Endovascular treatment of acute bleeding complications in traumatic aortic rupture and aortobronchial fistula

Life-Threatening Hemoptysis From Aorto-Bronchial Fistula in a Patient With Remote History of Aortic Coarctation Repair

"Hemoptysis" refers to the expectoration of blood from the respiratory tract. However, "life-threatening hemoptysis" includes any volume that leads to features such as airway obstruction, hypoxia, or hemodynamic instability. We present a case of life-threatening hemoptysis in a 65-year-old male with a history of benign prostatic hyperplasia and uncontrolled hypertension. Radiological investigations revealed a pseudo-aneurysm at the site of a prior thoracic aortic coarctation repair more than 50 years prior in childhood. He required vascular surgical intervention, during which there was evidence of an aorta-bronchial fistula as the likely cause of bleeding. Following the repair and optimal blood pressure control, the patient had no further episodes of hemoptysis and was discharged from the hospital. His case not only adds to the growing body of medical literature reporting hemoptysis as a complication of coarctation repair but also highlights the aorto-bronchial fistula as a possible and potentially catastrophic mechanism for bleeding in these patients.

Thoracic endovascular aortic repair for aortobronchial fistula: a case series

Background

Aortobronchial fistula (ABF) formation following the rupture of thoracic pseudoaneurysm is a rare clinical entity. Its aetiology includes atherosclerosis, infections, trauma, post-surgery, and post-endovascular aortic repair. The clinical presentation of ABF includes intermittent or massive haemoptysis, acute respiratory distress, hypotension, and even death. These patients require an emergency aortic intervention to stop active haemorrhage. Thoracic endovascular aortic repair (TEVAR) is a less invasive, safe, and effective treatment compared to conventional open surgical repair

Case summary

We hereby report three cases of ruptured descending thoracic aortic pseudoaneurysms resulting in a fistula formation. The first two cases had tuberculosis as their underlying aetiology, while the third case was the result of previous open post-aortic surgery. All patients presented with massive haemoptysis and were successfully treated by emergency TEVAR and had favourable outcomes.

Discussion

Thoracic endovascular aortic repair is a rapid, less invasive, and effective treatment for emergency management of ABF. It has more than 85% technical success rates in the reported literature. We had procedural success in all three cases. The short and midterm outcome of ABF following TEVAR is favourable and encouraging.

An uncommon cause of hemoptysis: aortobronchial fistula

Background

Hemoptysis is a frequent sign of respiratory and non-respiratory diseases. While in most cases the underlying cause is rapidly identified, sometimes the real etiology might be misdiagnosed with dramatic delay in treatment.

Case presentation

A 46-year-old man with hiatal hernia and a history of aortic surgery for aortic coarctation presented with dramatic episodes of hemoptysis and subsequent severe anemia (6,9 g/dl). Digestive and respiratory endoscopy resulted not exhaustive, thus he underwent a contrast-enhanced computed tomography (CT) scan of the chest that showed an aneurysmal dilatation of the descending thoracic aorta with suspected aortobronchial fistula. He underwent cardiac surgery that confirmed the diagnosis and successfully treated the fistula.

Conclusion

We briefly review the literature to raise clinical awareness on this uncommon cause of hemoptysis.

[Management of traumatic aortic rupture. About 37 cases]

OBJECTIVES

The aim of this study was to review our experience in the management of traumatic rupture of the aortic isthmus, to evaluate the results of surgery and endovascular exclusion and to develop an adequate therapeutic strategy based on the existence and severity of associated injuries.

MATERIAL

A series of 37 patients presenting posttraumatic aortic rupture associated with other severe lesions was collected from 2000 to 2012. There were 33 males and four females, mean age 38 years. In this series, 25 patients underwent surgical treatment and 12 endovascular exclusion.

RESULTS

Six patients died during or after surgery. Overall mortality was 16% (24% in the surgery group). The postoperative period was uneventful in all patients treated with the endovascular procedure. Postoperative computed tomography controls at one week, 1 month and 12 months showed good positioning of the stent without endoleakage.

CONCLUSION

Traumatic aortic rupture is often the result of a severe high-energy chest trauma. Other serious injuries are often associated. Results of immediate surgical repair are associated with high morbidity and mortality. The advent of endovascular treatment has revolutionized the treatment of traumatic aortic rupture, especially in patients with a high surgical risk.

Endovascular stent-graft repair of aortobronchial fistulas

BACKGROUND

Endovascular repair of the descending thoracic aorta has recently emerged as a feasible treatment option; however, little is known about its application for aortobronchial fistula (ABF). Experience with endovascular repair of the thoracic aorta and the outcome of patients with ABFs was reviewed to assess whether thoracic endovascular repair is a realistic option.

METHODS

From February 2001 to May 2011, 386 patients were successfully treated with endoluminal grafts to the distal arch or descending thoracic aorta. Among them, 26 patients with ABF underwent thoracic endovascular repair. These cases were reviewed and analyzed retrospectively. Follow-up was 100% complete (mean, 21 months).

RESULTS

The subjects included 26 patients (22 males, 85%; 4 females, 15%) with a median age of 71 years. Ten patients (38%) were diagnosed with atherosclerotic aneurysms, 13 (50%) had pseudoaneurysms associated with prior open surgical repair, 1 (4%) had rupture of dissecting aneurysm, and 2 (8%) had mycotic aneurysm. There were 4 (15%) in-hospital mortalities, in which the causes included bleeding owing to recurrence of hemoptysis (n=3, 11%) and multiple organ failure (n=1, 4%). None sustained postoperative stroke or paraplegia. During follow-up, ABFs recurred in 4 patients; of these, endograft explantation occurred in 3 patients and 1 patient required additional open surgery. No hospital mortality resulted among the 4 patients with ABF recurrence.

CONCLUSIONS

Endovascular management of ABFs appears to be safe and well tolerated with minimal risk, even in surgically high-risk patients. Endovascular stent-graft repair is likely the first choice for ABF presenting as hemoptysis.

Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels

BACKGROUND

Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times.

METHODS

A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma.

RESULTS

In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%.

CONCLUSION

The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

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.

Endovascular treatment of traumatic rupture of the thoracic aorta

Background

Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.

Methods

A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.

Results

A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.

Conclusion

Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.

Management of Blunt Thoracic Aortic Injury

Blunt traumatic aortic transection (TAT) is an uncommon injury in clinical practice that is associated with a high morbidity and mortality. The approach to patients with such an injury is controversial with specific regard to the most effective diagnostic tools, timing of surgical intervention and mechanisms of spinal cord protection. Chest X-ray with widening of the mediastinum is unreliable as a diagnostic tool. Contrast enhanced helical CT Scan has replaced the traditional angiography as the screening diagnostic tool of choice Emergency thoracotomy and repair should be reserved for the few patients with isolated TAT without any major concomitant injuries. Delayed management approach with aggressive blood pressure control and serial radiological monitoring is a safe and recommended option for those with severe concomitant injuries or other medical co-morbidity that puts surgery at high risk. Active augmentation of the distal perfusion pressure during cross clamp offers the best protection against development of paraplegia during open surgical repair. Endovascular stenting offers a minimally invasive method of treatment but the long-term durability of the endovascular stent is still unknown. We feel that the greater feasibility of the endovascular repair in the acute phase of the thoracic injury is an advantage over the open surgery and should be the treatment of choice in patients with severe concomitant injuries.

Radiologische Interventionen bei polytraumatisierten Patienten

The most frequent cause of mortality during the first 4 h following severe trauma is uncontrollable hemorrhage from large arteries and parenchymal organs, whereas traumatic injuries of the heart and aorta are responsible for sudden death occurring at the accident site. It is therefore mandatory to diagnose and treat these injuries rapidly. Multislice spiral computed tomography is a highly useful imaging modality for severely injured patients. In this group of patients, various interventional procedures such as embolisation, stenting and temporary balloon occlusion may contribute to saving lives. In ruptures of the aorta and major arteries, stenting and temporary balloon occlusion may prevent exsanguination. Transcatheter embolisation is useful in hemorrhage from visceral organs, arteriovenous fistulas and secondary onset hemorrhage.

Endovascular Repair of an Aortopulmonary Fistula via the Axillary Artery

A 62-year-old man presented with several months of progressive hemoptysis. He has a history of aortobifemoral bypass and thoracofemoral bypass grafts, which were both removed due to infection. Evaluation with multiple imaging modalities revealed a descending thoracic aortic pseudoaneurysm around the retained Dacrontrade mark graft with bronchiectatic changes and consolidation of the adjacent left lower lobe. No evidence of direct arterial communication between the aorta and the bronchioles was ever demonstrated, but an aortopulmonary fistula was suspected. Endovascular repair with several Excluder aortic cuffs stacked in the thoracic aorta was successfully performed via the axillary artery. Exclusion of the pseudoaneurysm with no evidence of endoleak was noted on computed tomography 2 months postoperatively, at which time the patient reported complete resolution of his hemoptysis. To our knowledge, this is the first report of endovascular repair of an aortopulmonary fistula via the axillary artery.

Emergent infrahepatic vena cava stenting for life-threatening perforation

During a lumbar vertebral fusion, a box cage perforated the inferior vena cava wall and migrated toward the right atrium. This case report describes the use of a Talent endoluminal stent-graft to control the subsequent life-threatening bleeding and to prevent further migration of the box cage into the right atrium, with the risk of pulmonary embolization. It shows that the use of minimal invasive endovascular stent-grafts to control for massive vena cava bleeding might be a less invasive procedure and, in similar cases, could be a life-saving alternative to open surgery.

Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management

Postoperative aortobronchial and aortopulmonary fistulas are rare and late complications of cardiac surgery. They mostly complicate descending thoracic aortic procedures. Hemoptysis is the main symptom, and may be massive or intermittent. The reported interval between the time of operation and the onset of hemoptysis ranges from 3 weeks to 25 years. Diagnostic examinations are often unable to directly visualize a fistula. Indication for surgical or endovascular repair mostly relies on clinical suspicion and nonspecific diagnostic features. Urgent treatment is based on the association of the following elements: (1) hemoptysis, (2) history of previous cardiac or aortic operation, (3) presence of lung infiltrates on the chest roentgenogram, (4) lung hemorrage on the computed tomographic scan, and (5) and visualization of a pseudoaneurysm. Aortobronchopulmonary fistulas are uniformly fatal if untreated. The overall surgical mortality rate is 15.3%. There is no procedure-related mortality after endovascular stent grafting. A review of the English-language literature from 1947 to October 2002 is presented.

Hybrid management of aortic rupture and lung failure: pumpless extracorporeal lung assist and endovascular stent-graft

Acute traumatic aortic rupture represents a potentially life-threatening situation. Because of the extremely high early mortality, emergency surgical repair used to be the preferred method of treatment. This group of patients usually is seen with a wide variety of injuries and comorbid conditions, all of which have a major impact on surgical outcome. We present an alternative hybrid approach that combines on-site placement of pumpless extracorporeal lung assist, subsequent patient transfer, and endovascular stent-graft implantation. This procedure may be a potentially useful strategy to reduce the comorbidity and the mortality of both lesions.