Staged complex reconstruction of infected thoracic aortic endograft and adjacent spinal hardware using latissimus wrapped lateral aortic graft.

Thoracic endovascular aortic repair (TEVAR) enables rapid and effective treatment of life-threatening aortic injuries. The occurrence of long-term complications from TEVAR and their management is ill-defined in young patients. This report describes a complex case of a 38-year-old male patient who underwent staged interventions for different acute pathologies instigated by blunt thoracic spinal trauma. The patient was initially treated with a TEVAR for aortic pseudoaneurysm in the setting of infected spinal hardware, which later resulted in an aortobronchial fistula and eroded spinal hardware. This report illustrates a successful multidisciplinary approach for definitive treatment with graft explant and aortic reconstruction.

Direct visualization of postoperative aortobronchial fistula on computed tomography.

BACKGROUND: Postoperative aortobronchial fistula (ABF) is a rare complication that can occur in 0.3%-5.0% of patients over an extended period of time after thoracic aortic surgery. Direct visualization of the fistula via imaging is rare. AIM: To investigate the relationship between computed tomography (CT) findings and the clinical signs/symptoms of ABF after thoracic aortic surgery. METHODS: Six patients (mean age 71 years, including 4 men and 2 women) with suspected ABF on CT (air around the graft) at our hospital were included in this retrospective study between January 2004 and September 2022. Chest CT findings included direct confirmation of ABF, peri-graft fluid, ring enhancement, dirty fat sign, atelectasis, pulmonary hemorrhage, and bronchodilation, and the clinical course were retrospectively reviewed. The proportion of each type of CT finding was calculated. RESULTS: ABF detection after surgery was found to have a mean and median of 14 and 13 years, respectively. Initial signs and symptoms were asymptomatic in 4 patients, bloody sputum was found in 1 patient, and fever was present in 1 patient. The complications of ABF included graft infection in 2 patients and graft infection with hemoptysis in 2 patients. Of the 6 patients, 3 survived, 2 died, and 1 was lost to follow-up. The locations of the ABFs were as follows: 1 in the ascending aorta; 1 in the aortic arch; 2 in the aortic arch leading to the descending aorta; and 2 in the descending aorta. ABFs were directly confirmed by CT in 4/6 (67%) patients. Peri-graft dirty fat (4/6, 67%) and peri-graft ring enhancement (3/6, 50%) were associated with graft infection, endoleaks and pseudoaneurysms were associated with hemoptysis (2/6, 33%). CONCLUSION: Asymptomatic ABF after thoracic aortic surgery can be confirmed on chest CT. CT is useful for the diagnosis of ABF and its complications.

Manejo endovascular de hemoptisis secundaria a pseudoaneurisma de la aorta torácica, mediante un abordaje proximal

Objetivo: Describir un caso clínico y una alternativa de manejo para el tratamiento de la hemoptisis secundaria a patología la aneurismática de la aorta torácica. Materiales y Métodos: Revisión de historia clínica y exámenes complementarios, disponibles en sistema digital del centro asistencial de origen. Resultados: Se presenta el caso de paciente masculino, 56 años, que cursó con cuadro de hemoptisis, posteriormente objetivado como secundario a un pseudoaneurisma de la aorta torácica. Entre sus antecedentes destaca, enfermedad aorto-ilíaca tratada mediante un bypass de aorta torácica. Se decidió la reparación endovascular, mediante un abordaje proximal, utilizando la arteria axilar. Discusión: Las indicaciones para el uso de la reparación torácica endovascular de la aorta (TEVAR) se están expandiendo ampliamente, incluyendo a pacientes previamente intervenidos o aquellos que antiguamente se consideraban con un riesgo prohibitivamente alto para una cirugía. La fístula aorto-bronquial, es una complicación rara, sin embargo, existe correlación entre su desarrollo y la cirugía de aorta torácica. La sospecha diagnóstica debe ser alta. La AngioTC, cumple un doble rol, tanto para el diagnóstico, como para la planificación preoperatoria, hecho fundamental para conseguir una terapia adecuada.

Objective: To describe a clinical case and a management alternative for the treatment of hemoptysis secondary to thoracic aortic aneurysm pathology. Material and Method: Review of clinical history and complementary examinations, available in the digital system of the health care center of origin. Results: We present the case of a male patient, 56 years old, presented with hemoptysis, later found to be secondary to a pseudoaneurysm of the thoracic aorta. History included aorto-iliac disease treated by thoracic aortic bypass. Endovascular repair was decided by a proximal approach using the axillary artery. Discussion: Indications for the use of TEVAR are expanding widely. Including previously operated patients or those formerly considered prohibitively high risk for surgery. Aortobronchial fistula is a rare complication, however, there is a correlation between its development and thoracic aortic surgery. Diagnostic suspicion should be high. AngioCT plays a dual role in diagnosis and preoperative planning, which is essential to achieve adequate therapy.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR.

BACKGROUND: Aortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft. CASE PRESENTATION: A 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway. CONCLUSION: Aortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

Aortobronchial fistula after Bentall procedure treated with elective arch replacement: A case report.

Aortobronchial fistula often requires emergency surgery as it causes rapidly progressing respiratory failure. Some patients present with recurrent hemoptysis episodes. We report the case of a patient who was saved by elective surgery after aortobronchial fistula following aortic pseudoaneurysm rupture into the lung. An 84-year-old man, who had undergone mechanical Bentall replacement of the ascending aorta 20 years ago, complained of persistent fever. Computed tomography indicated a pseudoaneurysm at the distal anastomosis of the ascending aorta, and an urgent surgery was planned. During hospitalization, his aneurysm ruptured, suddenly penetrating the right lung and triggering acute respiratory failure and unconsciousness before the planned urgent operation. Mechanical ventilation was immediately provided; his respiratory status remarkably improved through intensive care and medical therapy. After nutritional status recovery, partial arch replacement was performed as an elective operation without any intervention for the injured lung. He did not exhibit any respiratory or neurological complications postoperatively.

Endovascular repair of aortobronchial fistula three decades after open repair of traumatic aortic transection: A case report and 3-year follow-up.

A rare and lethal vascular condition is the communication of the thoracic aorta and tracheobronchial tree. Typically, the development occurs after open or endovascular aortic repair that has been complicated by infection and usually presents with hemoptysis as the heralding event, which can lead to massive hemorrhage. Computed tomography angiography remains the diagnostic imaging modality of choice. Medical management will be futile, with the need for expedited operative intervention via open, endovascular, or hybrid open and endovascular repair.

Hybrid Management of an Aortobronchial Fistula after Patch Aortoplasty for Aortic Coarctation in a Patient with SARS-CoV-2 Pneumonia: Case Report and Review of the Literature.

Aortobronchial fistula is a rare cause of repeated hemoptysis and a potentially fatal condition if left untreated. We present the case of a 40-year-old man with repeated hemoptysis, excessive cough, and epistaxis ongoing for several days after SARS-CoV-2 pneumonia diagnosis. The patient had a history of patch aortoplasty for aortic coarctation and aortic valve replacement with a mechanical valve for aortic insufficiency due to bicuspid aortic valve at the age of 24. Computed tomography scan performed at presentation revealed a severely dilated ascending aorta, a thoracic aorta pseudoaneurysm at the site of the former coarctation, an aortobronchial fistula suggested by the thickened left lower lobe apical segmental bronchus in contact with the pseudoaneurysm and signs of alveolar hemorrhage in the respective segment. The patient was treated with thoracic endovascular aneurysm repair (TEVAR) after prior hemi-aortic arch debranching and transposition of the left common carotid artery and subclavian artery through a closed-chest surgical approach. Our case report together with a systematic review of the literature highlight the importance of both considering an aortobronchial fistula in the differential diagnosis of hemoptysis in patients with prior history of thoracic aorta surgical intervention, regardless of associated pathology, and of taking into account endovascular and hybrid techniques as an alternative to open surgical repair, which carries a high risk of morbidity and mortality.

Cardiac device to plug an aorto-bronchial fistula.

BACKGROUND: Post-coarctoplasty aortic pseudoaneurysms constitute a lethal problem occurring in up to 38% of patients with a history of aortic coarctation surgical repair. Such pseudoaneurysms are prone to rupture if managed conservatively and high mortality and morbidity if treated with open surgery. Therefore, the endovascular approach has been proposed for their management. CASE REPORT: We describe a patient with a post-coarctoplasty aortic pseudoaneurysm complicated by an aortobronchial fistula. The case was treated via the endovascular approach (thoracic endovascular aortic repair and endovascular coarctoplasty) with an atrial septal defect occluder device. CONCLUSIONS: Endovascular repair is a feasible, safe, and promising treatment for thoracic aortic pseudoaneurysms secondary to coarctation repair.

Use of thoracic endovascular aortic repair for management of aortobronchial fistula.

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.

Ascending aorta graft pseudoaneurysm and aortobronchial fistula caused by a fractured sternal wire: a case report.

BACKGROUND: Pseudoaneurysm of ascending aorta is a rare but serious complication of cardiovascular surgeries and it infrequently occurs in the normal prosthetic graft materials. We share our experience with an unusual case of ascending aorta Dacron graft pseudoaneurysm caused by a fractured sternal wire. CASE PRESENTATION: A 34-year-old man, known case of Marfan syndrome, with history of two prior aortic surgeries for aneurysm of ascending aorta, arch and thoracoabdominal aorta, presented with hemoptysis. The hemoptysis originated from an aortobronchial fistula secondary to a huge ascending aorta Dacron graft pseudoaneurysm. The graft erosion and subsequent pseudoaneurysm was caused by a fractured sternal wire. Surgical repair of the pseudoaneurysm was performed successfully and a Gore-tex patch was placed behind the sternum over the graft to prevent further direct contact of the wire and the graft. CONCLUSION: Sternal wires can damage the adjacent vascular grafts and lead to fatal complications such as pseudoaneurysm formation. Thus, preventive measures such as using sternal bands and placing a covering layer between the sternal wires and aortic grafts are recommended in patients with dilated or replaced ascending aorta.

Combined endovascular and open treatment to prevent increase in afterload in anastomotic pseudoaneurysm and aortobronchial fistula after surgery for aortic coarctation.

We report the treatment of a patient who had presented with hemoptysis due to an aortobronchial fistula from an anastomotic pseudoaneurysm after extra-anatomic bypass for aortic coarctation. An aortobronchial fistula can often result from an aortic pseudoaneurysm and is associated with high mortality if not treated. We decided to use combined endovascular and open surgical treatment and obtained a satisfactory intraoperative result. The perioperative outcome and first follow-up visit were favorable. In recent years, endovascular repair of pathologic aortic conditions has increased; thus, we have placed the present case within the context of the relevant medical literature.

Massive Hemoptysis Caused by an Aortobronchial Fistula Related to Pedicle Screw Impingement.

We report a case of a 50-year-old man with a 10-year history of pedicle screw internal fixation in the thoracic spine and heroin abuse, who presented with sudden-onset massive hemoptysis with hemorrhagic shock and asphyxia. Urgent contrast-enhanced chest computed tomography (CT) characteristically showed thoracic aortic perforation, a paravertebral pseudoaneurysm, and an intrapulmonary hematoma. Emergency percutaneous thoracic endovascular aortic repair (pTEVAR) with the preclose technique using a vascular closure device under local anesthesia achieved success without any complications. The current case highlights the importance of understanding massive hemoptysis caused by an aortobronchial fistula related to pedicle screw impingement in clinical practice and the value of pTEVAR with the preclose technique under local anesthesia in the emergency setting.

Management of aortobronchial fistula: Experience of 14 cases.

OBJECTIVES: Aortobronchial fistula (ABF) is rare but lethal condition if left untreated, and the treatment still remains challenging. We retrospectively reviewed data at our Institution and report our experience in the management of ABF. METHODS: From September 2010 to May 2019, 14 patients (13 men, average age 52 ± 11 years) with ABF were treated in our hospital. Three types of management were applied according to the patients' different clinical presentation, including conservative treatment, that is, antibiotic treatment (n = 3), endovascular repair (n = 7), and open surgery (n = 4). In the open surgery group, Dacron grafts were used, two cases received in situ descending thoracic aortic replacement through left thoracotomy and two cases received extra-anatomic bypass through median thoracoabdominal incision. RESULTS: In the conservative treatment group (n = 3), two patients died during follow-up, the third was alive in good condition. In the endovascular repair group (n = 7), one patient died 22 days after the endovascular repair because of massive hemoptysis and another patient died 4 days after the procedure because of cerebral infarction. In the medium term, two patients died of massive hemoptysis, and one was lost at follow-up. In the open surgery group (n = 4), one patient died because of massive hemoptysis 2 days after his extra-anatomic bypass procedure, the remaining patients were alive in good condition at follow-up. CONCLUSIONS: ABF is catastrophic if left untreated. Endovascular repair might be a reasonable temporary bridge solution in emergency cases, but is less durable in the long run. Open surgery, despite more challenging, provides a more definitive treatment for ABF.

The Cause of Massive Hemoptysis After Thoracic Endovascular Aortic Repair May Not Always Be an Aortobronchial Fistula: Report of a Case.

Hemoptysis after thoracic endovascular/open aortic repair is relatively rare but a well-known complication, and normally diagnosed with aortobronchial fistula (ABF). Here, we present a patient who suffered from recurrent massive hemoptyses even after multiple thoracic endovascular aortic repairs (TEVARs), where hemoptysis was ultimately controlled by pneumonectomy. In this case, the bleeding source was not the aorta but the lung parenchyma itself, indicating the importance of raising awareness that the cause of massive hemoptysis after TEVAR may not always be an ABF.

Cough, Aortobronchial Fistula, and Air Migration in the Remnant Aneurysm Sac: An Unforeseen Path?

The pressure gap between the aortic lumen and bronchial air spaces makes hemoptysis the most frequent feature of aortobronchial fistula (ABF). However, air migration can be a rare cause of ABF. The literature has demonstrated some "indirect routes" that would serve as a bridge between ABF and consecutive air migrations. However, evidence suggesting the presence of a "direct route" between them is lacking. We present an extremely rare case of newly onset cough-induced "perigraft space ABF" and ABF-related air migration in the remnant aneurysm sac occurring 3 years after an aortic surgery and a near-misdiagnosis of a delayed graft infection.

Sudden death with massive hemoptysis from aortobronchial fistula.

Aortobronchial fistula is an uncommon clinical entity, with unpredictable clinical course and significant mortality. Here, we describe a case of fistulous tract between a descending aortic graft and a branch of the left upper lobar bronchus leading to massive hemoptysis causing death for hemorrhagic shock in a 72-year-old man.

Thoracic endovascular aortic repair for aortobronchial fistula: a case series.

BACKGROUND: Aortobronchial fistula (ABF) formation following the rupture of thoracic pseudoaneurysm is a rare clinical entity. Its aetiology includes atherosclerosis, infections, trauma, post-surgery, and post-endovascular aortic repair. The clinical presentation of ABF includes intermittent or massive haemoptysis, acute respiratory distress, hypotension, and even death. These patients require an emergency aortic intervention to stop active haemorrhage. Thoracic endovascular aortic repair (TEVAR) is a less invasive, safe, and effective treatment compared to conventional open surgical repair. CASE SUMMARY: We hereby report three cases of ruptured descending thoracic aortic pseudoaneurysms resulting in a fistula formation. The first two cases had tuberculosis as their underlying aetiology, while the third case was the result of previous open post-aortic surgery. All patients presented with massive haemoptysis and were successfully treated by emergency TEVAR and had favourable outcomes. DISCUSSION: Thoracic endovascular aortic repair is a rapid, less invasive, and effective treatment for emergency management of ABF. It has more than 85% technical success rates in the reported literature. We had procedural success in all three cases. The short and midterm outcome of ABF following TEVAR is favourable and encouraging.

Extra-anatomical ascending-thoraco-abdominal bypass for aortic fistula after thoracic endovascular aortic repair.

Aortobronchial and aorto-oesophageal fistulae after thoracic endovascular aortic repair (TEVAR) for traumatic aortic injuries are rare but serious. Potentially fatal complications may occur years after the stent graft deployment. Surgical management is challenging. We report on a 33-year-old male with aorto-oesophageal fistula and a 25-year-old male with aortobronchial fistula-both of whom received TEVAR for traumatic aortic injury. Each underwent successful staged open surgical repair with extra-anatomical bypass from the ascending aorta to the thoraco-abdominal aorta, along with arch vessel reconstructions and debridement of infected lesions. They remained alive after 18 months.