Aortobronchial fistula caused by an endobronchial lobar Y stent: a word of caution

Aortobronchial fistula caused by an endobronchial lobar Y stent: a word of caution Abstract A 17-year-old female patient with a history of pulmonary tuberculosis was admitted with progressive dyspnoea and haemoptysis. Five months prior to admission, a left bronchial carina Y stent was implanted. Because of the already destroyed parenchyma, a pneumonectomy was planned. Intraoperatively, an aortobronchial fistula was discovered as the source of bleeding, which could be stopped by pledget-armed sutures. The formation of an aortobronchial fistula has to be considered as a potential source of endobronchial bleeding after stent implantation. Endobronchial lobar Y stent, Aortobronchial fistula, Endobronchial bleeding INTRODUCTION The formation of an aortobronchial fistula is a very rare event that usually occurs after cardiac operations in patients with an aneurysm of the descending aorta or after aortic replacement. Other causes are rarely documented, the mortality rate is high, and the diagnosis is often established during autopsy. We present a case of an aortobronchial fistula caused by penetration of an endobronchial Y stent implanted at the lobar carina between the left upper and lower lobes due to postinflammatory stenosis. CASE REPORT A 17-year-old female patient received tuberculostatic treatment for 5 months due to a mycobacterial pulmonary infection. Consecutively, she developed a bronchial stenosis at the level of the left lobar carina. She received a silicone-covered lobar carinal Y stent and after 8 weeks a covered metal stent due to a restenosis at both the distal lumina in a peripheral hospital. Because of a severe inflammatory reaction, rechannelling of the bronchial system could not be achieved, and a chest computed tomography (CT) scan demonstrated a completely destroyed left upper lobe and a partially destroyed left lower lobe (Fig. 1). In spite of this situation, the patient was able to follow her daily routine and visit school. Figure 1: View largeDownload slide Destroyed left upper lobe with a lobar carina Y stent. Figure 1: View largeDownload slide Destroyed left upper lobe with a lobar carina Y stent. In this situation, she developed massive haemoptysis, and after intubation by the emergency physician with unilateral right-sided placement of the endotracheal tube to control the bleeding, she was transferred to our hospital. At the time of admission, active tuberculosis was not proved, and tuberculostatic drugs were not administered. In the operating room, a bronchus blocker was placed in the left-sided stent by rigid bronchoscopy, and a right-sided double-lumen endotracheal tube was placed in case the blockers should be dislocated due to intraoperative manipulations. A left posterolateral thoracotomy was performed in the 5th intercostal space. Massive postinflammatory adhesions were mobilized by meticulous dissection using electrocautery. The pulmonary artery and veins were stapled intrapericardially. During preparation of the main bronchus, a perforation of the central end of the metal stent into the distal part of the aortic arch was observed. After cross-clamping the aorta distal to the left subclavian artery, as well as distal to the bleeding site, the perforation was closed using the Teflon-patch-armed prolene 4-0 sutures. Subsequently, the bronchial stump was shortened to the level of the carina and closed by a polydioxanone (PDS) suture. A pericardial patch was used to cover the stump. Aortic cross-clamp time was 20 min. Eight packed red blood cells were administered intraoperatively. The patient was weaned from mechanical ventilation 2 days postoperatively. A final contrast CT scan revealed a circumscribed excavation of the descending aorta ventrally to the 6th vertebral body in the area of the reconstructed aortic wall (Fig. 2). Figure 2: View largeDownload slide A postoperative computed tomography scan showing the descending aorta without vascular constriction after surgery. Figure 2: View largeDownload slide A postoperative computed tomography scan showing the descending aorta without vascular constriction after surgery. The patient was discharged 14 days postoperatively. A regular follow-up was performed every 3 months, and currently—15 months postoperatively—the patient is symptom free. Pulmonary or neurological complications were not observed perioperatively. DISCUSSION An acquired aortopulmonary fistula is a very rare disease and is only described in the literature in a few cases [1–5]. The disease is associated with high mortality, especially in the stage of acute bleeding [3–5]. To the best of our knowledge, the formation of an aortobronchial fistula after implantation of a metal lattice stent has not been described in the literature so far. Aortic surgery is a known risk factor for the formation of an aortopulmonary fistula caused by the expansion of the aortic wall [5]. However, an aortopulmonary fistula should also be considered as a differential diagnosis in patients after pulmonary interventions, especially after implantation of foreign material. In our case, the initial chest CT revealed a paravertebral subpleural arrosion bleeding in the completely destroyed left lower lobe. A fistula, however, was not detected preoperatively. The laceration of the aortic wall caused by the stent and the subsequent formation of a fistula were only detected intraoperatively. If an aortic lesion is suspected preoperatively, endovascular aortic stenting may be an option [5]. In summary, the formation of an aortopulmonary fistula has to be considered as a rare cause of endobronchial bleeding after endobronchial stent implantation. Conflict of interest: none declared. REFERENCES 1 Killen DA, Muehlebach GF, Wathanacharoen S. Aortopulmonary fistula. South Med J  2000; 93: 195– 8. Google Scholar CrossRef Search ADS PubMed  2 Macintosh EL, Parrott JC, Unruh HW. Fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg  1991; 51: 515– 9. Google Scholar CrossRef Search ADS PubMed  3 Miyata T, Ohara N, Shigematsu H, Konishi T, Yamaguchi H, Kazama S et al.   Endovascular stent graft reair of aortopulmonary fistula. J Vasc Surg  1999; 29: 557– 60. Google Scholar CrossRef Search ADS PubMed  4 Slonim SM, Adams MT, Kollmeyer KR. Endovascular repair of an aortopulmonary artery fistula with use of controlled-release coils. J Vasc Interv Radiol  2004; 15: 861– 4. Google Scholar CrossRef Search ADS PubMed  5 Vriend JW, Mulder BJ. Late complications in patients after repair of aortic coarctation: implications for management. Int J Cardiol  2005; 101: 399– 406. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Aortobronchial fistula caused by an endobronchial lobar Y stent: a word of caution

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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10.1093/icvts/ivy149
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Abstract

Abstract A 17-year-old female patient with a history of pulmonary tuberculosis was admitted with progressive dyspnoea and haemoptysis. Five months prior to admission, a left bronchial carina Y stent was implanted. Because of the already destroyed parenchyma, a pneumonectomy was planned. Intraoperatively, an aortobronchial fistula was discovered as the source of bleeding, which could be stopped by pledget-armed sutures. The formation of an aortobronchial fistula has to be considered as a potential source of endobronchial bleeding after stent implantation. Endobronchial lobar Y stent, Aortobronchial fistula, Endobronchial bleeding INTRODUCTION The formation of an aortobronchial fistula is a very rare event that usually occurs after cardiac operations in patients with an aneurysm of the descending aorta or after aortic replacement. Other causes are rarely documented, the mortality rate is high, and the diagnosis is often established during autopsy. We present a case of an aortobronchial fistula caused by penetration of an endobronchial Y stent implanted at the lobar carina between the left upper and lower lobes due to postinflammatory stenosis. CASE REPORT A 17-year-old female patient received tuberculostatic treatment for 5 months due to a mycobacterial pulmonary infection. Consecutively, she developed a bronchial stenosis at the level of the left lobar carina. She received a silicone-covered lobar carinal Y stent and after 8 weeks a covered metal stent due to a restenosis at both the distal lumina in a peripheral hospital. Because of a severe inflammatory reaction, rechannelling of the bronchial system could not be achieved, and a chest computed tomography (CT) scan demonstrated a completely destroyed left upper lobe and a partially destroyed left lower lobe (Fig. 1). In spite of this situation, the patient was able to follow her daily routine and visit school. Figure 1: View largeDownload slide Destroyed left upper lobe with a lobar carina Y stent. Figure 1: View largeDownload slide Destroyed left upper lobe with a lobar carina Y stent. In this situation, she developed massive haemoptysis, and after intubation by the emergency physician with unilateral right-sided placement of the endotracheal tube to control the bleeding, she was transferred to our hospital. At the time of admission, active tuberculosis was not proved, and tuberculostatic drugs were not administered. In the operating room, a bronchus blocker was placed in the left-sided stent by rigid bronchoscopy, and a right-sided double-lumen endotracheal tube was placed in case the blockers should be dislocated due to intraoperative manipulations. A left posterolateral thoracotomy was performed in the 5th intercostal space. Massive postinflammatory adhesions were mobilized by meticulous dissection using electrocautery. The pulmonary artery and veins were stapled intrapericardially. During preparation of the main bronchus, a perforation of the central end of the metal stent into the distal part of the aortic arch was observed. After cross-clamping the aorta distal to the left subclavian artery, as well as distal to the bleeding site, the perforation was closed using the Teflon-patch-armed prolene 4-0 sutures. Subsequently, the bronchial stump was shortened to the level of the carina and closed by a polydioxanone (PDS) suture. A pericardial patch was used to cover the stump. Aortic cross-clamp time was 20 min. Eight packed red blood cells were administered intraoperatively. The patient was weaned from mechanical ventilation 2 days postoperatively. A final contrast CT scan revealed a circumscribed excavation of the descending aorta ventrally to the 6th vertebral body in the area of the reconstructed aortic wall (Fig. 2). Figure 2: View largeDownload slide A postoperative computed tomography scan showing the descending aorta without vascular constriction after surgery. Figure 2: View largeDownload slide A postoperative computed tomography scan showing the descending aorta without vascular constriction after surgery. The patient was discharged 14 days postoperatively. A regular follow-up was performed every 3 months, and currently—15 months postoperatively—the patient is symptom free. Pulmonary or neurological complications were not observed perioperatively. DISCUSSION An acquired aortopulmonary fistula is a very rare disease and is only described in the literature in a few cases [1–5]. The disease is associated with high mortality, especially in the stage of acute bleeding [3–5]. To the best of our knowledge, the formation of an aortobronchial fistula after implantation of a metal lattice stent has not been described in the literature so far. Aortic surgery is a known risk factor for the formation of an aortopulmonary fistula caused by the expansion of the aortic wall [5]. However, an aortopulmonary fistula should also be considered as a differential diagnosis in patients after pulmonary interventions, especially after implantation of foreign material. In our case, the initial chest CT revealed a paravertebral subpleural arrosion bleeding in the completely destroyed left lower lobe. A fistula, however, was not detected preoperatively. The laceration of the aortic wall caused by the stent and the subsequent formation of a fistula were only detected intraoperatively. If an aortic lesion is suspected preoperatively, endovascular aortic stenting may be an option [5]. In summary, the formation of an aortopulmonary fistula has to be considered as a rare cause of endobronchial bleeding after endobronchial stent implantation. Conflict of interest: none declared. REFERENCES 1 Killen DA, Muehlebach GF, Wathanacharoen S. Aortopulmonary fistula. South Med J  2000; 93: 195– 8. Google Scholar CrossRef Search ADS PubMed  2 Macintosh EL, Parrott JC, Unruh HW. Fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg  1991; 51: 515– 9. Google Scholar CrossRef Search ADS PubMed  3 Miyata T, Ohara N, Shigematsu H, Konishi T, Yamaguchi H, Kazama S et al.   Endovascular stent graft reair of aortopulmonary fistula. J Vasc Surg  1999; 29: 557– 60. Google Scholar CrossRef Search ADS PubMed  4 Slonim SM, Adams MT, Kollmeyer KR. Endovascular repair of an aortopulmonary artery fistula with use of controlled-release coils. J Vasc Interv Radiol  2004; 15: 861– 4. Google Scholar CrossRef Search ADS PubMed  5 Vriend JW, Mulder BJ. Late complications in patients after repair of aortic coarctation: implications for management. Int J Cardiol  2005; 101: 399– 406. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Apr 25, 2018

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