Ann Thorac Surg 2010;89:275-277. doi:10.1016/j.athoracsur.2009.06.035
© 2010 The Society of Thoracic Surgeons
Case Reports
Two-Stage Safe Repair of Aortobronchial Fistula
Paola De Rango, MDa,b,
Anthony L. Estrera, MDb,*,
Ali Azizzadeh, MDb,
Kourosh Keyhani, MDb,
Hazim J. Safi, MDb
a Division of Vascular and Endovascular Surgery, University of Perugia, Ospedale S. Maria della Misericordia, Perugia, Italy
b Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School, Houston, Texas
Accepted for publication June 4, 2009.
* Address correspondence to Dr Estrera, 6400 Fannin St, Ste 2850, Houston, TX 77030 (Email: anthony.l.estrera{at}uth.tmc.edu).
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Abstract
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Aortobronchial fistulas are a rare and frequently misdiagnosed cause of massive hemoptysis, which is often fatal. Aortic stent grafts now allow for a safer emergency repair. However, there is a high (40% to 50%) recurrence risk, with a high fatality rate. A patient with an aortobronchial fistula due to a ruptured thoracic aortic aneurysm underwent a two-stage repair. An aortic stent graft was deployed as an emergency, and a second surgical durable repair was performed 4 months later. The patient recovered well. The best management of aortobronchial fistula may be emergency use of stent graft, followed by a delayed durable open repair when the patient has achieved stability.
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Introduction
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During the last decade, aortic stent grafts have been used to manage aortic ruptures, including those occurring into the airways with aortobronchial fistulas (ABF). However, the durability of the procedure remains unknown. We describe a patient with a descending thoracic aneurysm (DTAA) rupture who presented with an ABF for which a two-stage approach was planned. Because the durability of stent graft placement in contaminated fields such as in ABF remains questionable, we suggest that aortic stent grafts may be useful in the emergency setting as a bridge to a subsequent, more durable treatment.
The patient was a 56-year-old man who was admitted with a 2-week history of worsening hemoptysis, chest pain, cough, fever, and fatigue. His medical history was significant for smoking and a DTAA. The initial hematocrit at admission was 24%, and the hemoglobin level was 8 mg/dL.
Chest roentgenogram revealed a 4-cm left upper mass indistinguishable from the mediastinum, with widening of the mediastinum. A computed tomography (CT) scan with contrast demonstrated a 7-cm proximal DTAA starting at the distal transverse arch adjacent to the left subclavian artery origin with surrounding hematoma and an adjacent consolidation of the left upper lobe, with possible communication of the aneurysm with the lung (Fig 1). A 5-cm saccular aneurysm was noted at the diaphragmatic hiatus.
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Fig 1. Contrast-enhanced computed tomography scan shows an eccentric aortic aneurysm on the distal arch encapsulated with an infiltrative mass (arrow) in the superior lobe of the left lung, suggestive of fistula communication.
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During the evaluation, an episode of massive hemoptysis occurred, requiring intubation for airway control. There was significant soilage of both lungs by blood with notable hypoxemia, and a partial pressure of oxygen of 53 mm Hg despite fraction of inspired oxygen of 100%.
Because of instability and severe respiratory compromise, the first of a two-stage approach was performed. The patient was transferred to the endovascular operating suite and the proximal DTAA associated with the ABF was immediately repaired using 2 (37 x 16 cm; 40 x 10 cm) TAG devices (W. L. Gore and Associates, Flagstaff, AZ) with coverage of the left subclavian artery ostium (Fig 2). A carotid-subclavian bypass was also performed. The patient recovered, was placed on oral antibiotics, and was discharged on postoperative day 8.
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Fig 2. (A) Diagnostic and (B) completion angiograms demonstrate successful exclusion of the aortobronchial fistula.
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After 4 months with aggressive physical therapy and respiratory rehabilitation, the patient returned for the anticipated second-stage open elective repair of the DTAA. The CT scan revealed no regression in the size of the aneurysm. There was productive cough of blood-tinged sputum. Fiberoptic bronchoscopy revealed no obvious fistula, with blood arising from the distal upper airway on the left side.
Open surgical repair was undertaken. The patient was intubated, and a left modified thoracoabdominal incision was used to expose the entire descending thoracic and upper abdominal aorta. The adjunct of cerebrospinal fluid drainage was used. Owing to the proximity of the proximal aneurysm to the distal arch and the need to explant the previously placed thoracic endograft, cardiopulmonary bypass with profound hypothermic circulatory arrest was used.
The previously placed thoracic stent grafts were removed without difficulty and the perforation in the aortic wall that had been sealed by the stent graft was identified. Exploration revealed extensive adherence of the thoracic aorta to the left upper lobe, and a fistula was evident (Fig 3) from the inside of the aneurysm wall in the lung parenchyma of the left upper lobe. However, there was a large well-functioning left upper lung, not damaged by the fistula, therefore lobectomy was not performed. Leaving the expanding parenchyma in place could be helpful for postoperative recovery.
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Fig 3. Operative field shows descending thoracic aortic aneurysm attached to the left lung. In the box: at the opening of the aortic aneurysm the stent graft was easily removed. A fistula (arrow) extending into left upper lobe was visualized from the inside of the aortic wall.
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A woven Dacron graft (DuPont, Wilmington, DE) was used for replacement of the thoracic aorta with the proximal anastomosis at the distal arch, just below the level of left subclavian artery (that was not further approached at this time), and the distal anastomosis was completed with reattachment of the celiac axis. The previous carotid-subclavian bypass graft was left in place. To address the fistula, omentum was harvested as a pedicled graft and used to cover the thoracoabdominal graft and seal the left upper lobe fistula.
The patient tolerated the second procedure and awoke neurologically intact, without further complications or respiratory complaints. No more bloody sputum episodes occurred postoperatively. He was discharged with 6 weeks of intravenous antibiotics and life-long oral antibiotics.
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Comment
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Most cases of ABF are secondary and detected in patients with previous thoracic or cardiac operations, therefore requiring a redo emergency aortic procedure. Despite the improved results with traditional open repair in recent years [1, 2], surgical mortality and morbidity are still a major concern due to the complexity of the procedure, emergency conditions, contaminated field, and the difficulties of exposure in the reoperative setting. Emergency perioperative mortality ranges from 16% to 24%, with a mortality as high as 41% in secondary ABF [1, 3].
Thoracic stent graft repair may be an alternative for aortic rupture into the airways. Although most of the recent studies have reported no perioperative death, stroke, or paraplegia, these primarily have been reports of single patients or small series, with the largest including 8 patients [3, 4]. In a recent review of ABF, perioperative mortality was 0% in the stent graft vs 16% in the open surgical group [1].
Advantages of stent graft repair include the avoidance of the stress of an open repair with anticoagulation for cardiopulmonary bypass, lessening the risk for bleeding. The primary concern remains durability. Stent grafts may migrate, develop endoleaks, or lead to bronchial wall erosion with recurrent ABF. Although these complications may occur less frequently with later-generation devices, recurrences requiring reintervention have been reported in 40% of patients, with an associated 30% mortality.
Recurrence of ABF is likely related to the deployment of a stent graft in a potentially infected field adjacent to a vulnerable aortic wall susceptible even to the small forces generated by endotension. Furthermore, rushed aortic evaluation in the emergency setting may lead to imperfect stent graft sizing [5]. With open repair, extensive débridement, graft replacement of the aorta, and pedicled flap coverage are possible, none of which can be achieved with endovascular repair.
In conclusion, the natural history of ABF is lethal hemorrhage without prompt treatment. The mortality of open surgical repair remains high when performed in the emergency setting. Stent graft repair decreases the perioperative risk, allowing for recovery from the initial insult of bleeding and rupture; however, this is fraught with frequent recurrences associated with significant mortality. A good treatment strategy is the staged approach using a thoracic stent graft to control initial bleeding and prevent respiratory soilage, followed later by a more definitive open thoracic surgical repair.
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Acknowledgments
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G. Ken Goodrick is acknowledged for his editing help and Chris Akers for the figures.
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References
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- Piciche M, De Paulis R, Fabbri A, et al. Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management Ann Thorac Surg 2003;75:1998-2006.[Abstract/Free Full Text]
- Eren E, Keles C, Toker ME, et al. Surgical treatment of aortobronchial and aortoesophageal fistulae due to thoracic aortic aneurysm Texas Heart Inst J 2005;32:522-528.[Medline]
- Wheatley 3rd GH, Nunez A, Preventza O, et al. Have we gone too far?. Endovascular stent-graft repair of aortobronchial fistulas. J Thorac Cardiovasc Surg 2007;133:1277-1285.[Abstract/Free Full Text]
- Bockler D, Schumacher H, Schwarzbach M, et al. Endoluminal stent-graft repair of aortobronchial fistulas: bridging or definitive long-term solution? J Endovasc Ther 2004;11:41-48.[Medline]
- Pitton MB, Herber S, Schmiedt W, et al. Long-term follow-up after endovascular treatment of acute aortic emergencies Cardiovasc Intervent Radiol 2008;31:23-35.[Medline]
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Abstract
Introduction
