Case 18

Aorto-Bronchial Fistula secondary to previous Coarctation repair

A 28 year old gentleman is referred with haemoptysis due to an aorto-bronchial fistula. He underwent coarctation repair 12 years previously, with a Dacron patch. CT scanning shows aneurysm formation at the site of repair, and the lung fields on CT scan show evidence of blood in the left lung parenchyma. Bronchoscopy confirms blood coming from the left lung with no endobronchial lesions seen. What would you do?

This gentleman needs excision of the aneurysm, tube graft replacement of the defect and fistula closure on the lung.

There is a known increase incidence of fistula and aneurysm formation with patch repair of coarctation, especially if the internal aortic ridge is resected, classically 10 to 20 years post initial procedure.

Option 1

Operative approach will almost certainly involve circulatory arrest. 

The collateral circulation is probably minimal as their has not been any significant gradient for 12 years, so clamp and go in redo setting probably unwise.

Cannulation is probably easier femoral vein to femoral artery. Heart is vented via pulmonary vein.

The left subclavian, arch of the aorta, and the descending aorta are encircled with tapes, and when the circulation is cooled right down and turned off the arch, descending aorta and subclavian are clamped.

The aneurysmal segment is resected and a tube graft is inserted. 

The patient is rewarmed.

Alternative bypass scenarios

• As above but keep femoral inflow at mean of 50 to 60mmHg during period of clamping to minimize ischaemia reperfusion injury of lower body.
• Cannulate right axillary artery as well so when clamp on arch of aorta antegrade cerebral perfusion can continue

Option 2

Left heart bypass is utilised.

The left subclavian, arch of the aorta, and the descending aorta are encircled with tapes, and then when on left heart support all three are clamped. (spinal cord should be safe)

The aneurysmal segment is resected and a tube graft is inserted.

Clamps removed.

Option 3

Stent across the aneurysm, if an appropriate take off and landing zone are apparent. Worry is this patient is only 28 years old and hopefully will live ? 30 to 40 years if this doesn't kill him.