A review of aortopulmonary fistulas in aortic dissection

Severe obstructive sleep apnoea, aortic dissection and aortopulmonary fistula in a 56-year-old patient with syncope

We present a case of a 56-year-old patient with obstructive sleep apnoea (OSA) presenting with acute decompensated heart failure and signs of cardiogenic shock. Echocardiography and CT imaging led to the diagnosis of acute type A aortic dissection (AD) complicated by aortopulmonary fistula (APF). The patient underwent successful surgical repair with complicated postoperative course including pulseless electrical activity arrest. This case highlights the underappreciated role of untreated OSA as a risk factor for AD. Furthermore, it presents an opportunity to review APFs as a rare complication of AD. We discuss the available evidence linking OSA and AD, review currently reported cases of APF, briefly outline the haemodynamics of this acute left-to-right shunt and discuss management of this rare but deadly complication.

Aortic Fistulas: Pathophysiologic Features, Imaging Findings, and Diagnostic Pitfalls

Fistulas between the aorta and surrounding organs are extremely rare but can be fatal if they are not identified and treated promptly. Most of these fistulas are associated with a history of trauma or vascular intervention. However, spontaneous aortic fistulas (AoFs) can develop in patients with weakened vasculature, which can be due to advanced atherosclerotic disease, collagen-vascular disease, vasculitides, and/or hematogenous infections. The clinical features of AoFs are often nonspecific, with patients presenting with bleeding manifestations, back or abdominal pain, fever, and shock. Confirmation with invasive endoscopy is often impractical in the acute setting. Imaging plays an important role in the management of AoFs, and multiphasic multidetector CT angiography is the initial imaging examination of choice. Obvious signs of AoF include intravenous contrast material extravasation into the fistulizing hollow organ, tract visualization, and aortic graft migration into the adjacent structure. However, nonspecific indirect signs such as loss of fat planes and ectopic foci of gas are seen more commonly. These indirect signs can be confused with other entities such as infection and postoperative changes. Management may involve complex and staged surgical procedures, depending on the patient's clinical status, site of the fistula, presence of infection, and anticipated tissue friability. As endovascular interventions become more common, radiologists will need to have a high index of suspicion for this entity in patients who have a history of aneurysms, vascular repair, or trauma and present with bleeding. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ^©RSNA, 2021.

Post-traumatic Aortopulmonary Fistula after Bentall Procedure

Pseudoaneurysm complicated by aortopulmonary fistula (APF) after a Bentall procedure is extremely rare but potentially fatal, so timely diagnosis and treatment are critical. We present a subacute case of a post-traumatic APF which has had initial aspecific symptoms and later an acute worsening heart failure with chest pain not responding to medical treatment and requiring emergency surgery.

Use of Amplatzer occluders for treatment of aorto-pulmonary fistulas - case and review of the literature

INTRODUCTION

the use of amplatzer occluder family in daily clinical practice has already overcome on-label indications, with growing clinical experience and the technological evolution of devices. Areas covered: We present the case of a patient with a very rare complication following proximal aortic surgery treated using a unique strategy. A huge pseudoaneurysm around an ascending aortic prosthesis ruptured into the right pulmonary artery. A hybrid treatment strategy consisting of percutaneous closure of the fistula followed by cardiosurgery was chosen due to the patient's poor haemodynamic condition. We also review current clinical experience of endovascular treatment of aortopulmonary fistulas by searching case reports in PubMed. Expert commentary: Closure of the APF using an Amplatzer occluder via the antegrade venous approach is feasible, and may improve the haemodynamic conditions and decrease the risk of subsequent cardiac surgery.

Thoracic aortic rupture in horses

The aorta can rupture at the aortic root or aortic arch. In most breeds, the aortic root is the likely site and rupture leads to aortocardiac fistula with communication between the aorta and the right atrium, right ventricle and/or the interventricular septum. There is a high prevalence of aortic rupture in young Friesian horses and rupture occurs at the aortic arch with pseudoaneurysm and potentially aortopulmonary fistulation. Echocardiographic and post-mortem techniques must be adapted to identify aortic arch rupture that is not generally identified with standard approaches. Given the narrow genetic base of the Friesian breed and the significant differences found in extracellular matrix composition and metabolism between Friesians and Warmbloods, genetic factors are likely to contribute to the condition in the Friesian breed.

A Patient with Aortic Arch Aneurysm Perforating the Left Pulmonary Artery

An aortic arch aneurysm rarely perforates the pulmonary artery, but once this occurs symptoms of heart failure may develop rapidly and result in a serious course. Here, we report such a case that was treated with life-saving emergency surgery. The patient was an 86-year-old man in whom aortic arch aneurysm had been pointed out 8 years earlier, but left untreated. In January 2014, dyspnea developed and he visited the emergency unit of our hospital. Continuous murmur was heard on auscultation, and aorta-pulmonary artery shunt was noted on transthoracic echocardiography. Chest computed tomography revealed a giant aortic arch aneurysm of size 106 mm that had perforated the left pulmonary artery (LPA). Emergency surgery was performed for a diagnosis of acute heart failure associated with perforation of the LPA by a giant aortic arch aneurysm. The postoperative course was favorable, and the patient was discharged with independent walking on postoperative day 28.

Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations

OBJECTIVES

To investigate the spectrum, etiology, and management of traumatic aortopulmonary (AP) communications after transcatheter interventions on the pulmonary circulation.

BACKGROUND

An iatrogenic AP communication is an unusual complication after balloon pulmonary artery (PA) angioplasty or stenting, or transcatheter pulmonary valve replacement (TPVR). However, with the increasing application of transcatheter therapies for postoperative PA stenosis and right ventricular outflow tract (RVOT) dysfunction, including percutaneous pulmonary valve replacement, consideration of the etiology, diagnosis, and management of this problem is important for interventional cardiologists performing such procedures.

METHODS AND RESULTS

We present three new cases, as well as gross anatomy and histopathology data, related to AP communications after PA interventions. We also review the literature relevant to this topic. Including these new cases, there have been 18 reported cases of iatrogenic AP communication after transcatheter interventions on the PAs or RVOT, primarily patients with transposition of the great arteries who underwent PA angioplasty after an arterial switch operation, or after TPVR in patients who had undergone a Ross procedure. The likely cause of such defects is PA trauma plus distortion of the neo-aortic anastomosis resulting from angioplasty or stenting of the RVOT or central PAs, with subsequent dissection through the extravascular connective tissue and into the closely adjacent vessel through the devitalized tissue at the anastomosis.

CONCLUSIONS

Cardiologists performing PA or RVOT interventions should be aware of the possibility of a traumatic AP communication and consider this diagnosis when confronted with suggestive signs and symptoms.

Aortopulmonary fistula in acute dissection: findings at unenhanced and enhanced computed tomographic imaging

Acquired aortopulmonary fistulas are a rare complication of acute aortic dissections. We present a case of an aortopulmonary fistula after a Stanford type A dissection, focusing on the imaging findings and etiology of this entity. Early recognition can lead to proper surgical planning and increase the chance of survival.

Aorto-right atrial fistula following acute type A aortic dissection repair

This report describes a rare case of aorto-right atrial fistula caused by rupture of a huge pseudoaneurysm that developed at the proximal aortic anastomotic site after total aortic arch replacement for acute type A aortic dissection. Preoperative aortography revealed that the fistula communicated with the right heart, but it was intraoperative Doppler transesophageal echocardiography that confirmed its course into the right atrium. Repeat total aortic arch replacement with concomitant direct closure of the fistula was performed successfully. The underlying cause of the pseudoaneurysm was the dehiscence of sutures at the proximal aortic anastomotic site, probably due to gelatin-resorcin-formaldehyde glue.

Acute concomitant pulmonary artery and aortic dissection with rupture

Pulmonary artery (PA) dissection is uncommon and may lead to rupture and sudden death if encountered. A 63-year-old man presented to our emergency room with episodic left chest pain radiating to the back followed by shortness of breath. A 64-row multidetector computed tomography (MDCT) revealed ruptured dissection of the PA and the aorta with hemopericardium, hemomediastinum, and prominent extravasated blood along the central bronchovascular bundles of both lungs. The patient experienced cardiogenic shock immediately following CT study and died after resuscitation. Concomitant PA and aortic dissection with rupture is extremely rare with the pathogenesis remaining investigated. MDCT proves to be a powerful tool in its diagnosis for a timely surgical repair if the patient could survive to have the operation.

Endovascular repair of an aortopulmonary artery fistula with use of controlled-release coils

Aortopulmonary artery fistula is traditionally treated surgically. The present case report describes endovascular repair of an aortopulmonary artery fistula in a patient in whom two thoracotomies had been performed. The fistula occurred at the site of a pseudoaneurysm from the proximal anastomosis of a graft placed to treat a type B aortic dissection. Two controlled-release endovascular coils were positioned across the fistula, resulting in immediate closure. The fistula remains closed with resolution of the pseudoaneurysm after more than 3 years of follow-up.

Aortopulmonary fistula after aortic root replacement

This report describes a rare case of aortopulmonary fistula in pseudoaneurysm of the left coronary ostial button. A 66-year-old woman suddenly developed congestive heart failure 3 years after aortic root replacement for acute type A aortic dissection. The diagnosis of aortopulmonary fistula was confirmed preoperatively by aortography, heart catheterization, and spiral computed tomography. She was discharged in good condition after surgical treatment. This serious complication should be considered in patients who have severe congestive heart failure after aortic root replacement.