ANOTHER BLOODY PNEUMONIA? PULMONARY HEMORRHAGE DUE TO LARGE PSEUDOANEURYSM WITH AORTOBRONCHIAL FISTULA

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aortic pseudoaneurysms are a rare complication of prior vascular or valvular surgery with high mortality. A pseudoaneurysm is a disruption in the blood vessel allowing blood to flow between the tunica media and adventitia. We present a case of an aortic pseudoaneurysm secondary to previous carotid-subclavian bypass presenting as pulmonary hemorrhage. CASE PRESENTATION: A 57-year-old male with a history of carotid-subclavian bypass and recent pulmonary embolism on apixaban presented with hemoptysis. Chest xray showed a left upper lobe mass with consideration for necrotizing pneumonia. Antibiotics were started, however sputum cultures were unrevealing. Then, CT chest revealed an aortic pseudoaneurysm adjacent to a large consolidation that was concerning for malignancy, but follow up PET scan was inconclusive. The patient was discharged home to have further outpatient malignancy workup, but returned within a month for continued hemoptysis. CT aortic dissection protocol revealed a partially thrombosed pseudoaneurysm with aortobronchial fistula. Cardiology evaluated the patient and recommended novel occlusion of pseudoaneursym with duct occluder device given patient’s continued deterioration. The patient was transferred to a quaternary care center for urgent thoracic endovascular aortic repair (TEVAR). DISCUSSION: Hemoptysis is a common presenting complaint typically caused by viral bronchitis, pneumonia, or malignancy. However, rare causes of hemoptysis including aortic pseudoaneurysm should be considered in patients with prior history of cardiothoracic surgery. Pseudoaneurysms typically remain asymptomatic and present late, which leads to high mortality. Most pseudoaneurysms require urgent TEVAR with proposed long-term prophylactic antibiotics to prevent graft infection. Interestingly, in a patient with prohibitively high surgical risk, the pseudoaneurysm can be percutaneously closed with duct occluder devices typically used to close patent foramen ovale and patient ductus arteriosus. CONCLUSIONS: Maintaining a wide differential and pursuing further evaluation in the setting of a declining patient is imperative to determine the appropriate treatment. Rarely, hemoptysis can be caused by aortic pseudoaneurysm and should be considered in the differential of patients with a history of cardiothoracic surgery. Reference #1: Fontana, M., Tonelli, R., Gozzi, F. et al. An uncommon cause of hemoptysis: aortobronchial fistula. Multidiscip Respir Med 13, 25 (2018). https://doi.org/10.1186/s40248-018-0146-3 Reference #2: MacIntosh EL, Parrott JCW, Unruh HW. Fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg. 1991;51:515e9. DISCLOSURES: No relevant relationships by Anas Ahmed, source=Web Response No relevant relationships by Joy Wang, source=Web Response No relevant relationships by Steven Young, source=Web Response