Endovascular repair with extracorporeal membrane oxygenation as a rescue strategy for aortobronchial fistula: a case report

Kyosuke Takahashi,Misa Kajitani,Takaaki Kamada,Wataru Takayama,Yoshiro Kobayashi

doi:10.1186/s40981-017-0103-8

Abstract

Aortobronchial fistula (ABF) is a rare and potentially lethal complication of thoracic aortic replacement surgery. Currently, thoracic endovascular aortic repair (TEVAR) has emerged as a less invasive alternative to open surgery for ABF to facilitate prompt hemostasis. However, there are no published reports of TEVAR for ABF, particularly for presentation with life-threatening respiratory failure from massive hemoptysis.A 48-year-old male patient, who had recently undergone aortic root and arch replacement due to aortic dissection, was transferred to the emergency department with massive hemoptysis and severe dyspnea. A single-lumen endotracheal tube was immediately placed in the right main bronchus to protect the nonbleeding lung from spillage of blood. Chest computed tomography (CT) showed leakage of contrast material from the distal anastomosis of the aortic graft and consolidated lung tissue adjacent to the leakage. He was diagnosed with an ABF following aortic arch replacement, and an emergency TEVAR was performed. After adequate hemostasis, severe hypercapnia remained uncorrected despite the maximum ventilatory support. Thus, venovenous extracorporeal membrane oxygenation (VV ECMO) was immediately initiated, and severe respiratory acidosis improved dramatically. Furthermore, VV ECMO facilitated prompt bronchoscopic washout of the remaining blood clot without any danger of respiratory collapse and was weaned off successfully after 5 days as ventilation improved.This case demonstrates that emergency TEVAR in combination with VV ECMO can be a rescue strategy for massive hemoptysis from an ABF.

Highlights

Aortobronchial fistula (ABF) is a rare and potentially lethal complication of thoracic aortic replacement surgery [1]
We describe a successful combination of venovenous extracorporeal membrane oxygenation (VV Venovenous extracorporeal membrane oxygenation (ECMO)) with emergency Thoracic endovascular aortic repair (TEVAR) for a patient with ABF and life-threatening hemoptysis
There are several reports of successful management with VV ECMO in patients with pulmonary hemorrhage or hemoptysis [5–8], to our knowledge, this is the first case of ABF with life-threatening hemoptysis treated successfully under VV ECMO after emergency TEVAR

Summary

Background

Aortobronchial fistula (ABF) is a rare and potentially lethal complication of thoracic aortic replacement surgery [1]. Arterial blood gas analysis showed severe respiratory acidosis (pH, 7.13; pCO2 76.2 mmHg, pO2 92.8 mmHg; HCO3− 25.2 mEq/L; BE −4.0 mmol/L). Chest computed tomography showed leakage of contrast material from the distal anastomosis of the aortic arch, and chest X-ray showed consolidated lung tissue adjacent to the leakage (Fig. 1) He was diagnosed with ABF following aortic arch replacement, and emergency TEVAR was scheduled. At this time, massive hemothorax and lung bleeding from the ABF had led to potentially lethal hypercapnic respiratory failure and hemodynamic instability. Hypercapnia was corrected after removing blood clots, subsequent oxygenation failure emerged after the ICU admission impeded weaning from VV ECMO for 5 days. Despite the intensive therapy including resection of the necrotic intestine, his infection was difficult to treat and the patient died on postoperative day 56

Discussion

Conclusions