INTRODUCTION: Fistulas between the aorta and tracheobronchial tree are uncommon but usually lethal if not treated surgically and timely as they can cause massive fatal hemoptysis. Aortobronchial fistulas occur most often in patients who have a history of thoracic vascular surgery. Few cases without previous thoracic surgery, trauma or infectious process of the aorta have been described in the literature.
CASE PRESENTATION: A 75-year-old Caucasian man with history of hypertension, hyperlipidemia, duodenal ulcer and abdominal aortic aneurysm who presented to the emergency room after an episode of “spitting up” a small amount of red blood. The patient was seen and discharged home but returned four days later when he was hospitalized with provisional diagnosis of upper gastrointestinal bleeding after having three episodes of “vomiting / spitting” red blood. The patient was found to be orthostatic and the physical exam was remarkable for mild tenderness to palpation of epigastrium. Hemoccult was positive. Chest x-ray showed old left hemi-diaphragm elevation but no infiltrate, pleural effusion or nodules. A CT of the chest was requested. Gastroenterology consult was placed. Eighteen hours after admission the patient suffered an episode of hemoptysis, (approximately 100 cc), followed four hours later by an incident of massive hemoptysis estimated in 700 cc. The patient suffered a cardiac arrest and could not be resuscitated. The autopsy performed showed a saccular atherosclerotic aneurysm of the descending thoracic aorta, measuring 8.0 x 7.0 x 5.0 cm, adjacent to the left lower lobe, eroding into the left lower lobe and forming an aortobronchial parenchymal fistula.
DISCUSSIONS: Aortobronchial Fistula (ABF) is uncommon but lethal if not treated Surgically. Girardet was the first who described an aortobronchial fistula secondary to TB in 1914. Prior to 1960, the most common infectious causes were tuberculosis, syphilis, and fungal infections. Since then, most cases have occurred in the setting of atherosclerosis . Intermittent hemoptysis is the most common symptom, occurring in 95% of the patients and massive hemoptysis occurs in 50% of the patients. Other signs and symptoms of ABF are dyspnea, cough, chest or back pain, pulmonary rales or hypoxia.Routine radiological imaging technique as CT , MRA or angiogram can be employed but sensitivity and specificity is not high. Bronchoscopy can identify the source of the bleeding, but the fistulous tract might not be visible. It is concluded that timely diagnosis and surgical intervention can be life saving. Unfortunately, the correct diagnosis of ABF is established premortem in only 54% of the cases. Prior to the use of stenting techniques, surgeons performed open procedures via thoracotomy or sternotomy.From our literature review, we found that 18 out of 36 patients (50%) had their ABF repaired in timely basis with endovascular technique with significant impact on mortality (100% survival). Overall, a 72% survival was identified when combining endovascular and conventional procedures.Although ABF is a rare condition, our presenting case demonstrates the relevance of a careful differential diagnosis and a high degree of suspicion in patients with unexplained hemoptysis. If an ABF cannot be excluded, surgery should be performed by Endovascular technique, which is safer and quicker.
CONCLUSION: Aortobronchial fistula (ABF) is an anomalous communication between the aorta and a segment of the tracheobronchial tree with non specific symptomatology and lack of sensitivity of diagnostic tests, high index of suspicion is critical to improve mortality.
DISCLOSURE: Abhijit Raval, No Financial Disclosure Information; No Product/Research Disclosure Information