Since its first systematic description, aortobronchial fistula remains a rare condition characterized by acute symptomatology such as hemoptysis sustained by massive endobronchial bleeding [
2,
3]. It represents a misdiagnosed disease especially in patients with coexistent clinical complaints with underestimated incidence and more than 30% cases diagnosed at autopsy [
4]. In more recent years the etiology of this unusual condition has been better characterized [
5], being now mostly associated with a history of aortic surgery [
6,
7]. Studies have showed that complications may occur even many years after the intervention [
8], being lethal sequelae of aortic aneurysmal disease [
9,
10]. Fistulas usually involve the left side of the bronchial tree because of the narrow distance between the descending thoracic aorta and the left bronchial hemi system, while on the right side the greater distance between the ascending aorta and bronchial tree make this condition unusual [
6,
9]. Nevertheless several case reports describing fistulas from the ascending aorta to the right bronchial tree are reported. Aortic fistulas both into the left and right bronchial tree can follow aortic surgery after unpredictable periods, being often the consequence of pseudo-aneurysms [
5]. Once the presence of the fistula has been established a rapid multidisciplinary decision regarding further management should be made considering comorbidity, risk factors and clinical stability. In the past the open surgical approach was the only available with prosthetic graft replacement, patch closure or direct suturing of the aortic side of the fistula [
11]. Several complications have been described when patients with aortobronchial fistulas undergo open surgery: stroke, paralysis, respiratory failure, acute renal insufficiency, ischemic cardiac events, acute hemorrhage and secondary graft infection [
9,
11]. The reported mortality rates range from 25 to 41% [
3,
12]. Thoracic endovascular aortic repair with endovascular stent grafting is a simpler and less invasive approach to exclude the fistulous tract with reduced morbidity and mortality, particularly in high risk and unstable patients [
13]. Although less invasive, the technique presents some limitations, mainly due to graft contamination, leakage and migration [
11,
13]. Furthermore a variety of combinations of TEVAR with surgical aortic repair have been proposed but further studies are needed to assess the long-term efficacy and safety of these techniques [
14].
This clinical report is intended to raise attention on this uncommon but dramatic cause of massive hemoptysis.