A Case Series of Aorto-Pulmonary Fistula: Review of Operative Management, and an Algorithm for Treatment
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0006
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Tylor Thai (1), Elizabeth Devine (1), Donald Jacobs (1), Rafael Malgor (1), T. Brett Reece (1), Muhammad Aftab (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Tylor Thai
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University of Colorado Anschutz
University of Colorado Anschutz
Elizabeth Devine
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University of Colorado Anschutz
University of Colorado Anschutz
Donald Jacobs
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University of Colorado Anschutz
University of Colorado Anschutz
Rafael Malgor
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Tylor Thai
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective:
Aorto-pulmonary fistulas carry a high risk of morbidity and mortality given the potential for spontaneous massive bleeding events, and the high risk of associated infection. Patients are typically complex, and either present primarily such as in the setting of congenital aortopathy, and/or after previous aortic intervention. Management remains sparsely described given their rarity. We describe three patients who presented with aorto-pulmonary fistula at our institution and subsequent management and an algorithm for treatment.
Methods:
Included were three patients who presented with aorto-pulmonary fistulas from 2017 to 2023. We review their relevant history, presentation, and subsequent management.
Results:
All three patients presented with symptoms of hemoptysis related to the aorto-pulmonary fistula. All three patients had histories of prior aortic intervention, with two patients having a history of congenital aortopathy. One patient had multiple prior presentations for aorto-pulmonary fistula, previously undergoing both open and endovascular therapy at outside institutions over the course of 15 years. All three patients were successfully managed with endovascular therapy, with uncomplicated post-operative courses.
Patients were maintained on lifelong antimicrobial suppression therapy and underwent frequent surveillance with imaging and serial inflammatory markers including ESR and CRP. Two patients developed new findings on surveillance imaging: one patient developed in-stent thrombus while undergoing treatment for colorectal cancer and was started on a DOAC, and the patient with prior recurrent fistulas developed a slight increase in perigraft air, however, he was asymptomatic with normal inflammatory markers, and the multidisciplinary team assessed the perigraft air that was present was likely a residual abscess cavity. The patient was closely surveilled, with stability for over a year following.
Conclusion:
Aorto-pulmonary fistulas remains a rare, but challenging pathology that carries high risk of morbidity and mortality, exacerbated by potential hemodynamic instability and a contaminated, inflammatory, and often re-operative surgical field. Although typically amenable to endovascular repair in stable patients, when necessary open repair should be performed promptly, as any delays carry a high risk of mortality. Close surveillance imaging is of paramount importance, however, although there is no clear evidence, given the high risk of mortality patients are routinely placed on anticoagulation with monitoring of inflammatory markers. Given the potential for antimicrobial resistance, and the unclear benefit and potential distress of inflammatory markers, it is vital to continue to gather evidence to determine the best practice for these patients.
Aorto-pulmonary fistulas carry a high risk of morbidity and mortality given the potential for spontaneous massive bleeding events, and the high risk of associated infection. Patients are typically complex, and either present primarily such as in the setting of congenital aortopathy, and/or after previous aortic intervention. Management remains sparsely described given their rarity. We describe three patients who presented with aorto-pulmonary fistula at our institution and subsequent management and an algorithm for treatment.
Methods:
Included were three patients who presented with aorto-pulmonary fistulas from 2017 to 2023. We review their relevant history, presentation, and subsequent management.
Results:
All three patients presented with symptoms of hemoptysis related to the aorto-pulmonary fistula. All three patients had histories of prior aortic intervention, with two patients having a history of congenital aortopathy. One patient had multiple prior presentations for aorto-pulmonary fistula, previously undergoing both open and endovascular therapy at outside institutions over the course of 15 years. All three patients were successfully managed with endovascular therapy, with uncomplicated post-operative courses.
Patients were maintained on lifelong antimicrobial suppression therapy and underwent frequent surveillance with imaging and serial inflammatory markers including ESR and CRP. Two patients developed new findings on surveillance imaging: one patient developed in-stent thrombus while undergoing treatment for colorectal cancer and was started on a DOAC, and the patient with prior recurrent fistulas developed a slight increase in perigraft air, however, he was asymptomatic with normal inflammatory markers, and the multidisciplinary team assessed the perigraft air that was present was likely a residual abscess cavity. The patient was closely surveilled, with stability for over a year following.
Conclusion:
Aorto-pulmonary fistulas remains a rare, but challenging pathology that carries high risk of morbidity and mortality, exacerbated by potential hemodynamic instability and a contaminated, inflammatory, and often re-operative surgical field. Although typically amenable to endovascular repair in stable patients, when necessary open repair should be performed promptly, as any delays carry a high risk of mortality. Close surveillance imaging is of paramount importance, however, although there is no clear evidence, given the high risk of mortality patients are routinely placed on anticoagulation with monitoring of inflammatory markers. Given the potential for antimicrobial resistance, and the unclear benefit and potential distress of inflammatory markers, it is vital to continue to gather evidence to determine the best practice for these patients.
Aortic Symposium:
Aortic Arch
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