Endovascular Repair of an Aortopulmonary Fistula via the Axillary Artery

A systematic review of therapies for aortobronchial fistulae

OBJECTIVE

The aim of the study was to summarize epidemiologic data about aortobronchial fistulas and compare outcomes (mortality, recurrence, re-operation) of open, staged, and endovascular repair of aortobronchial fistula.

METHODS

A systematic literature review was conducted to identify eligible studies published between January of 1999 and December of 2019. The Cochrane Library, PubMed and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series and thus, only descriptive data with data heterogeneity was available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death).

RESULTS

Overall, 214 patients (90 studies) underwent 271 procedures (including re-do procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae located most often in the descending thoracic aorta (Zone 3,4) (64,6%) and in Zone 2 (23,8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43 patients). Recurrences were at some extend associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whilst 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61, 3 received life-long antibiotics and for 58 patients data were not available. Considering outcomes, mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments.

LIMITATIONS

Literature review has revealed only case reports and small case series and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies which till today have not been conducted.

CONCLUSION

Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and in recurrence process and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal and thus, surgeons should feel confident to apply the treatment of their choice, taking in mind their experience, patient's age, and clinical condition.

Outcomes of thoracic endovascular aortic repair for aortobronchial and aortoesophageal fistulas

PURPOSE

To identify in-hospital and follow-up outcomes of thoracic endovascular aortic repair (TEVAR) for aortobronchial fistula (ABF) and aortoesophageal fistula (AEF).

METHODS

The authors reviewed all published cases of ABF and AEF undergoing TEVAR indexed in the MEDLINE, Cochrane Library CENTRAL, and EMBASE databases. After removal of duplicates, 850 articles were scrutinized for relevance and validity. Exclusion criteria included: (1) no clear description of the organs involved with the fistula, (2) no description of outcomes after TEVAR for ABF or AEF, or (3) no original data presented in the article. In this manner, 66 relevant articles were identified that included original data on 114 patients (76 men; mean age 63+/-1.5 years) with ABF (n = 71) or AEF (n = 43). Meta-analyses were performed to investigate outcomes of TEVAR for ABF and AEF.

RESULTS

Patients with AEF presented more frequently with hypovolemic shock (33% versus 13%, p = 0.012) and systemic infection (36% versus 9%, p<0.001) compared to patients with ABF. In-hospital mortality was 3% (n = 2) after TEVAR for ABF and 19% (n = 8) after TEVAR for AEF (p = 0.004). Additional thoracic surgery in the first 30 days after TEVAR was performed in 3% (n = 2) of ABF patients and in 37% (n = 16) of AEF patients (p<0.001); 12 AEF patients who had received esophageal surgery in the first month after TEVAR showed lower fistula-related mortality during 6 months of follow-up compared to patients who did not receive additional esophageal surgery (p = 0.018).

CONCLUSION

TEVAR is associated with superior outcomes in patients with ABF. Endovascular management of AEF is associated with poor results and should not be considered definitive treatment. TEVAR could serve as a bridge to surgery for emergency cases of AEF only, with definitive open surgical correction of the fistula undertaken as soon as possible.

Traumatic ascending aortopulmonary window following pulmonary artery stent dilatation: therapy with aortic endovascular stent graft

Endovascular stent grafts have become an established therapy in adults for descending thoracic aortic disease. We report a case of a 13-year-old boy with a hemodynamically significant traumatic aortopulmonary window following angioplasty of pulmonary artery stent. Endovascular stent graft implantation into the ascending aorta was performed to seal off the communication, with dramatic hemodynamic improvement.

Have we gone too far? Endovascular stent-graft repair of aortobronchial fistulas

OBJECTIVE

Although endovascular repair of the descending thoracic aorta has emerged as a viable treatment option, little is known about its potential to treat patients diagnosed with aortobronchial fistulas. We reviewed our comprehensive thoracic endografting experience with regard to the endovascular management and subsequent outcome of patients with aortobronchial fistulas to assess whether endoluminal graft repair is a realistic option.

METHODS

Between February 2000 and November 2005, 255 patients were successfully treated with an endoluminal graft to the descending thoracic aorta. Indications for intervention included: atherosclerotic aneurysms (109/255, 42.7%), acute and chronic dissections (75/255, 29.4%), miscellaneous (34/255, 13.3%), penetrating aortic ulcers (30/255, 11.8%), and aortobronchial fistulas (7/255, 2.7%).

RESULTS

Average patient age was 73.4 +/- 10.1 years, with 4 male patients (4/7, 57.1%) and 3 female patients (3/7, 42.9%). All patients presented with hemoptysis, with 1 patient (1/7, 14.3%) requiring preoperative blood transfusion. Three patients (3/7, 42.9%) were diagnosed with atherosclerotic aneurysms, 3 patients (3/7, 42.9%) had pseudoaneurysms associated with prior open surgical repair, and 1 patient (1/7, 14.3%) had a prior endoluminal graft placed for a traumatic aortic transection. No standard postoperative antibiotic regimen was followed. There were no endoleaks, no incidences of paraplegia, and no endoluminal graft infections. Survival was 100% (7/7) at both 30 days and 1 year, and all patients are currently alive. Follow-up computed tomography was available for all 7 patients, with an average follow-up of 42.6 +/- 28.5 months.

CONCLUSIONS

Endovascular management of aortobronchial fistulas appears to be safe and well tolerated, even in surgically high-risk patients, with minimal risk of prosthesis infection. Long-term surveillance and continued investigation are warranted.