Endovascular repair of arterio-bronchial fistula of the outflow graft of HeartMate II left ventricular assist device

Abstract

Arterio-bronchial fistula in combination with prostheticvascular graft infection is a formidable challenge for sur-geons. We describe a patient with arterio-bronchial fistulaof the outflow graft of a left ventricular assist device(LVAD) who presented with hemoptysis and hemothorax.CLINICAL SUMMARYThe patient is a 58-year-old obese female who under-went implantation of a HeartMate XVE (Thoratec Corp,Pleasanton, Calif) for advanced heart failure. The LVADwas exchanged for a HeartMate II (Thoratec Corp) within15 months because of device failure. Four months later,she presented with copious hemoptysis. She was hemo-dynamically stable with a patent airway. Computed to-mography (CT) angiogram of the chest revealed a righthemothorax and extravasation of the contrast at the mid-portion of the outflow graft of the LVAD (Figure 1).This location corresponded to the site of the Dacron graftto graft anastomosis or the de-airing site. Emergency sur-gical exploration and graft repair were contemplated;however, morbidity of a third sternotomy was consideredsignificant in this anticoagulated, obese patient. Further-more, the right hemothorax was considered contaminatedwith lower respiratory bacterial flora, which can causea deep sternal wound infection; therefore, we decided toproceed with a non-sternotomy option, such as an endo-vascular approach.In a hybrid operating room, a pigtail catheter was ad-vancedthroughtheleftfemoralartery into theoutflowgraftthatwasanastomosedtothemid-ascendingaorta.Preproce-dural angiogram confirmed active extravasation of the con-trast. The right common carotid artery was chosen for stentgraft delivery. After the right common carotid artery wasexposed, the patient was heparinized. Via a 5F sheath, an180-cm Nitrex wire was advanced into the ascending aortaand subsequently into the outflow graft. Thewirewas care-fully ‘‘parked’’ just downstream from the rotor inside theLVAD.Theoutflowgraftwas16mm,measuredonthebasisoftheCTfindingsandintraoperativeangiogram.A20355mm AneuRx iliac limb stent graft (Medtronic, Santa Rosa,Calif)wasdeployedintheoutflowgraft.Completionangio-gram showed a type Ib endoleak; therefore, a secondAneuRx aortic cuff stent graft (22 3 40 mm) was placedjustdistaltothefirstgraftflushtotheascendingaorta.Are-peat angiogram revealed successful endovascular repair(Figure 2).On postoperative day 1, neurologic examination re-vealed slight motor weakness in the left foot; however,the patient regained full strength 2 days later and was dis-chargedonpostoperativeday6withlong-termantibiotics.A follow-up CT scan before her discharge revealed a suc-cessful endovascular exclusion of the arterio-bronchialfistula.DISCUSSIONArterio-bronchialfistulawithinvolvementofaprostheticvasculargraftisasignificantsurgicalchallengethatusuallyrequires excision of the graft with extra-anatomic bypass.