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Ann Thorac Surg 2000;69:667
© 2000 The Society of Thoracic Surgeons
a U. O. di Cardiochirurgia, Ospedale Cisanello, Universita di Pisa, Via Paradisa, 2, 56124 Pisa, Italy
To the Editor
We wish to thank Dr Toker and coworkers for the interesting observations on our case report about the treatment of a posttraumatic aortobronchial fistula in a 34-year-old man who had undergone patch aortoplasty for aortic coarctation 17 years before. Dr Toker and colleagues report a 17-year-old boy who developed an aortobronchial fistula 7 years after coarctation repair. They decided to perform bronchoscopy in the operating room before intubation to rule out an undiagnosed endobronchial lesion before operating on the aorta.
Concerning the specific questions posed by Dr Toker and colleagues, we have to add some information that we did not include in the report for the sake of brevity. First, bronchoscopy was performed, as should be done in these patients, provided that they are hemodynamically stable. However, bronchoscopy was not diagnostic because the presence of abundant fresh blood in the left superior bronchus prompted interruption of the exam in order to avoid accidental displacement of a thrombus obstructing the bronchial opening of the fistula. Second, angiography had also been scheduled for the patient before operation, but a new severe episode of hemoptysis urged immediate operation. Finally, chest computed tomographic (CT) scan and magnetic resonance imaging (MRI), although not showing a continuous communication between the aorta and the bronchial tree, were highly suggestive of the presence of an aortobronchial fistula by showing an aortic pseudoaneurysm at the aortic patch level and a hematoma in the adjacent left superior pulmonary lobe.
In conclusion, we do not suggest that if CT and/or MRI confirm an aortic pathology and secondary changes in the adjacent lung in a patient with hemoptysis and a history of aortic surgery, no further diagnostic procedure is needed. Bronchoscopy and angiography should be performed if diagnosis is not sure, unless hemodynamic instability prompts urgent operation. However, it should be pointed out that these exams are often nondiagnostic and potentially dangerous in such patients, and they rarely affect the therapeutic approach when chest CT and MRI are highly suggestive of the presence of an aortobronchial fistula.
Related Article
Ann. Thorac. Surg. 2000 69: 666-667.
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