AORTOBRONCHIAL FISTULA DUE TO GRAFT FAILURE: A RARE CAUSE OF HEMOPTYSIS

Abstract

SESSION TITLE: Case Report Semifinalists 10 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Aortobronchial Fistula (ABF) is a rare etiology of hemoptysis, an otherwise common finding. ABF is a complication of aortic surgery and is fatal if untreated. Its high mortality rate along with unequivocal symptoms and imaging make it a challenging diagnosis. We present a case of a patient presenting with hemoptysis secondary to ABF from thoracic aortic graft failure that was first detected via bedside ultrasound CASE PRESENTATION: An 84-year-old female with history of hypertension, tracheostomy, CVA, aortic dissection with multiple surgical repairs and stents presents for hemoptysis and suspected sepsis from Nursing Home. Vital Signs showed Blood Pressure 142/116 mmHg, Pulse 133 BPM, Temperature 101.6 F. Patient was obtunded, and found to have copious intermittent bloody secretions from tracheostomy tube. Labs revealed WBC 30 K/mm3. Hemoglobin 10 mg/dL, lactate 5.5. Urinalysis was positive leukocyte esterase with elevated WBCs. Chest XR showed left sided opacity. She was admitted to ICU for Sepsis. Bedside ultrasound of thorax showed findings seen in Figure 1, raising suspicion of hematoma. Subsequent Chest CT Angiography (CTA) seen in Figure 2. Descending aorta showed separation of stent graft component, indicating graft failure, and extravasation of contrast adjacent to this site with the hematoma.Diagnosed with aortic graft failure with endoleak, she was transferred for emergent surgical repair. Surgery revealed endoleak in thoracic aorta forming aortobronchial fistula with pooling of blood in left lung. Blood was suctioned and surgical repair was performed. Patient was stable during monitoring and shortly returned to nursing home DISCUSSION: ABFs are a rare complication after TEVAR with a 100% mortality rate if untreated. Symptoms are nonspecific, with intermittent hemoptysis being the first and often, only sign. Imaging via CTA, x-rays and even bronchoscopy is vague, leading to missed diagnoses with more than 30% of cases diagnosed at autopsy. Early detection and prompt surgical repair require a strong index of suspicion. ABFs present chronically after surgery, due to formation of an endoleak due to graft failure leading to hematoma compressing on nearby bronchial tree. Treatment is emergent surgical repair. ABF has high risk of complications, leading to mortality of 71% despite treatment. In our patient, high clinical suspicion prompted early BUS of thorax, revealing a likely hematoma. Early detection led to a CTA confirming diagnosis of graft failure, and subsequent ABF during surgery CONCLUSIONS: With its reputation as a misdiagnosed and fatal complication, we hope to raise awareness of ABF in the differential of hemoptysis and encourage clinicians to consider a through bedside ultrasound of the thorax in high risk patients for graft failure Reference #1: Fontana M et al. An uncommon cause of hemoptysis: aortobronchial fistula. Multidiscip Respir Med. 2018 Reference #2: Czerny M, Reser D, Eggebrecht H, Janata K, Sodeck G, Etz C, Luehr M, Verzini F, Loschi D, Chiesa R, Melissano G, Kahlberg A, Amabile P, Harringer W, Janosi RA, Erbel R, Schmidli J, Tozzi P, Okita Y, Canaud L, Khoynezhad A, Maritati G, Cao P, Kölbel T, Trimarchi S. Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications. Eur J Cardiothorac Surg. 2015 Reference #3: 3. Youssef Touma, Pierre Demondion, Akhtar Rama, Pascal Leprince; Aortobronchial fistula in the presence of a midgraft hole after endovascular repair of thoracic aortic aneurysms, European Journal of Cardio-Thoracic Surgery, Volume 43, Issue 6, 1 June 2013, Pages 1259–1261 DISCLOSURES: No relevant relationships by Artur Alaverdian, source=Web Response No relevant relationships by Shiva Arjun, source=Web Response No relevant relationships by Javed Iqbal, source=Web Response No relevant relationships by Hyfaa Mashaal, source=Web Response