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J Thorac Cardiovasc Surg 2006;131:240-243
© 2006 The American Association for Thoracic Surgery

Brief Communication

Aortobronchial fistula after aortic coartactation

Alfonso L. Quintana, MD, PhD * , Esther Martínez Aguilar, MD, Alvaro Fernandez Heredero, MD, Vicente Riambau, MD, Laura Paul, MD, Francisco Acín, MD, PhD

Department of Angiology and Vascular Surgery, Getafe University Hospital, Madrid, Spain

Received for publication July 3, 2005; revisions received September 30, 2005; accepted for publication October 7, 2005.

* Address for reprints: Alfonso Lopez Quintana, MD, Department of Angiology and Vascular Surgery, Getafe University Hospital, Road Toledo 12,5 Km, Getafe, Madrid 28905, Spain (Email: esthermartinezaguilar{at}hotmail.com).

Aortobronchial fistulas are an uncommon, but potentially fatal, complication of reconstructive surgery in the thoracic aorta. Endovascular treatment is a less-invasive technique and represents an alternative for the treatment of this disease, particularly when conditions are inadequate for open surgery. We report a case of an aortobronchial fistula occurring 15 years after surgery for aortic coarctation that was resolved by use of endovascular treatment.

Clinical Summary

A 47-year-old man was transferred to our department because of an episode of massive hemoptysis not requiring recovery measures. The patient had undergone surgery for an aortic coarctation 15 years before. In the last year, he had had several minor episodes of hemoptysis for which he was being monitored by the pneumology department.

An initial bronchoscopic examination showed glandular openings that filled with blood in the medial wall of the right main bronchus and a slow sheet bleeding from both left lobes. The chest computed tomographic (CT) report suggested an aortobronchial fistula (Figure 1, A), and this diagnosis was confirmed by angio-magnetic resonance imaging.


Figure 1
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  		Figure 1. A, Computed tomography (CT) showing contrast extravasation at the aneurysmal dilatation. B, Arteriography showing dilatation of left subclavian artery, postcoarctation stenosis, and fraying of the posterior aspect of the aortic segment with aneurysmal dilatation distal to the subclavian artery. C, Control arteriography after stent implantation confirming exclusion of aneurysmal region and absence of endoleaks.

 
The patient underwent surgery with general anesthesia and systemic heparinization. A left femoral approach and a 5F inserter were used for arteriography, which showed a dilated left subclavian artery, postcoarctation stenosis, and fraying of the posterior aspect of the aortic segment with aneurysmal dilatation distal to the subclavian artery (area of the aortobronchial fistula) (Figure 1, B).

A 30 x 130 Talent stent (Medtronic, Santa Rosa, Calif) was implanted in the aortic arch with fixation at the origin of the left subclavian artery. A baseline arteriogram revealed leakage in the aneurysmal dilatation. A proximal 30 x 80 Talent extension (Medtronic) was implanted. A baseline angiogram confirmed endovascular exclusion of the aneurysmal region, as well as absence of endoleaks (Figure 1, C).

On the fifth postoperative day, the patient had a new episode of massive hemoptysis requiring recovery measures. Angiography showed a minor filling of a space between the aortic wall and the stent because of inferior reentry. Selective catheterization of this area with a 5F vertebral catheter and a Terumo (Tokyo, Japan) 0.35 guidewire revealed filling at the expense of right and left intercostal arteries and right bronchial arteries. Several coils 8 to 15 mm in diameter were released to seal this endoleak area. An immediate selective angiogram showed decreased filling of these arteries. The patient remained subsequently stable and did not have hemoptysis again at any time.

The CT performed at 4 weeks showed adequate placement of the stent with minimal distal leak and decreased endoleaks. No ruptures, migrations, or endoleaks were seen in the follow-up CT performed at 12 months (Figure 2). The patient is asymptomatic and has not had any new episodes of hemoptysis.


Figure 2
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  		Figure 2. Follow-up CT after 12 months showing absence of ruptures, migrations, and endoleaks.

 
Discussion

Aortobronchial fistulas are an uncommon complication of surgery in the thoracic aorta. The possibility of an aortobronchial fistula should always be considered in patients with hemoptysis and a history of surgery in the thoracic aorta. The next step is documentation of the existence of an anastomotic aneurysm, for which CT is considered the best single diagnostic tool. CT is able to detect a pseudoaneurysm, periaortic hematoma, and consolidation in the adjacent pulmonary area. However, visualization of the aortobronchial fistula is only possible in 17% of cases. 1 Go

Perioperative mortality with conventional surgical treatment exceeds 18% at 30 days for primary thoracic aortic aneurysms 2 Go and is up to 41% when pseudoaneurysm exists. Postoperative morbidity is 42% and includes long-term mechanical ventilation, pneumonia, acute myocardial infarction, and paraplegia. 3 Go

Endovascular repair in the thoracic aorta is less invasive and causes fewer cardiopulmonary (12%), neurologic (3.7%), renal (5.5%), or spinal (0%-12%) complications. 4 Go Initial series reported a 30-day mortality of approximately 10%, 5 Go but with the development of new prostheses and increased understanding and experience in the procedure, the number of perioperative complications has gradually decreased.

To conclude, endovascular treatment for aortobronchial fistulas is technically feasible and is associated with higher survival than conventional surgery. Midterm results in regard to cessation of hemoptysis episodes are good. Specific complications, such as endoleaks or the need for adjuvant processes, have not been eliminated yet. Stent improvement and optimal patient management will most likely decrease these complications inherent to the method. A longer term follow-up is required to establish the results of these procedures. Prospective, randomized studies allowing for an analysis of the results and a comparison with the results of conventional surgery are difficult to conduct because of the low prevalence of the condition and the urgent solution required.

References

  1. Miyata T, Ohara N, Shigematsu H, Konishi T, Yamaguchi H, Kazama S, et al. Endovascular stent graft repair of aortopulmonary fistula. J Vasc Surg 1999;29:557-560.[Medline]
  2. Leobon B, Roux D, Mugniot A, Rousseau H, Cérene A, Glock Y, et al. Endovascular treatment of thoracic aortic fistulas. Ann Thorac Surg. 2002;74:247-249.[Abstract/Free Full Text]
  3. Thompson CS, Ramaiah VG, Rodriguez-Lopez JA, Vranic M, Rajogopalan R, DiMugno L, et al. Endoluminal stent graft repair of aortobronchial fistulas. J Vasc Surg. 2002;35:387-391.[Medline]
  4. Neuhauser B, Perkmann R, Greiner A, Steingruber I, Tauscher T, Jaschke W, et al. Mid-term results after endovascular repair of the atherosclerotic descending thoracic aortic aneurysm. Eur J Vasc Endovasc Surg. 2004;28:146-153.[Medline]
  5. Orend KH, Scharrer-Pamler R, Kapfer X, Kotsis T, Görich J, Sunder-Plassmann L. Endovascular treatment in diseases of the descending thoracic aorta. 6-year results of a single center. J Vasc Surg. 2003;37:91-99.[Medline]



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