Acute management of aortobronchial and aortoesophageal fistulas using thoracic endovascular aortic repair
Received 3 March 2009; accepted 17 April 2009. published online 01 June 2009.
Background
Aortobronchial fistula (ABF) and aortoesophageal fistula (AEF) are rare but lethal if untreated; open thoracic surgery is associated with high operative mortality and morbidity. In this case series, we sought to investigate outcomes of thoracic endovascular aortic repair (TEVAR) for emergency cases of ABF and AEF.
Methods
We retrospectively reviewed all patients with AEF and ABF undergoing TEVAR in three European teaching hospitals between 2000 and January 2009. Eleven patients were identified including 6 patients with ABF, 4 patients with AEF, and 1 patient with a combined ABF and AEF. In-hospital outcomes and follow-up after TEVAR were evaluated.
Results
Median age was 63 years (interquartile range, 31); 8 were male. Ten patients presented with hemoptysis or hematemesis; 4 developed hemorrhagic shock. All patients underwent immediate TEVAR, and 3 AEF patients required additional esophageal surgery. Five patients died (45%), including 3 patients with AEF, 1 patient with ABF, and 1 patient with a combined ABF and AEF, after a median duration of 22 days (interquartile range, 51 days). The patient with AEF that survived had received early esophageal reconstruction. Causes of death were: sepsis (n = 2), acute respiratory distress syndrome (ARDS) (n = 1), thoracic infections (n = 1), and aortic rupture (n = 1). Median follow-up of surviving patients was 45 months (interquartile range, 45 months). Six additional vascular interventions were performed in 3 survivors.
Conclusion
TEVAR does prevent immediate exsanguination in patients admitted with AEF and ABF, but after initial deployment of the endograft and control of the hemodynamic status, most patients, in particular those with AEF, are at risk for infectious complications. Early esophageal repair after TEVAR appears to improve the survival in case of AEF. Therefore, TEVAR may serve as a bridge to surgery in emergency cases of AEF with subsequent definitive open operative repair of the esophageal defect as soon as possible. In patients with ABF, additional open surgery may not be necessary after the endovascular procedure.
aSection of Vascular Surgery, Department of Surgery at Yale University School of Medicine, New Haven, Conn
bDepartment of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
cCardiovascular Center “E Malan,” Policlinico San Donato IRCCS, San Donato Milanese, Italy
dDepartment of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
eSection of Vascular Surgery, Department of Surgery at the University Medical Center Utrecht, Utrecht, The Netherlands
fSections of Vascular Surgery and Interventional Radiology, Departments of Surgery and Radiology at Yale University School of Medicine, New Haven, Conn
Reprint requests: Bart E. Muhs, MD, PhD, Assistant Professor of Surgery and Radiology, Co-Director, Endovascular Program, Yale University School of Medicine, 333 Cedar St, BB-204, New Haven, CT 06510
ABSTRACT