Endovascular repair with extracorporeal membrane oxygenation as a rescue strategy for aortobronchial fistula: a case report.

Aortobronchial fistula (ABF) is a rare and potentially lethal complication of thoracic aortic replacement surgery. Currently, thoracic endovascular aortic repair (TEVAR) has emerged as a less invasive alternative to open surgery for ABF to facilitate prompt hemostasis. However, there are no published reports of TEVAR for ABF, particularly for presentation with life-threatening respiratory failure from massive hemoptysis. A 48-year-old male patient, who had recently undergone aortic root and arch replacement due to aortic dissection, was transferred to the emergency department with massive hemoptysis and severe dyspnea. A single-lumen endotracheal tube was immediately placed in the right main bronchus to protect the nonbleeding lung from spillage of blood. Chest computed tomography (CT) showed leakage of contrast material from the distal anastomosis of the aortic graft and consolidated lung tissue adjacent to the leakage. He was diagnosed with an ABF following aortic arch replacement, and an emergency TEVAR was performed. After adequate hemostasis, severe hypercapnia remained uncorrected despite the maximum ventilatory support. Thus, venovenous extracorporeal membrane oxygenation (VV ECMO) was immediately initiated, and severe respiratory acidosis improved dramatically. Furthermore, VV ECMO facilitated prompt bronchoscopic washout of the remaining blood clot without any danger of respiratory collapse and was weaned off successfully after 5 days as ventilation improved. This case demonstrates that emergency TEVAR in combination with VV ECMO can be a rescue strategy for massive hemoptysis from an ABF.

[Steroid].

It has been more than 60 years since the introduc- tion of glucocorticoid therapy as an effective treatment for patients with inflammatory process. Although glu- cocorticoid therapy has been widely accepted as an essential part of certain clinical settings, long-term administration can suppress the hypothalamic pitu- itary-adrenal axis, causing secondary adrenocortical insufficiency with surgical or medical stress. Periopera- tive glucocorticoid replacement may be required in such circumstances, but the amount of supplementa- tion needed to cover their stress during severe illness or following surgery has not been clearly determined. Recent recommendations for glucocorticoid supplemen- tation suggest that steroid coverage should be based on the duration and dosage of chronic steroid therapy, in addition to the type and probable length of the sur- gery. In this article, we give an overview of the cur- rent strategy for determining optimal dose, frequency, and duration of supplemental steroid for the patients with chronic glucocorticoid therapy.