Endovascular Repair of Aortobronchial Fistula Three Decades After Open Repair of Traumatic Aortic Transection
Joseph A. Di Como, MD, Graham T. Endler, DO, Stephen G. Lalka, MD, Savas Mavridis, MD, James Tretter, DO.
Conemaugh Memorial Medical Center, Johnstown, PA, USA.
OBJECTIVES: An aortobronchial fistula (ABF) is a rare but potentially lethal vascular condition that can be associated with open thoracic aortic repair when complicated by anastomotic pseudoaneurysm. The ABF is considered secondary when the connection exists between the reconstructed aorta and the bronchial tree or lung parenchyma. ABFs often present as vascular emergencies and, historically, open repair of this complication carries a high mortality rate reported at 15-41%.
We report on a 54 year old male who presented with a single episode of painless hemoptysis without any other abnormal signs or symptoms and stable vital signs. His history was significant for a motor vehicle collision 29 years previous resulting in traumatic thoracic aortic transection requiring open thoracic aortic graft repair. Computed tomographic angiography demonstrated a saccular aneurysm arising from the superior-lateral margin of the proximal descending thoracic aorta, involving the proximal anastomosis of his previous aortic repair, 2 cm distal to the origin of the left subclavian artery. The pseudoaneurysm measured 14 mm x 12 mm with a 12 mm neck. An enhancing vessel arising from the pseudoaneurysm was identified as an ABF. His afebrile status with a normal white blood cell count, erythrocyte sedimentation rate, C-reactive protein and Ceretec white blood cell scan supported the diagnosis of an ABF associated with a non-infected anastomotic aortic pseudoaneurysm.
Our patient underwent successful thoracic endovascular aortic repair (TEVAR) with a single 30 x 30 x 100 mm endograft via bilateral percutaneous femoral access. No residual ABF, endoleak or left subclavian obstruction was demonstrated post-deployment. He was discharged without complication on postoperative day one.
An ABF is a rare vascular condition that has been reported after open and even endovascular thoracic aortic repair. Patients most commonly present with hemoptysis. This can be a herald bleed before hemorrhagic catastrophe. ABFs with anastomotic pseudoaneurysms after aortic repair are often associated with infection. As we demonstrate in this report, ABFs can occur even decades after open thoracic aortic repair and can be successfully treated by TEVAR.
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