Two-Stage Safe Repair of Aortobronchial Fistula

Use of thoracic endovascular aortic repair for management of aortobronchial fistula

We report the case of a 66-year-old man who had been emergently transferred to our institution with hemoptysis and hemodynamic instability. His computed tomography findings were consistent with the presence of an aortobronchial fistula. The patient had undergone open repair of coarctation of aorta via thoracotomy 20 years previously, and he was not deemed a suitable candidate for open repair. He was successfully treated with thoracic endovascular aortic repair with successful exclusion of the fistula. The patient was discharged home, and the subsequent follow-up imaging study at 12 months showed the graft in a stable position without evidence of infection, pseudoaneurysm, or endoleak. This case has demonstrated the successful use of thoracic endovascular aortic repair for urgent management of an aortobronchial fistula.

Thoracic Endovascular Aortic Repair for Aortobronchial Fistula 18 Years after Graft Replacement of the Descending Aorta

A 77-year-old woman who had undergone graft replacement of the descending aorta 18 years prior presented to our hospital complaining of a cough with bloody sputum. She was diagnosed with aortobronchial fistula by computed tomography. Thoracic endovascular aortic repair was performed, and the patient was discharged from the hospital without any major complications. Postoperatively, bloody sputum disappeared, and computed tomography examination at 12 months postoperatively showed that the preoperative infiltrative shadows in the lung fields were reduced. In conclusion, thoracic endovascular aortic repair is an effective treatment for aortobronchial fistula.

Recurrent Aortobronchial Fistula after Endovascular Stenting for Infected Pseudoaneurysm of the Proximal Descending Thoracic Aorta: Case Report

Aortobronchial fistula (ABF) induced by an infected pseudoaneurysm of the thoracic aorta is a life-threatening condition. As surgical treatment is associated with significant mortality and morbidity, thoracic endovascular aneurysm repair (TEVAR) may be an alternative for the treatment of ABF. However, the long-term durability of this intervention is largely unknown and the recurrence of ABF is a potential complication. We experienced a case of recurrent ABF after stent grafting as an early procedure for an infected pseudoaneurysm of the thoracic aorta. Remnant ABF, bronchial and/or aortic wall erosion, vasa vasorum connected with ABF, and recurrent local inflammation of the thin aortic wall around ABF might cause recurrent hemoptysis. As a result, we suggest that TEVAR should be considered as a bridge therapy for the initial treatment of ABF resulting from an infected pseudoaneurysm, and that several options, such as second-stage surgery, should be considered to prevent the recurrence of ABF.

Management of aortobronchial fistula: Experience of 14 cases

OBJECTIVES

Aortobronchial fistula (ABF) is rare but lethal condition if left untreated, and the treatment still remains challenging. We retrospectively reviewed data at our Institution and report our experience in the management of ABF.

METHODS

From September 2010 to May 2019, 14 patients (13 men, average age 52 ± 11 years) with ABF were treated in our hospital. Three types of management were applied according to the patients' different clinical presentation, including conservative treatment, that is, antibiotic treatment (n = 3), endovascular repair (n = 7), and open surgery (n = 4). In the open surgery group, Dacron grafts were used, two cases received in situ descending thoracic aortic replacement through left thoracotomy and two cases received extra-anatomic bypass through median thoracoabdominal incision.

RESULTS

In the conservative treatment group (n = 3), two patients died during follow-up, the third was alive in good condition. In the endovascular repair group (n = 7), one patient died 22 days after the endovascular repair because of massive hemoptysis and another patient died 4 days after the procedure because of cerebral infarction. In the medium term, two patients died of massive hemoptysis, and one was lost at follow-up. In the open surgery group (n = 4), one patient died because of massive hemoptysis 2 days after his extra-anatomic bypass procedure, the remaining patients were alive in good condition at follow-up.

CONCLUSIONS

ABF is catastrophic if left untreated. Endovascular repair might be a reasonable temporary bridge solution in emergency cases, but is less durable in the long run. Open surgery, despite more challenging, provides a more definitive treatment for ABF.

Combined endovascular and surgical approach for aortobronchial fistula

OBJECTIVE

The perioperative outcomes of the endovascular approach to aortobronchial fistula have been favorable. However, it is uncertain whether thoracic endovascular aneurysm repair (TEVAR) alone provides a complete and durable cure for an aortobronchial fistula. TEVAR does nothing to address the issue of the defect in the respiratory tract, leaving the patient at risk of aortobronchial fistula recurrence and/or stent graft infection. The authors believe that the bronchial defect should be addressed.

METHODS

Over the last 10 years, 5 patients were treated for an aortobronchial fistula using a combined endovascular and surgical approach (primary treatment in 3 patients and secondary after TEVAR in 2 patients). All the patients underwent emergency stent graft placement and concomitant (n=1) or staged (n=4) open repair including pulmonary resection with coverage of the stent graft using muscle or pleural flaps. All patients received a 6-week course of broad-spectrum intravenous antibiotics followed by lifelong oral antibiotics.

RESULTS

All patients survived the surgical procedure. After a mean follow-up of 23.2 months, 4 patients are asymptomatic and postprocedure computed tomography scans were unremarkable. One patient treated for an aortobronchial fistula after TEVAR was readmitted 4 months after surgical conversion. Stent graft explantation and silver-coated tube graft replacement of the descending thoracic aorta were performed for severe mediastinitis with associated thoracic stent graft infection. The postoperative course of this patient was uneventful.

CONCLUSIONS

Emergency TEVAR for an aortobronchial fistula is an appealing strategy for this devastating complication. However, to achieve a lasting result, direct contact between the stent graft and the pulmonary tissue should be avoided to prevent further erosive damage. Concomitant or staged repair should entail primary repair or resection and anastomosis of the bronchus and/or pulmonary resection with coverage of the stent graft using muscle or pleural flaps combined with broad-spectrum intravenous antibiotic therapy. Long-term surveillance and continued investigation are warranted.

Aortobronchial fistula presenting 14 years following ligation of a patent ductus arteriosus

Aortobronchial fistula (ABF) presenting as massive hemoptysis is a rapidly fatal process that is extremely difficult to diagnose and manage. ABF following ligation of patent ductus arteriosus (PDA) is extremely rare. We now report a case of an ABF developing 14 years after ligation of a PDA.

Aortobronchial fistula after esophagectomy for esophageal cancer -- a very rare complication

Most aorto-respiratory fistulas are related to aortic pathology or procedures, but fistula formation after esophageal resection has never been reported in the literature. We are now reporting a case of hemoptysis that occurred after esophagectomy for locally advanced esophageal cancer. Aortobronchial fistula was detected by computed tomography scan. The patient was finally saved by emergency surgery-Dacron graft interposition of the descending thoracic aorta. There was no malignant cell in the postoperative specimen of the fistula. The erosion of the ligaclips (Johnson & Johnson) might be responsible for the aortobronchial fistula formation. For esophageal surgery, avoidance of trauma to aortic wall and careful using of ligaclips are important to circumvent this complication.