Ann Thorac Surg 2000;70:964-966
© 2000 The Society of Thoracic Surgeons
Case report
Aortobronchial fistula late after transverse arch replacement
Minoru Ono, MDa,
Shinichi Takamoto, MDa,
Motohiro Kawauchi, MDa,
Jun Egami, MDa,
Yutaka Kotsuka, MDa
a Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan
Address reprint requests to Dr Ono, Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 113-8655, Japan
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Abstract
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We report an unusual case of aortobronchial fistula late after transverse arch replacement caused by the remnant of a temporary bypass near the ascending aorta. In reconstructive surgery of the ascending aorta, antegrade perfusion is preferably performed through a side branch after completion of the distal anastomosis by some surgeons. This report suggests possible risk of a serious late complication unless the side branch is placed and tailored properly.
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Introduction
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An aortobronchial fistula (ABF) is a rare late complication in thoracic aortic operations. It may cause lethal massive hemoptysis if left untreated, and an expeditious surgical intervention is essential. We herein report a successful surgical case of an unusual postoperative ABF to the right lung. We also review the literature, and discuss its etiology, symptoms, treatment, and results.
A 70-year-old man with a 1-month history of hemoptysis was admitted to another hospital with massive hemoptysis and loss of consciousness. He was not on anticoagulant or antiaggregatory therapy. A chest radiograph showed an abnormal shadow in the right upper lung. Massive bleeding occurred from inside the endotracheal tube during computed tomographic scan. Transverse arch replacement for an arch aneurysm had been performed 8 years before by a modification of Larmi’s procedure [1] without an extracorporeal circulation. Briefly, a bifurcated woven Dacron graft was anastomosed from the ascending aorta to the arch vessels. The aortic arch was then replaced with another woven Dacron graft, maintaining distal perfusion by a temporary bypass established between the bifurcated graft and the left common iliac artery. Finally, the temporary graft was closed at both ends and removed (Fig 1). The patient was referred to our hospital with a strong suspicion of ABF. Extravasation from the remnant of the temporary bypass was demonstrated by digital subtraction aortography (Fig 2). An emergency operation was performed using deep hypothermia and circulatory arrest with antegrade and retrograde brain perfusion. A fistula was formed between the right upper lobe and the remainder of the temporary graft without a clear evidence of abscess. Complete removal of the previous bifurcated graft with en bloc wedge resection of the right upper lobe was performed. The ascending aorta was replaced with a new woven Dacron graft, to which the two arch vessels were reattached. The remaining pleura and the aneurysmal wall were used to insulate the graft from the lung. The patient showed no sign of infection 18 months postoperatively.
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Fig 2. Digital subtraction angiogram taken just before the operation (left anterior oblique projection). Extravasation from the remnant of the temporary bypass graft is shown by an arrow.
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Comment
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Postoperative ABF is a rare but serious late complication encountered after thoracic aortic operations. Without appropriate surgical treatment, it may result in exsanguinating hemoptysis and death. Fifty episodes in 46 cases have been reported in the literature, including ours. Thirty-two patients were male, and the patients’ ages ranged from 5 to 78 years (mean 41.3 years). The most common preceding operation (18 cases) was repair of coarctation, of which, prosthetic material was used in 13. The second most common was graft repair of atherosclerotic descending aortic aneurysm in 14 cases. Also carried out were repair of traumatic descending aortic aneurysm in 5, patent ductus arteriosus in 4, aortic dissection in 2, and valvular heart disease in 2 patients. Fistula formation is overwhelmingly dominant in the left bronchoalveolar tree (89%). Only 5 patients presented with a fistula to the right lung. This is attributable to the direct contact of the descending thoracic aorta with the left lung. The average interval between the previous operation and the onset of symptoms was 89 months (3 weeks to 23 years). The duration of hemoptysis was less than 1 month in two-thirds of patients. Massive hemoptysis was encountered in more than half, and cardiopulmonary resuscitation was necessary in 6 patients. Several factors are considered to be involved in the occurrence of ABF. In 73% of cases, pseudoaneurysm was found at the fistula. Psuedoaneurysm may have been a result of a local infection, or developed due to mechanical stress to the anastomosis or graft wall, causing tight adherence and pressure necrosis of the bronchopulmonary tissue [2]. The presence of local infection was proved only in 25% of 28 cases with information available. In 39 patients, 43 operations were performed with five early deaths. Exsanguinating hemoptysis prevented surgical intervention in 6 patients. Therefore, a total mortality rate was 22%. Prosthetic graft repair was performed in 21 episodes, and simple resuture of failed anastomosis in 9. An extraanatomical bypass from the ascending aorta, with interruption of blood flow at the distal arch, was constructed in five cases in which local infection was strongly suspected or proved. Wrapping with an omental [3, 4] or a muscular flap [2, 5] was performed in some cases. For the pulmonary end of the fistula, direct closure was performed in 13 cases, and lung resection in nine, ranging from wedge to pneumonectomy.
To our knowledge, there were only two cases in which the remnant of the temporary bypass caused an ABF [4, 5]. The remnants were located on the descending aorta in both cases. Ishizaki and associates [4] abandoned the descending aorta for a temporary bypass placement after this event. In the present case, bilateral thoracic cavities were entered through the mediastinum and left open during the previous operation. Slow pressure necrosis of the lung caused by a direct contact with the graft remnant through the pleural window and the resultant microinfection may have produced the unusual communication.
Recently, a branched graft with a perfusion limb has been also commercially available and used for the reconstruction of ascending or arch aortic disease. If the remnant of this limb is left unwrapped, direct contact with the lung may occur when one of pleural spaces is entered. We thus emphasize that great care must be taken to place and tailor a side limb properly, and cover its cut end with the aneurysmal wall or other surrounding tissue.
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References
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Larmi T.K., Karkola P. Resection of aneurysm of the transverse aortic arch. New simplified technique using permanent bypass graft and extracorporeal circulation. J Thorac Cardiovasc Surg 1974;68:70-75.[Medline]
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MacIntosh E.L., Parrott J.C., Unruh H.W. Fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg 1991;51:515-519.[Abstract/Free Full Text]
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Paull D.E., Keagy B.A. Management of aortobronchial fistula with graft replacement and omentopexy. Ann Thorac Surg 1990;50:972-974.[Abstract/Free Full Text]
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Ishizaki Y., Tada Y., Takagi A., et al. Aortobronchial fistula after an aortic operation. Ann Thorac Surg 1990;50:975-977.[Abstract/Free Full Text]
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Graeber G.M., Farrell B.G., Neville J.F., Jr, Parker F.B., Jr Successful diagnosis and management of fistulas between the aorta and the tracheobronchial tree. Ann Thorac Surg 1980;29:555-561.[Abstract/Free Full Text]
Accepted for publication December 29, 1999.
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Abstract
Introduction
