SESSION TYPE: Airway Cases II
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Aorto-bronchial fistulae secondary to thoracic aortic repair has only been reported fifteen times in literature. Massive hemoptysis can occur and prompt recognition of a fistula improves survival.
CASE PRESENTATION: An 88 year old man with history of hypertension and a thoracic aorta aneurysm, repaired with a surgical graft placement 7 years earlier, presented to the hospital with massive hemoptysis. Chest X rays and computerized tomography (CT) showed no lesion on parenchyma. He underwent a bronchoscopy that showed only blood clots in the left main bronchus but no active source of bleeding was identified. His hemoptysis resolved and he was sent home without a specific diagnosis. A week later he returned with recurrent episodes of hemoptysis producing up to 300 milliliters of blood. Chest CT with aneurysm protocol was done showing a subtle air tract coming from the superior segment of left lower lobe (Figure 1) and extravasation of contrast coming from thoracic aorta (Figure 2) suggestive of aorto-bronchial fistulae. The patient was taken for a thoracic endovascular aortic repair (TEVAR) which confirmed the diagnosis and corrected his hemoptysis.
DISCUSSION: Aorto-bronchial fistulae were first described secondary to infections such as tuberculosis and fungi. In 1934 such fistulae were described post-mortem in patients with aneurysm of the descending thoracic aorta. Infection or close contact between the vessel and the bronchial wall causes an inflammatory response that produces a connection between structures. In our case it appears that the prior aneurysm graft repair triggered the fistula formation. Published data about the benefits between open surgery repair versus endovascular intervention for aorto-bronchial fistulae is lacking. Comparison between both procedures is well known in thoracic aortic aneurysm repair, which reports better lower 30 day mortality rate and stroke incidence in patients who undergo endovascular grafts compared to open surgery. In our case patient underwent successful endovascular grafting because of high risk of post-procedure complications.
CONCLUSIONS: Massive hemoptysis secondary to aorto-bronchial fistulas in patients with history of thoracic aorta aneurysm repair has to be always considered and endovascular grafting is a reasonable intervention that may decrease post-operative complications.
1) MacIntosh EL, Parrott JC, Unruh HW. Fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg. 1991 Mar;51(3):515-9.
2) Kazerooni EA, Williams DM, Abrams GD, Deeb GM, Weg JG. Aortobronchial fistula 13 years following repair of aortic transection. Chest. 1994 Nov;106(5):1590-4.
3) Jonker FH, Verhagen HJ, Lin PH, Heijmen RH, Trimarchi S, Lee WA, Moll FL, Atamneh H, Rampoldi V, Muhs BE. Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms. J Vasc Surg. 2011 May;53(5):1210-6. Epub 2011 Feb 5.
DISCLOSURE: The following authors have nothing to disclose: Hiram Rivas-Perez, Mark Wewers
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