Fistulas between the aorta and traceobronchial tree

doi:10.1016/0003-4975(91)90888-W

The Annals of Thoracic Surgery

Volume 51, Issue 3, March 1991, Pages 515-519

https://doi.org/10.1016/0003-4975(91)90888-W Get rights and content

Abstract

Aortobronchial fistula is a rare condition that is invariably fatal if not diagnosed and surgically treated. With appropriate surgical intervention, survival rates greater than 70% can be achieved. A review of the literature and an illustrative case report are presented. A total of 63 fistulas in 62 patients have been described. The case we present is unusual in the use of serratus anterior muscle for repair of the fistula. Eighty-seven percent of the cases documented in the literature were associated with an aneurysm of the thoracic aorta. Eighty-six percent of the fistulas were between the descending aorta and left bronchopulmonary tree. More than 95% of patients experienced at least a single episode of hemoptysis, and massive hemoptysis occurred in more than half of the reported cases. A correct preoperative diagnosis was made in only 54% of cases. Plain chest radiographs definitively demonstrated an aneurysm in only 16%. The computed tomographic scan was the most rewarding test, identifying an aneurysm in 11 of 12 patients and the fistula in 50% of them. Surgical repair resulted in a 76% survival rate.

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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.
Tuberculous aortitis as a rare cause of aortobronchial fistula with massive haemoptysis: A case report
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Aortobronchial fistula is a rare condition, which is difficult to diagnose. It is fatal if misdiagnosed or not well treated. Massive haemoptysis is usually the first common symptom. Computed tomography angiogram (CTA) is the best non-invasive diagnostic modality. Treatment options include open repair procedure or Transthoracic Endovascular Aortic Repair (TEVAR) and resection of the destroyed lung tissue. The recurrent rate is high.
This report is a case of a 26-year-old African female patient who presented with massive haemoptysis. She had been treated for pulmonary tuberculosis two years before. The patient was diagnosed with retroviral disease and had been on treatment for two years. She underwent a 2-stage repair procedure. The initial treatment was TEVAR, which was followed by lung resection after two weeks. Both operations were uneventful. Histopathology analysis confirmed tuberculous aortitis as aetiology. The patient had been followed up for a year, with no recurrence.
Aortobronchial is divided into primary and secondary subtypes. Primary aortobronchial fistula is commonly caused by inflammatory disease and atherosclerosis. Secondary aortobronchial fistula is a complication of surgery for thoracic aorta and congenital cardiac disease. Tuberculous fistula is an uncommon cause of aortobronchial fistula. Surgery for aortobronchial fistula should include controlling both aortic and pulmonary fistula sites. A healthy tissue or muscle flap should be used between the repaired sites to prevent refistulisation. Recurrence is common; hence, long-term follow up is important.
Early diagnosis and adequate treatment are important. A high index of suspicion is important for diagnosis, because the diagnosis is difficult.
“In situ” endografting in the treatment of arterial and graft infections
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Citation Excerpt :
Reports suggest that thoracic aortic disease is responsible for up to 50% of aortobronchial fistulae reported in the literature. Without intervention, this condition has reported mortality rates of 100%.13-15 Thoracic aortic repair with a stent graft for aortobronchial fistulae appears to a viable alternative to conventional open repair with excellent short-term results.
Endografts (eg, aortic aneurysm device or covered stent) are increasingly being used to temporize or treat arterial and graft infections in inaccessible areas, in patients with compromised anatomy, or in the presence of active bleeding or rupture. This summary examines the evidence for “in situ” endografting in the treatment these conditions.
A two-level search strategy of the literature (MEDLINE, PubMed, Google Scholar, and The Cochrane Library) was performed for relevant articles listed between January 2000 and December 2015. The review was confined to patients with primary and secondary bacterial or viral arterial infections, with or without fistulization and infection of bypass grafts and arteriovenous accesses. For the purposes of this summary, endografts can be considered to be an aortic aneurysm device or a covered stent.
There are no societal guidelines. Endografts have been successfully applied to mycotic arterial aneurysms, aortoenteric, aortobronchial, and arterioureteric fistulae, and to anastomotic bleeds secondary to infection. Multiple reports indicate success at the control of hemorrhage in all locations. Short-term outcomes are good, but fatal infection-related complications, especially if antibiotic therapy is halted, are well reported and necessitate a more definitive plan for the long term.
Stent grafts remain an important and viable option for the treatment of mycotic aneurysms, aortoesophageal and aortobronchial fistulae, and infected pseudoaneurysms in anatomically or technically inaccessible locations. In patients with a short life span (<6 months), no further intervention is generally required. In patients with a predicted life span >6 months, careful consideration should be given to a more definitive procedure. Life-long appropriate antibiotic therapy is strongly recommended for any patient receiving an endograft in an infected field.
Predictors of outcome and different management of aortobronchial and aortoesophageal fistulas
2014, Journal of Thoracic and Cardiovascular Surgery
Aortoesophageal and aortobronchial fistulas are uncommon but life-threatening conditions. The present study aimed to identify potential differences in outcomes, depending on the etiology, type, and management of the fistulas, and to determine mortality predictors.
We retrospectively reviewed a series of 26 consecutive patients with thoracic aorta fistulas admitted to our institution from 1998 to 2013 (18 aortobronchial, 7 aortoesophageal, and 1 combined fistula).
The mean age was 61.5 ± 13.4 years, with 22 men. Management was thoracic endovascular aortic repair (TEVAR) in 8, open repair in 7, and conservative in 11. The TEVAR and nonoperative patients were significantly older and presented with more comorbidities. Shock developed in 15 patients and sepsis in 9. The most common radiologic findings were intramural hematoma (65.4%), pseudoaneurysm (53.8%), and bronchial compression (46.20%). Active contrast extravasation (23.1%) and ectopic gas (19.2%) were associated with a worse prognosis. In-hospital mortality was 100% in the conservative group, 37.5% in the TEVAR group, and 14.3% in the open repair group (P = .04). Septic shock was the most common cause of death. The risk factors for in-hospital mortality were hemodynamic instability on admission (P = .02), sepsis (P = .04), and conservative management (P < .001). The overall long-term survival in surgical patients at 1 and 5 years was 66% and 58.7%, respectively. Infectious and malignant etiologies resulted in the worst prognosis.
The outcomes are ultimately conditioned by the etiology of the fistula. Both open and endovascular management of aortic fistulas can prevent death by exsanguination; however, patients remain at high risk of infectious complications. Failure to treat the underlying cause will result in poor midterm outcomes.
Sudden death with massive hemoptysis from aortobronchial fistula
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Collective reviewFistulas between the aorta and traceobronchial tree

Abstract

Am Heart J

J Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am Heart J

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Tubercle

Dis Chest

Ann Thorac Surg

Semin Roentgenol

Ann Thorac Surg

Ann Thorac Surg

Rupture of tuberculous aortic aneurysm into lung

Ann Surg

Aorto-pulmonary fistula due to failure of an Ivalon graft for coarctation of the aorta

Thorax

Repair of a traumatic false aneurysm of the aorta perforating into the bronchus

J Cardiovasc Surg (Torino)

Occult hemoptysis: iatrogenic aortobronchial fistula [Letter]

Arch Surg

Surgical management of bleeding aortopulmonary fistula and removal of an infected graft

J Cardiovasc Surg (Torino)

Fistule, aorto-bronchique complication d'une coarctation de l'aorte opérée [Letter]

Presse Med

Aortobronchial fistula as a complication of surgery for correction of congenital aortic anomalies

Radiology

Collective review
Fistulas between the aorta and traceobronchial tree