- Email: [email protected]
Aortobronchial Fistula after Thoracic Endovascular Aortic Repair (TEVAR) for Descending Thoracic Aortic Aneurysm
Accepted Manuscript Aortobronchial Fistula after Thoracic Endovascular Aortic Repair (TEVAR) for Descending Thoracic Aortic Aneurysm John Nicholas Melvan, Jacob DeLaRosa, Julio C. Vasquez PII:
S0890-5096(17)30332-1
DOI:
10.1016/j.avsg.2016.10.040
Reference:
AVSG 3178
To appear in:
Annals of Vascular Surgery
Received Date: 5 May 2016 Revised Date:
7 September 2016
Accepted Date: 13 October 2016
Please cite this article as: Melvan JN, DeLaRosa J, Vasquez JC, Aortobronchial Fistula after Thoracic Endovascular Aortic Repair (TEVAR) for Descending Thoracic Aortic Aneurysm, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.10.040. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Aortobronchial Fistula after Thoracic Endovascular Aortic Repair (TEVAR) for Descending Thoracic
2
Aortic Aneurysm
3 John Nicholas Melvan1, Jacob DeLaRosa1, 2 and Julio C. Vasquez2
5
Division of Cardiothoracic Surgery, Emory University, Atlanta, GA 1, Portneuf Medical Center,
6
Pocatello, ID2
RI PT
4
SC
7
Conflicts of Interest: No funding sources or conflicts of interests to disclose.
9
Acknowledgements: None.
M AN U
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10
Journal: Annals of Vascular Surgery.
11
Consent: Consent has been obtained for publication.
Correspondence:
14
Julio C. Vasquez, M.D.
15
777 Hospital Way, Ste G-11
16
Pocatello, ID 83201
17
Phone: (208) 239-2580
18
Fax: (208) 239-2589
19
Email: [email protected]
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ABSTRACT Continued enlargement of the aneurysm sac after thoracic endovascular aortic repair (TEVAR) is a known risk after endovascular treatment of thoracic aortic aneurysms. For this reason, periodic
25
outpatient follow up is required to identify situations that require repair. Here we describe an
26
aortobronchial fistula (ABF) in a patient lost to follow up, that presented 3 years after an elective TEVAR
27
done for a primary, descending thoracic aortic aneurysm (dTAA). Our patient arrived in extremis and
28
suffered massive hemoptysis leading to her demise. CT angiogram near the time of her death
29
demonstrated a bleeding ABF immediately distal to her previous TEVAR repair. Aortic aneurysmal
30
disease remains life threatening even after repair. Improved endovascular techniques and devices have
31
resulted in decreased need for reintervention. However, this case demonstrates the risk of thoracic aortic
32
disease progression and highlights the importance of establishing consistent, long term follow up after
33
TEVAR.
M AN U
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24
34
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CASE REPORT An 84 year old, hypertensive woman with a history of breast cancer, spine fracture, and chronic back pain was initially evaluated in our office for a primary, 4.7 cm descending thoracic aortic aneurysm
39
(dTAA) and treated conservatively. During the following year, she was hospitalized twice for acute on
40
chronic back pain that prompted axial imaging to rule out thoracic aortic dissection or rupture. Imaging
41
studies demonstrated more than a 1 cm diameter increase in the size of her aneurysm over 12 months.
42
Due to the rapid growth of the aneurysm and complicated clinical picture, we recommended she undergo
43
an elective, percutaneous thoracic endovascular aortic repair (TEVAR) of her dTAA. We placed
44
overlapping Medtronic Talent Captiva endografts covering 18 cm of her descending thoracic aorta. The
45
proximal endograft (34x34x160 mm) overlapped with the distal endograft (38x34x112 mm) for
46
approximately 9 cm in length (Figure 1A). The proximal landing zone of the native aorta had a diameter
47
of 30 mm (40 mm long) and a distal landing zone diameter of 30 mm (37 mm long). The left subclavian
48
artery was not covered but several bronchial and intercostal vessels were covered during repair.
SC
M AN U
Following an uncomplicated postoperative course, the patient was discharged home and followed
TE D
49
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38
up in our clinic 2 weeks after her procedure. Our standard TEVAR follow up includes a 2 week post
51
procedure office visit, followed by CT angiogram of the thoracic and abdominal aorta at 1 month, 6
52
months, and 12 months post procedure. Imaging is performed during yearly follow up visits thereafter.
53
After the first postoperative visit the patient did not return phone calls and letters indicating the need to
54
return to clinic. The main barrier to her care was poor compliance. Unfortunately, after being lost to
55
follow up, she presented 3 years later with massive hemoptysis and profound hypotension. She was
56
immediately intubated in our emergency department with prompt return of 500cc bright red blood through
57
her endotracheal tube. CT angiogram near the time of her death demonstrated a bleeding aortobronchial
58
fistula (ABF) originating distal to her TEVAR repair (Figure 1B and 1C). The patient expired soon after
59
presentation as she had an established DNR order and her family requested that aggressive resuscitation
60
efforts be withheld. No information is available concerning the interval growth of her dTAA after repair.
61
At the time of rupture, the seal of her distal landing zone had been lost and its diameter had grown from
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30 mm at the time of TEVAR repair to 44 mm at the time of her death. This represented a type 1b
63
endoleak from the distal edge of her endograft that resulted from interval growth of her aneurysmal
64
disease, as the graft was properly sized at the initial intervention. There was no evidence of graft infection
65
at the time of her death. Her caretakers did not recall any exacerbation of her chronic back pain and she
66
had no previous episodes of hemoptysis. Unfortunately, she had not been evaluated by any other
67
physicians over the interval period. Had the patient been clinically stable for repair, we would have
68
attempted another endograft stent placement to cover the area of active bleeding, which had resulted in an
69
ABF.
SC
ABF can result from thoracic aneurysm rupture directly into the bronchial tree due to adhesions
M AN U
70
RI PT
62
that form between the aorta and airways. Hemoptysis is often the initial presentation of ABF and is
72
associated with extremely high mortality. Endograft placement for dTAA results in 96% freedom from
73
aneurysm-related death, but up to 14% of patients may need repeat intervention at 5 years for various
74
reasons, including progression of aneurysm dilatation beyond the stented aorta [1]. Unfortunately, our
75
patient developed aneurysmal progression after TEVAR and arrived in extremis with no time to
76
intervene. This case emphasizes the importance of close patient follow up and repeat imaging after
77
TEVAR.
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DISCUSSION Repair of thoracic aortic aneurysm is advocated when the diameter of the aneurysm is equal to or greater than 5.5 cm [2]. An endovascular approach is recommended over open surgery when feasible [2,
83
3]. Endovascular techniques can result in complications including stroke, paraplegia, visceral ischemia,
84
access complications, device migration, endoleaks, or post implantation syndrome [4]. Multiple
85
commercially available endografts for TEVAR repair are available including Zenith (Cook Inc.,
86
Bloomington, IN), Valiant (Medtronic Corp., Santa Rosa, CA), Conformable GORE TAG (W.L. Gore
87
and Associates Inc., Flagstaff, AZ), and Relay Endografts (Bolton Medical Inc., Sunrise, FL) [5].
88
Following the use of these endografts in the treatment of thoracic aortic aneurysms, one European registry
89
review estimated an annual reintervention rate of 4.6% or 14% risk at 4 years for management of
90
endoleaks and progression of aneurysmal disease [5].
M AN U
SC
RI PT
82
Several series of TEVAR patients have been published that include 5 year outcomes and
92
prevalence of reintervention [6-8]. Geisbush et al published their single center experience of 264 TEVAR
93
patients, which showed an overall reintervention rate of 22%. Indications for reintervention were led by
94
endoleaks (44%) and progression of aortic disease (29%). Risk factors included chronic expanding aortic
95
dissections (OR 2.35), hybrid aortic procedures (OR 2.11), and connective tissue disease (OR 7.54) [7].
96
This same group reported 5 year mortality of 50% and freedom from complication of 52%, 47.2%, and
97
47.2% at 1, 3, and 5 years respectively [6]. A meta-analysis of 17 studies including 567 patients, reported
98
considerable variability (range 0-60%) in rates of reintervention after TEVAR for type B aortic
99
dissection. Causes for reintervention included endoleaks (8.1%) and progression of aneurysmal disease
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100
(7.8%). Rare complications included retrograde type A dissection (0.67%), aortoesophageal fistula
101
(0.22%), paraplegia (0.45%), and stroke (1.5%) [8]. Based on our imaging studies, we have concluded
102
that this patient developed a type 1b endoleak after progression of her aneurysmal disease that lead to
103
fistulization into the airway distal to her previous TEVAR repair.
104
Different rates of reintervention are reported depending on the specific type of endoleak.
105
Preventza et al reported on 249 patients undergoing dTAA repair with TEVAR, and found that endoleaks 5
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occurred in 38 patients: type 1a (n = 13, 34.2%), type 1b (n = 15, 39.5%), type 2 (n = 8, 21.1%), and type
107
3 (n = 2, 5.3%) respectively. Of these, 12 patients required reintervention; type 1a (n = 8, 66.7%), type 1b
108
(n = 2, 16.7%), combined type 1 and 3 (n = 1, 8.3%), and type 3 (n = 1, 8.3%) [9]. Szeto et al reviewed
109
680 patients undergoing TEVAR at the University of Pennsylvania and found that endoleaks (45/80)
110
accounted for the greatest majority of their cases requiring reintervention (11.7%, 80/680); type 1 (24/45),
111
type 2 (5/45), type 3 (9/45), and multiple/unclear (7/45). Other lesser causes of endograft failure in their
112
series included proximal aortic events (14%), distal aortic events (18%), multiple failure modes (5%),
113
endograft infection (4%), and carotid occlusion/stent collapse (3%). The median time for reintervention
114
was 210 days [10]. Boufi et al have found that short proximal aortic neck length may be the only
115
independent risk factor for the development of a secondary type I endoleak, not clinical urgency or aortic
116
length covered. Using receiver operating characteristics, Boufi and colleagues have advocated for ≥ 24
117
mm landing zone [11]. The proximal landing zone in our case was 30 mm.
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Our patient originally underwent TEVAR for a primary dTAA using a Talent (Medtronic) thoracic stent graft with Captiva delivery system. This device was first launched in 2005 and received
120
FDA approval in 2008. Outcomes from the use of these endografts are available for at least 7 separate
121
clinical trials [12]. Following the development of second generation Valiant endografts, Talent and
122
Valiant endografts were compared head-to-head. Effectiveness end points only differed in that
123
reinterventions due to endoleak after > 30 days were significantly greater for Talent versus Valiant
124
endografts (6.5% v 0%). Loss of graft patency, stent graft migration at 1 month, and endoleak at 12
125
months were not different between devices [13]. Valiant endografts were not available for our patient at
126
the time of her procedure.
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ABF results from the erosion of an aneurysm into the bronchial tree or pulmonary parenchyma
128
that is adjacent to the aneurysm. Previous placement of a prosthetic graft and severe atherosclerosis have
129
been associated with this condition [14]. Little evidence however is available concerning the incidence of
130
ABF after TEVAR [15-18]. Piceche et al studied all available case reports and reviews for postoperative
131
aortic fistulas into the airways after cardiothoracic surgery. Uniformly fatal if untreated, surgical mortality 6
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rates were 15% for open repair and 6.8% for endovascular repair [17]. Hemoptysis was the first, and often
133
the only, clinical finding of ABF. These authors found that aortic fistulas into the airways were more
134
common after dTAA procedures compared to other fistula after cardiac and thoracic surgery [17]. Using a
135
nationwide survey of 17 centers in Italy, Chiesa et al reported a 1.7% (19/1113) incidence of
136
aortoesophageal and aortobronchial fistula after TEVAR. Higher rates of fistula formation in this survey
137
were associated with aortic pseudoaneurysms, complex operations, and emergent procedures. Overall
138
survival was a dismal 16% [15]. Similarly, Czerny and colleagues reviewed the European Registry of
139
Endovascular Aortic Repair Complications, comprised of 4680 TEVAR patients at 14 European centers,
140
and found the incidence of aortobronchial or aortopulmonary fisulta after TEVAR was 0.56%. Leading
141
mechanisms of fistula formation were external compression of the bronchial tree, endoleak formation, and
142
further aortic ischemia [16]. Therefore, ABF after TEVAR are rare, but carry a high mortality rate.
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In conclusion, endovascular treatment of aortic aneurysm is a reliable therapy for the management of this condition. However, like any other therapeutic intervention, it can result in
145
complications. Aneurysmal progression and aortic fistulization can occur and result in fatal outcomes.
146
TEVAR patients must be educated that aortic aneurysm is a dynamically evolving disease process that
147
requires close observation and periodic imaging. Common intervals for follow up are 1 month, 6 months,
148
and then yearly. With aggressive outpatient management, the catastrophic outcome experienced by our
149
patient can hopefully be avoided.
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FIGURE LEGEND
153
Figure 1: CT angiogram taken (A) intraoperatively and (B, C) 3 years postoperatively during rupture of
154
the aortrobronchial fistula. Aortic aneurysm distal to the TEVAR stent and filling of the aortobronchial
155
fistula are shown.
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REFERENCES
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[1] Foley PJ, Criado FJ, Farber MA, Kwolek CJ, Mehta M, White RA, et al. Results with the Talent
161
thoracic stent graft in the VALOR trial. J Vasc Surg. 2012;56:1214-21 e1.
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[2] Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Jr., et al. 2010
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ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management
164
of patients with Thoracic Aortic Disease: a report of the American College of Cardiology
165
Foundation/American Heart Association Task Force on Practice Guidelines, American Association for
166
Thoracic Surgery, American College of Radiology, American Stroke Association, Society of
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Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of
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Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation.
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2010;121:e266-369.
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[3] Katzen BT, Dake MD, MacLean AA, Wang DS. Endovascular repair of abdominal and thoracic aortic
171
aneurysms. Circulation. 2005;112:1663-75.
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[4] Wang GJ, Fairman RM. Endovascular repair of the thoracic aorta. Semin Intervent Radiol.
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2009;26:17-24.
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[5] Hobo R, Sybrandy JE, Harris PL, Buth J, Collaborators E. Endovascular repair of abdominal aortic
175
aneurysms with concomitant common iliac artery aneurysm: outcome analysis of the EUROSTAR
176
Experience. J Endovasc Ther. 2008;15:12-22.
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[6] Bischoff MS, Ante M, Meisenbacher K, Bockler D. Outcome of thoracic endovascular aortic repair in
178
patients with thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg. 2016.
179
[7] Geisbusch P, Hoffmann S, Kotelis D, Able T, Hyhlik-Durr A, Bockler D. Reinterventions during
180
midterm follow-up after endovascular treatment of thoracic aortic disease. J Vasc Surg. 2011;53:1528-33.
181
[8] Thrumurthy SG, Karthikesalingam A, Patterson BO, Holt PJ, Hinchliffe RJ, Loftus IM, et al. A
182
systematic review of mid-term outcomes of thoracic endovascular repair (TEVAR) of chronic type B
183
aortic dissection. Eur J Vasc Endovasc Surg. 2011;42:632-47.
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[9] Preventza O, Wheatley GH, 3rd, Ramaiah VG, Rodriguez-Lopez JA, Williams J, Olsen D, et al.
185
Management of endoleaks associated with endovascular treatment of descending thoracic aortic diseases.
186
J Vasc Surg. 2008;48:69-73.
187
[10] Szeto WY, Desai ND, Moeller P, Moser GW, Woo EY, Fairman RM, et al. Reintervention for
188
endograft failures after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg. 2013;145:S165-70.
189
[11] Boufi M, Aouini F, Guivier-Curien C, Dona B, Loundou AD, Deplano V, et al. Examination of
190
factors in type I endoleak development after thoracic endovascular repair. J Vasc Surg. 2015;61:317-23.
191
[12] McGrath J. Valiant Captiva Thoracic Stent Graft System From Medtronic Receives FDA Approval
192
for Treating Aortic Dissections. In: Release MP, editor.
193
http://newsroom.medtronic.com/phoenix.zhtml?c=251324&p=irol-newsArticle&ID=1894375: Medtronic.
194
[13] Fairman RM, Tuchek JM, Lee WA, Kasirajan K, White R, Mehta M, et al. Pivotal results for the
195
Medtronic Valiant Thoracic Stent Graft System in the VALOR II trial. J Vasc Surg. 2012;56:1222-31 e1.
196
[14] Yoo JH, Lee CT, Shim YS, Chung JW, Ahn H, Kim KW. Aortobronchial fistula presenting as
197
recurrent hemoptysis and successfully treated with an endovascular stent graft. Respiration. 2001;68:537-
198
9.
199
[15] Chiesa R, Melissano G, Marone EM, Marrocco-Trischitta MM, Kahlberg A. Aorto-oesophageal and
200
aortobronchial fistulae following thoracic endovascular aortic repair: a national survey. Eur J Vasc
201
Endovasc Surg. 2010;39:273-9.
202
[16] Czerny M, Reser D, Eggebrecht H, Janata K, Sodeck G, Etz C, et al. Aorto-bronchial and aorto-
203
pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of
204
Endovascular Aortic Repair Complications. Eur J Cardiothorac Surg. 2015;48:252-7.
205
[17] Piciche M, De Paulis R, Fabbri A, Chiariello L. Postoperative aortic fistulas into the airways:
206
etiology, pathogenesis, presentation, diagnosis, and management. Ann Thorac Surg. 2003;75:1998-2006.
207
[18] Touma Y, Demondion P, Rama A, Leprince P. Aortobronchial fistula in the presence of a midgraft
208
hole after endovascular repair of thoracic aortic aneurysms. Eur J Cardiothorac Surg. 2013;43:1259-61.
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ACCEPTED MANUSCRIPT
S0890-5096(17)30332-1
DOI:
10.1016/j.avsg.2016.10.040
Reference:
AVSG 3178
To appear in:
Annals of Vascular Surgery
Received Date: 5 May 2016 Revised Date:
7 September 2016
Accepted Date: 13 October 2016
Please cite this article as: Melvan JN, DeLaRosa J, Vasquez JC, Aortobronchial Fistula after Thoracic Endovascular Aortic Repair (TEVAR) for Descending Thoracic Aortic Aneurysm, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.10.040. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Aortobronchial Fistula after Thoracic Endovascular Aortic Repair (TEVAR) for Descending Thoracic
2
Aortic Aneurysm
3 John Nicholas Melvan1, Jacob DeLaRosa1, 2 and Julio C. Vasquez2
5
Division of Cardiothoracic Surgery, Emory University, Atlanta, GA 1, Portneuf Medical Center,
6
Pocatello, ID2
RI PT
4
SC
7
Conflicts of Interest: No funding sources or conflicts of interests to disclose.
9
Acknowledgements: None.
M AN U
8
10
Journal: Annals of Vascular Surgery.
11
Consent: Consent has been obtained for publication.
Correspondence:
14
Julio C. Vasquez, M.D.
15
777 Hospital Way, Ste G-11
16
Pocatello, ID 83201
17
Phone: (208) 239-2580
18
Fax: (208) 239-2589
19
Email: [email protected]
21
AC C
20
EP
13
TE D
12
1
ACCEPTED MANUSCRIPT
22 23
ABSTRACT Continued enlargement of the aneurysm sac after thoracic endovascular aortic repair (TEVAR) is a known risk after endovascular treatment of thoracic aortic aneurysms. For this reason, periodic
25
outpatient follow up is required to identify situations that require repair. Here we describe an
26
aortobronchial fistula (ABF) in a patient lost to follow up, that presented 3 years after an elective TEVAR
27
done for a primary, descending thoracic aortic aneurysm (dTAA). Our patient arrived in extremis and
28
suffered massive hemoptysis leading to her demise. CT angiogram near the time of her death
29
demonstrated a bleeding ABF immediately distal to her previous TEVAR repair. Aortic aneurysmal
30
disease remains life threatening even after repair. Improved endovascular techniques and devices have
31
resulted in decreased need for reintervention. However, this case demonstrates the risk of thoracic aortic
32
disease progression and highlights the importance of establishing consistent, long term follow up after
33
TEVAR.
M AN U
SC
RI PT
24
34
AC C
EP
TE D
35
2
ACCEPTED MANUSCRIPT
36 37
CASE REPORT An 84 year old, hypertensive woman with a history of breast cancer, spine fracture, and chronic back pain was initially evaluated in our office for a primary, 4.7 cm descending thoracic aortic aneurysm
39
(dTAA) and treated conservatively. During the following year, she was hospitalized twice for acute on
40
chronic back pain that prompted axial imaging to rule out thoracic aortic dissection or rupture. Imaging
41
studies demonstrated more than a 1 cm diameter increase in the size of her aneurysm over 12 months.
42
Due to the rapid growth of the aneurysm and complicated clinical picture, we recommended she undergo
43
an elective, percutaneous thoracic endovascular aortic repair (TEVAR) of her dTAA. We placed
44
overlapping Medtronic Talent Captiva endografts covering 18 cm of her descending thoracic aorta. The
45
proximal endograft (34x34x160 mm) overlapped with the distal endograft (38x34x112 mm) for
46
approximately 9 cm in length (Figure 1A). The proximal landing zone of the native aorta had a diameter
47
of 30 mm (40 mm long) and a distal landing zone diameter of 30 mm (37 mm long). The left subclavian
48
artery was not covered but several bronchial and intercostal vessels were covered during repair.
SC
M AN U
Following an uncomplicated postoperative course, the patient was discharged home and followed
TE D
49
RI PT
38
up in our clinic 2 weeks after her procedure. Our standard TEVAR follow up includes a 2 week post
51
procedure office visit, followed by CT angiogram of the thoracic and abdominal aorta at 1 month, 6
52
months, and 12 months post procedure. Imaging is performed during yearly follow up visits thereafter.
53
After the first postoperative visit the patient did not return phone calls and letters indicating the need to
54
return to clinic. The main barrier to her care was poor compliance. Unfortunately, after being lost to
55
follow up, she presented 3 years later with massive hemoptysis and profound hypotension. She was
56
immediately intubated in our emergency department with prompt return of 500cc bright red blood through
57
her endotracheal tube. CT angiogram near the time of her death demonstrated a bleeding aortobronchial
58
fistula (ABF) originating distal to her TEVAR repair (Figure 1B and 1C). The patient expired soon after
59
presentation as she had an established DNR order and her family requested that aggressive resuscitation
60
efforts be withheld. No information is available concerning the interval growth of her dTAA after repair.
61
At the time of rupture, the seal of her distal landing zone had been lost and its diameter had grown from
AC C
EP
50
3
ACCEPTED MANUSCRIPT
30 mm at the time of TEVAR repair to 44 mm at the time of her death. This represented a type 1b
63
endoleak from the distal edge of her endograft that resulted from interval growth of her aneurysmal
64
disease, as the graft was properly sized at the initial intervention. There was no evidence of graft infection
65
at the time of her death. Her caretakers did not recall any exacerbation of her chronic back pain and she
66
had no previous episodes of hemoptysis. Unfortunately, she had not been evaluated by any other
67
physicians over the interval period. Had the patient been clinically stable for repair, we would have
68
attempted another endograft stent placement to cover the area of active bleeding, which had resulted in an
69
ABF.
SC
ABF can result from thoracic aneurysm rupture directly into the bronchial tree due to adhesions
M AN U
70
RI PT
62
that form between the aorta and airways. Hemoptysis is often the initial presentation of ABF and is
72
associated with extremely high mortality. Endograft placement for dTAA results in 96% freedom from
73
aneurysm-related death, but up to 14% of patients may need repeat intervention at 5 years for various
74
reasons, including progression of aneurysm dilatation beyond the stented aorta [1]. Unfortunately, our
75
patient developed aneurysmal progression after TEVAR and arrived in extremis with no time to
76
intervene. This case emphasizes the importance of close patient follow up and repeat imaging after
77
TEVAR.
EP
79
AC C
78
TE D
71
4
ACCEPTED MANUSCRIPT
80 81
DISCUSSION Repair of thoracic aortic aneurysm is advocated when the diameter of the aneurysm is equal to or greater than 5.5 cm [2]. An endovascular approach is recommended over open surgery when feasible [2,
83
3]. Endovascular techniques can result in complications including stroke, paraplegia, visceral ischemia,
84
access complications, device migration, endoleaks, or post implantation syndrome [4]. Multiple
85
commercially available endografts for TEVAR repair are available including Zenith (Cook Inc.,
86
Bloomington, IN), Valiant (Medtronic Corp., Santa Rosa, CA), Conformable GORE TAG (W.L. Gore
87
and Associates Inc., Flagstaff, AZ), and Relay Endografts (Bolton Medical Inc., Sunrise, FL) [5].
88
Following the use of these endografts in the treatment of thoracic aortic aneurysms, one European registry
89
review estimated an annual reintervention rate of 4.6% or 14% risk at 4 years for management of
90
endoleaks and progression of aneurysmal disease [5].
M AN U
SC
RI PT
82
Several series of TEVAR patients have been published that include 5 year outcomes and
92
prevalence of reintervention [6-8]. Geisbush et al published their single center experience of 264 TEVAR
93
patients, which showed an overall reintervention rate of 22%. Indications for reintervention were led by
94
endoleaks (44%) and progression of aortic disease (29%). Risk factors included chronic expanding aortic
95
dissections (OR 2.35), hybrid aortic procedures (OR 2.11), and connective tissue disease (OR 7.54) [7].
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This same group reported 5 year mortality of 50% and freedom from complication of 52%, 47.2%, and
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47.2% at 1, 3, and 5 years respectively [6]. A meta-analysis of 17 studies including 567 patients, reported
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considerable variability (range 0-60%) in rates of reintervention after TEVAR for type B aortic
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dissection. Causes for reintervention included endoleaks (8.1%) and progression of aneurysmal disease
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(7.8%). Rare complications included retrograde type A dissection (0.67%), aortoesophageal fistula
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(0.22%), paraplegia (0.45%), and stroke (1.5%) [8]. Based on our imaging studies, we have concluded
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that this patient developed a type 1b endoleak after progression of her aneurysmal disease that lead to
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fistulization into the airway distal to her previous TEVAR repair.
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Different rates of reintervention are reported depending on the specific type of endoleak.
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Preventza et al reported on 249 patients undergoing dTAA repair with TEVAR, and found that endoleaks 5
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occurred in 38 patients: type 1a (n = 13, 34.2%), type 1b (n = 15, 39.5%), type 2 (n = 8, 21.1%), and type
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3 (n = 2, 5.3%) respectively. Of these, 12 patients required reintervention; type 1a (n = 8, 66.7%), type 1b
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(n = 2, 16.7%), combined type 1 and 3 (n = 1, 8.3%), and type 3 (n = 1, 8.3%) [9]. Szeto et al reviewed
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680 patients undergoing TEVAR at the University of Pennsylvania and found that endoleaks (45/80)
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accounted for the greatest majority of their cases requiring reintervention (11.7%, 80/680); type 1 (24/45),
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type 2 (5/45), type 3 (9/45), and multiple/unclear (7/45). Other lesser causes of endograft failure in their
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series included proximal aortic events (14%), distal aortic events (18%), multiple failure modes (5%),
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endograft infection (4%), and carotid occlusion/stent collapse (3%). The median time for reintervention
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was 210 days [10]. Boufi et al have found that short proximal aortic neck length may be the only
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independent risk factor for the development of a secondary type I endoleak, not clinical urgency or aortic
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length covered. Using receiver operating characteristics, Boufi and colleagues have advocated for ≥ 24
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mm landing zone [11]. The proximal landing zone in our case was 30 mm.
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Our patient originally underwent TEVAR for a primary dTAA using a Talent (Medtronic) thoracic stent graft with Captiva delivery system. This device was first launched in 2005 and received
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FDA approval in 2008. Outcomes from the use of these endografts are available for at least 7 separate
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clinical trials [12]. Following the development of second generation Valiant endografts, Talent and
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Valiant endografts were compared head-to-head. Effectiveness end points only differed in that
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reinterventions due to endoleak after > 30 days were significantly greater for Talent versus Valiant
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endografts (6.5% v 0%). Loss of graft patency, stent graft migration at 1 month, and endoleak at 12
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months were not different between devices [13]. Valiant endografts were not available for our patient at
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the time of her procedure.
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ABF results from the erosion of an aneurysm into the bronchial tree or pulmonary parenchyma
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that is adjacent to the aneurysm. Previous placement of a prosthetic graft and severe atherosclerosis have
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been associated with this condition [14]. Little evidence however is available concerning the incidence of
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ABF after TEVAR [15-18]. Piceche et al studied all available case reports and reviews for postoperative
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aortic fistulas into the airways after cardiothoracic surgery. Uniformly fatal if untreated, surgical mortality 6
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rates were 15% for open repair and 6.8% for endovascular repair [17]. Hemoptysis was the first, and often
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the only, clinical finding of ABF. These authors found that aortic fistulas into the airways were more
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common after dTAA procedures compared to other fistula after cardiac and thoracic surgery [17]. Using a
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nationwide survey of 17 centers in Italy, Chiesa et al reported a 1.7% (19/1113) incidence of
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aortoesophageal and aortobronchial fistula after TEVAR. Higher rates of fistula formation in this survey
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were associated with aortic pseudoaneurysms, complex operations, and emergent procedures. Overall
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survival was a dismal 16% [15]. Similarly, Czerny and colleagues reviewed the European Registry of
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Endovascular Aortic Repair Complications, comprised of 4680 TEVAR patients at 14 European centers,
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and found the incidence of aortobronchial or aortopulmonary fisulta after TEVAR was 0.56%. Leading
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mechanisms of fistula formation were external compression of the bronchial tree, endoleak formation, and
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further aortic ischemia [16]. Therefore, ABF after TEVAR are rare, but carry a high mortality rate.
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In conclusion, endovascular treatment of aortic aneurysm is a reliable therapy for the management of this condition. However, like any other therapeutic intervention, it can result in
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complications. Aneurysmal progression and aortic fistulization can occur and result in fatal outcomes.
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TEVAR patients must be educated that aortic aneurysm is a dynamically evolving disease process that
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requires close observation and periodic imaging. Common intervals for follow up are 1 month, 6 months,
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and then yearly. With aggressive outpatient management, the catastrophic outcome experienced by our
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patient can hopefully be avoided.
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FIGURE LEGEND
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Figure 1: CT angiogram taken (A) intraoperatively and (B, C) 3 years postoperatively during rupture of
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the aortrobronchial fistula. Aortic aneurysm distal to the TEVAR stent and filling of the aortobronchial
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fistula are shown.
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