HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Hratch L. Karamanoukian Marco Ricci Jacob Bergsland Tomas A. Salerno Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by VonFricken, K. Articles by Salerno, T. A. Search for Related Content PubMed PubMed Citation Articles by VonFricken, K. Articles by Salerno, T. A.

Ann Thorac Surg 2000;70:1407-1409
© 2000 The Society of Thoracic Surgeons

---

Case report

Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta

^a Division of Cardiothoracic Surgery, Kaleida Health System-Buffalo General Hospital, SUNY at Buffalo, Buffalo, New York, USA

Address reprints requests to Dr Karamanoukian, Division of Cardiothoracic Surgery, Buffalo General Hospital, 100 High St, Buffalo, NY 142034
e-mail: lisbon5{at}yahoo.com

	Abstract

Top Abstract Introduction Comment References

 
Endovascular stent graft repair of descending thoracic aortic aneurysms has been recently introduced as an alternative to conventional graft replacement of the diseased aorta. As experience with this new technique accumulates, complications may occur. We herein report the case of a patient in whom we observed distal migration with leak of an endovascular stent graft previously inserted in the descending thoracic aorta, associated with an aortobronchial fistula. The urgent surgical treatment undertaken, which consisted of graft replacement of the previously stented aorta, had a fatal outcome.

	Introduction

Top Abstract Introduction Comment References

 
Endovascular stent grafting of the descending thoracic aorta was introduced as a new therapeutic modality in the management of patients with various diseases of the descending thoracic aorta [1, 2]. Although this novel technique has been predominantly employed to treat degenerative and atherosclerotic aneurysms involving the thoracic aorta, it has also been employed in the setting of aortic dissections, posttraumatic aneurysms, and postoperative aortobronchial fistula [2–6]. To date, the majority of adverse outcomes associated with this innovative technique have been mostly related to the implantation of the endovascular stent graft. Complications such as arterial injury, erroneous graft deployment, left upper extremity ischemia, distal embolization, stroke, and paraplegia have been reported [2]. In contrast, only a few long-term complications have been described to date. In this regard, in addition to the relatively common perigraft endoleak caused by delayed recanalization of the aneurysm, aortoesophageal fistula, intestinal ischemia, and stent erosion through the aorta have been reported [2, 7].

The aim of this brief report is to describe the occurrence of distal migration and leak of an endovascular stent graft previously inserted in the descending thoracic aorta in a patient with aneurysmal disease, which was associated with an aorto-bronchial fistula. To our knowledge, such a complication has not been previously reported.

A 72-year-old man with a history of hypertension and peripheral vascular disease underwent resection of a thoracoabdominal aortic aneurysm 4 years before this most recent hospitalization. One and a half years later, he developed progressive aneurysmal dilatation of the proximal descending thoracic aorta involving the proximal anastomosis of the aortic graft and was treated by insertion of an endovascular stent graft in the diseased descending thoracic aorta to obliterate the aneurysm. The device was a custom-made stent graft, which consisted of a self-expanding stent covered by a woven Dacron (C. R. Bard, Haverhill, PA) tube graft. Subsequently, he developed severely symptomatic aortofemoral occlusive disease, for which he underwent aortobifemoral bypass grafting. That was followed by left above-the-knee amputation for gangrene of the left lower extremity and shortly thereafter by left carotid endarterectomy. Several months after carotid endarterectomy the patient came to our institution complaining of several episodes of hemoptysis.

Flexible esophagoscopy was negative, and bronchoscopy revealed a moderate amount of blood in the left main stem bronchus. Computed tomography of the chest with intravenous contrast (Fig 1) disclosed the descending thoracic aortic aneurysm with the proximal end of the stent graft in close proximity to the left lower lobe bronchus. Extravasation of contrast into the perigraft space was also noted, consistent with an endoleak. In addition, compared with a previous chest radiograph obtained at the time of insertion of the endovascular stent graft (Fig 2), a chest radiograph performed on admission revealed that the endovascular device previously inserted in the thoracic aorta had migrated distally and was kinked at its midportion (Fig 3).

View larger version (111K): [in this window] [in a new window]   Fig 1. Computed tomography scan of the chest with intravenous contrast enhancement showing the endovascular stent in the descending aortic aneurysm and endoleak.

View larger version (147K): [in this window] [in a new window]   Fig 2. Chest roentgenogram performed shortly after stent graft placement, demonstrating the endovascular device within the descending thoracic aorta.

View larger version (144K): [in this window] [in a new window]   Fig 3. Chest radiograph performed upon admission, showing migration and kinking of the endovascular stent.

	Comment

Top Abstract Introduction Comment References

 
Aneurysm resection followed by graft interposition is the most widely adopted therapeutic modality in the management of aneurysms involving the descending thoracic aorta [8]. This procedure is associated with substantial morbidity and mortality rates, however, as patients with aortic aneurysms are often elderly and frequently have various comorbid conditions [2, 8]. As a result, endovascular stent graft repair has been recently introduced in an attempt to decrease complications and reduce mortality associated with surgical repair [1, 2].

Mitchell and coworkers [2] recently reported their experience with 103 patients who underwent endovascular stent graft repair of descending thoracic aortic aneurysms. Although complete aneurysm exclusion was accomplished in a considerable proportion of patients (83%), they observed an operative mortality of 9%. These outcomes, however, were reported for a patient population in which 60% of the patients would not have been considered candidates for conventional surgical repair based on coexistent medical conditions and advanced age [2]. In their investigation, they also reported a substantial rate of treatment failure, with as many as 32% of the patients experiencing failure at 30 days after implantation of the stent graft. Importantly, the stent graft-related rate of complications was nearly 50%, with endoleak being the most common early complication in 24% of the patients. In their analysis, which summarizes the largest experience on endovascular stenting of thoracic aneurysms reported in the literature, migration of the stent graft has not been observed.

Of note, in our patient the clinical picture and the radiographic findings were suggestive of distal migration of the endovascular stent in combination with an endoleak. This was clearly demonstrated on computed tomography by the extravasation of contrast between the stent graft itself and the aneurysmal aortic wall (Fig 1). In addition, distal migration of the endovascular device was associated with kinking that, we hypothesize, resulted in erosion of the stent graft through the aneurysm and ultimately into the lung. As a result, blood leaking through the "nonexcluding" endovascular device into the perigraft space (endoleak) could then find its way outside the aorta and into the lung parenchyma. This would explain why the hemoptysis observed in our patient was not as severe as would be expected if the aneurysm communicated directly with the tracheobronchial tree.

	References

Top Abstract Introduction Comment References

 

1. Dake M.D., Miller D.C., Semba C.P., Mitchell R.S., Walker P.J., Liddell R.P. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
2. Dake M.D., Miller D.C., Mitchell R.S., Semba C.P., Moore K.A., Sakai T. The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg 1998;116:689-704.[Abstract/Free Full Text]
3. Mitchell R.S. Endovascular stent graft repair of thoracic aortic aneurysm. Thorac Cardiovasc Surg 1997;9:257-268.
4. Sakakibara Y. Endovascular stent-grafts for traumatic thoracic aortic aneurysm. Radiology 1998;209:283-284.[Free Full Text]
5. Miyata T., Ohara N., Shigematsu H., et al. Endovascular stent graft repair of aorto-pulmonary fistula. J Vasc Surg 1999;29:557-560.[Medline]
6. Karmy-Jones R., Lee C.A., Nicholls S.C., Hoffer E. Management of aortobronchial fistula with an aortic stent-graft. Chest 1999;116:255-257.[Abstract/Free Full Text]
7. Malina M., Brunkwall J., Ivancev K., et al. Late aortic arch perforation by graft-anchoring stent. J Endovasc Surg 1998;5:274-277.[Medline]
8. Svensson L.G., Crawford E.S., Hess K.R., et al. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357-363.[Medline]

This article has been cited by other articles:

				M. Piciche, R. De Paulis, A. Fabbri, and L. Chiariello Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management Ann. Thorac. Surg., June 1, 2003; 75(6): 1998 - 2006. [Abstract] [Full Text] [PDF]

				X. Roques, J. Remes, M.N. Laborde, J.P. Guibaud, F. Rosato, T. MacBride, and E. Baudet Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture Eur. J. Cardiothorac. Surg., January 1, 2003; 23(1): 46 - 49. [Abstract] [Full Text] [PDF]

				B. Leobon, D. Roux, A. Mugniot, H. Rousseau, A. Cerene, Y. Glock, and G. Fournial Endovascular treatment of thoracic aortic fistulas Ann. Thorac. Surg., July 1, 2002; 74(1): 247 - 249. [Abstract] [Full Text] [PDF]

				M. Totaro, F. Miraldi, F. Fanelli, and G. Mazzesi Emergency surgery for retrograde extension of type B dissection after endovascular stent graft repair Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 1057 - 1058. [Abstract] [Full Text] [PDF]

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): Hratch L. Karamanoukian Marco Ricci Jacob Bergsland Tomas A. Salerno Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by VonFricken, K. Articles by Salerno, T. A. Search for Related Content PubMed PubMed Citation Articles by VonFricken, K. Articles by Salerno, T. A.