopic and angiographic examinations. The authors mentioned that "the presence of ABF was confirmed by chest magnetic resonance imaging, even though a fistulous connection between the pseudoaneurysm and the tracheobronchial tree could not be visualized" [1]. This was not a clear explanation. How could the authors confirm ABF diagnosis without visualizing the fistula? The only diagnostic procedure in the detection of the site of entrance of fistula into bronchial tree is bronchoscopy [2]. But this procedure may be fatal in the case of accidentally dislodging the cloth acting as a stopcock of the fistula [3]. We performed the bronchoscopic examination on the table before the operation and confirmed that no other pathology in the main bronchial system was present. Did the authors consider bronchoscopy during preoperative work up? Angiographic examination was not mentioned. Angiographic examination, performed in our case, was not succesful in confirming fistulous connection like other cases presented up to now, because fistulous connections were covered with blood clots [2, 4]. We believe patients presenting with hemoptysis deserve further evaluation. Bronchoscopic and angiographic examinations were not mentioned in the paper.
Do the authors suggest that: If the computed tomography confirmed an aortic pathology and secondary changes in the adjacent lung (assuming the patient had an aortic surgical procedure), the patient should be evaluated as having an aortobronchial fistula in case of hemoptysis, and no further diagnostic procedure is needed?
References
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Milano A., De Carlo M., Mussi A., Falashi F., Bortolotti U. Aortobronchial fistula after coarctation repair and blunt chest trauma. Ann Thorac Surg 1999;67:539-542.[Abstract/Free Full Text]
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Wood A.E., Stevenson H.M., Cleland J. Aortobronchial fistula. Ann Thorac Surg 1984;38:402-405.[Abstract/Free Full Text]
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Ishizacki Y., Tada Y., Tagaki A., et al. Aortobronchial fistula after aortic operation. Ann Thorac Surg 1990;50:975-977.[Abstract/Free Full Text]
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Graeber G.M., Farrel B.G., Neville J.F., Jr, Parker F.B., Jr Succesful diagnosis and management of fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg 1980;29:555-561.[Abstract/Free Full Text]
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- Aldo Milano, Marco De Carlo, and Uberto Bortolotti
Ann. Thorac. Surg. 2000 69: 667.
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