Endovascular management for aortobronchial fistula following patent ductus arteriosus ligation

Nitesh B Karnire; Pravat K Dash; Nishita C Pujary; Chetan Kumar

doi:10.4103/mgmj.MGMJ_38_20

CASE REPORT

Year : 2020 | Volume : 7 | Issue : 1 | Page : 50-52

Endovascular management for aortobronchial fistula following patent ductus arteriosus ligation

Nitesh B Karnire¹, Pravat K Dash¹, Nishita C Pujary², Chetan Kumar¹
¹ Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
² Bandra Nursing Home, Mumbai, Maharashtra, India

Date of Submission	08-May-2020
Date of Acceptance	08-May-2020
Date of Web Publication	06-Jun-2020

Correspondence Address:
Dr. Nitesh B Karnire
L-5/39, Vrindavan Colony, Tilak Nagar, Chembur, Mumbai 400089, Maharashtra.
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.MGMJ_38_20

Abstract

We report herein a patient with endobronchial fistula post-patent ductus arteriosus ligation surgery, who presented with massive hemoptysis. Cook’s embolization coil 0.052 inch × 8cm × 6mm was used to close the fistula through the endovascular procedure.

Keywords: Aortobronchial fistula, coil closure, patent ductus arteriosus

How to cite this article:
Karnire NB, Dash PK, Pujary NC, Kumar C. Endovascular management for aortobronchial fistula following patent ductus arteriosus ligation. MGM J Med Sci 2020;7:50-2

How to cite this URL:
Karnire NB, Dash PK, Pujary NC, Kumar C. Endovascular management for aortobronchial fistula following patent ductus arteriosus ligation. MGM J Med Sci [serial online] 2020 [cited 2022 Oct 1];7:50-2. Available from: http://www.mgmjms.com/text.asp?2020/7/1/50/286108

Background

A 12-year-old male child with Down syndrome had patent ductus arteriosus (PDA) ligation in 2007. Atrial septal defect (ASD) device closure (cocoon septal occluder 18mm) was carried out on June 25, 2018 for 16-mm ostium secundum (OS) ASD in a local hospital. He was presented with recurrent hemoptysis for 15 days since March 2019. Upper gastrointestinal (GI) endoscopy performed elsewhere was normal. Transthoracic echocardiography (TTE)-ASD device in situ, no residual shunt across ASD device, mild tricuspid regurgitation (TR)/mild pulmonary arterial hypertension (PAH), and normal biventricular function (BV) function. Chest X-ray showed left supra hilar mass [Figure 1]. A contrast-enhanced computed tomography (CT) scan of the chest was performed, which showed pseudoaneurysm of the aorta with aortobronchial fistula.[Figure 2]

Figure 1: X-ray showing left supra hilar mass

Click here to view

Figure 2: (A) CT aortogram showing pseudoanneursm and aortobronchial fistula. (B) CT aortogram showing pseudoanneurysm with aortobronchial fistula

Click here to view

Patients developed massive hemoptysis on the day of admission requiring endotracheal intubation and mechanical ventilation. He required packed cell transfusion (hemoglobin dropped from 11 g/dL to 8.6g/dL).

Procedure

Aortogram done showed pseudoaneurysm of the descending thoracic aorta (DTA) with aortobronchial fistula [Figure 3].

Figure 3: (A) Aortogram plain image. (B) JR catheter in pseudoaneurysm. (C) Coiling procedure. (D) Post coiling

Click here to view

JR 6F guiding catheter was taken into the fistula. The neck of the aneurysm measured to be 2.36 mm.

◻ Cook’s embolization coil 0.052 inch × 8 cm × 6 mm attached to bioptome loaded into JR 6F guiding catheter.

◻ Cook’s embolization coil 0.052 inch × 8 cm × 6 mm released into the pseudoaneurysm with its last coil in descending aorta.

◻ Repeat aortogram showed complete occlusion of the pseudoaneurysm with no residual flow.[Video 1], [Video 2], [Video 3]

The patient had no further episodes of hemoptysis after coil embolization

Discussion

Aortic fistulas into the airways are seen after DTA procedures. They can be seen after PDA and aortic coarctation repair. Aortic fistulas have also been reported after surgical repair of the aortic arch and thoracoabdominal aneurysms, DTA traumatic rupture, type A and B aortic dissection, Takayasu arteritis, and aortic sarcoma.^[1]

The left bronchial tree is far more commonly involved in aortobronchial fistula formation than the right, and the communication is usually between the aneurysm and the membranous wall of the bronchus. Compression of the tracheobronchial tree by enlargement of the thoracic aneurysm may induce pressure necrosis, which can lead to erosion of both the aortic and bronchial walls. A fistula between the aortic and bronchial lumina is created, giving rise to mild or severe hemoptysis, which is the most typical sign of aortobronchial fistula.^[2]

Although hemoptysis is not specific to aortobronchial fistula, fistula must be strongly suspected when hemoptysis occurs in a patient who has had a thoracic aortic aneurysm or has undergone thoracic aortic surgery.^[3] The lesions (aortic aneurysm or pseudoaneurysm, surgical sutures, aortic stent grafting, and PDA) in the aortic artery are irritated or oppressed continuously, which may lead to inflammation and scar conformation. Eventually, a fistula tube would communicate between the aorta and the adjacent lobe of the lung.^[4]

The clinical presentation of aortobronchial fistulas varies, including chest pain, back pain, cough, dyspnea, and hemoptysis. Hemoptysis is the most often symptom, which occurs in over 95% of cases. Cessation of hemoptysis depends on the formation of a clot and occlusion of the fistula.^[1]

The literature research performed by the authors identified 134 patients. The technical success rate was 93.2%. The overall 30-day mortality was 5.9%. After a mean follow-up of 17.4 months, the aortic-related mortality was 14.3%. Recurrence of the aortobronchial fistula was observed in 11.1% of the patients. Thoracic endovascular aortic repair of aortobronchial fistulas appears to be a viable alternative with excellent short-term results.^[5]

Conclusion

◻ Aortobronchial fistula should be suspected in patients with thoracic aneurysm and postaortic repair patients presenting with hemoptysis.

◻ CT aortogram can help in the early detection of such aneurysms.

◻ Aortic pseudoaneurysms can be treated with endovascular procedures such as coil embolization or covered stent.

◻ Endovascular procedures have a lower rate of complications when compared to surgery and may be the preferred option, whenever feasible

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Picichè M, De Paulis R, Fabbri A, Chiariello L. Postoperative aortic fistulas into the airways: Etiology, pathogenesis, presentation, diagnosis, and management. Ann Thorac Surg 2003;75:1998-2006.
2.	Nishizawa J, Matsumoto M, Sugita T, Matsuyama K, Tokuda Y, Yoshida K, et al. Surgical treatment of five patients with aortobronchial fistula in the aortic arch. Ann Thorac Surg 2004;77:1821-3.
3.	Vogt PR, Pfammatter T, Schlumpf R, Genoni M, Künzli A, Candinas D, et al. In situ repair of aortobronchial, aortoesophageal, and aortoenteric fistulae with cryopreserved aortic homografts. J Vasc Surg 1997;26:11-7.
4.	Sheng T, Yu L. Aortobronchial fistula: Secondary to patent ductus arteriosus. J Formos Med Assoc 2012;111:584-5.
5.	Canaud L, Ozdemir BA, Bahia S, Hinchliffe R, Loftus I, Thompson M. Thoracic endovascular aortic repair for aortobronchial fistula. Ann Thorac Surg 2013;96:1117-21.