Endovascular Stent-Graft Repair of Aortobronchial Fistulas

Endovascular Stent-Graft Repair of Aortobronchial Fistulas ADULT CARDIAC

Nobuyoshi Kawaharada, MD, PhD, Yoshihiko Kurimoto, MD, PhD, Toshiro Ito, MD, PhD, Mayuko Uehara, MD, Toshiyuki Maeda, MD, Tetsuya Koyanagi, MD, Satoshi Muraki, MD, PhD, Atsushi Watanabe, MD, PhD, and Tetsuya Higami, MD, PhD Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan

Background. Endovascular repair of the descending thoracic aorta has recently emerged as a feasible treatment option; however, little is known about its application for aortobronchial fistula (ABF). Experience with endovascular repair of the thoracic aorta and the outcome of patients with ABFs was reviewed to assess whether thoracic endovascular repair is a realistic option. Methods. From February 2001 to May 2011, 386 patients were successfully treated with endoluminal grafts to the distal arch or descending thoracic aorta. Among them, 26 patients with ABF underwent thoracic endovascular repair. These cases were reviewed and analyzed retrospectively. Follow-up was 100% complete (mean, 21 months). Results. The subjects included 26 patients (22 males, 85%; 4 females, 15%) with a median age of 71 years. Ten patients (38%) were diagnosed with atherosclerotic aneurysms, 13 (50%) had pseudoaneurysms associated with

prior open surgical repair, 1 (4%) had rupture of dissecting aneurysm, and 2 (8%) had mycotic aneurysm. There were 4 (15%) in-hospital mortalities, in which the causes included bleeding owing to recurrence of hemoptysis (n ⴝ 3, 11%) and multiple organ failure (n ⴝ 1, 4%). None sustained postoperative stroke or paraplegia. During follow-up, ABFs recurred in 4 patients; of these, endograft explantation occurred in 3 patients and 1 patient required additional open surgery. No hospital mortality resulted among the 4 patients with ABF recurrence. Conclusions. Endovascular management of ABFs appears to be safe and well tolerated with minimal risk, even in surgically high-risk patients. Endovascular stentgraft repair is likely the first choice for ABF presenting as hemoptysis. (Ann Thorac Surg 2012;94:524 –9) © 2012 by The Society of Thoracic Surgeons

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especially when aortic rupture or ABF occurs [9]. For ABFs, thoracic endovascular aortic repair (TEVAR) permits rapid control of hemorrhage while avoiding the inherent morbidity associated with thoracic aortic exposure and aortic cross-clamping. The aim of our study was to further examine the efficacy of TEVAR for ABF. A retrospective review of our single-institution experience with TEVAR in the management of ABFs was performed.

ortobronchial fistula (ABF) is a rare but potentially fatal disease. Death can result from the massive hemoptysis as a result of erosion of an aneurysm into the adjacent pulmonary parenchyma or bronchial wall. Aortobronchial fistulas have been associated with a number of diseases of the thoracic aorta, including atherosclerotic aneurysms of the descending thoracic aorta, anastomotic pseudoaneurysms that occur subsequent to previous open aortic surgery, mycotic aneurysms, traumatic injuries to the thoracic aorta, and even in the setting of penetrating aortic ulcers [1– 6]. Conventional open surgical intervention for ABFs is associated with substantial morbidity and mortality [7, 8]. The high complication rate can be attributed to the need for an emergency intervention in patients with multiple preexisting comorbidities through what will often be a reoperative surgical approach. During the last decade, endovascular stentgrafting has been used with increasing frequency as an alternative or a complement to surgical treatment for an aneurysm or dissection of the descending thoracic aorta,

Accepted for publication March 26, 2012. Presented at the Forty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28 –Feb 1, 2012. Address correspondence to Dr Kawaharada, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, S 1 W 16, Chuo-ku, Sapporo 060-8543, Japan; e-mail: nobuyosh@ sapmed.ac.jp.

© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc

Material and Methods Institutional review board approval was obtained for the review of all patients’ records relevant to this study. A search was conducted on the institutional database from February 2001 to May 2011. During this period, 386 patients received endografts for multiple thoracic aortic diseases, and 26 patients (6.7%) underwent emergency TEVAR for ABFs. Before commercially developed grafts became available, the devices used in these cases were a homemade type using Gianturco Z stents (Cook Inc, Bloomington, IN), which were preconstructed to fit the aortic tortuosity and covered with a prosthetic vascular graft (Ube Corp, Ube, Japan). Various types (9-, 12-, 16-, and 20-cm lengths using 20-, 30-, and 40-mm wide stents) of endoskeleton consisting of 2.5-cm long Z-stents, which had been gas sterilized and stored onsite for emergency 0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.03.068

use, were used. Axial computed tomography (CT) scan images were used to determine the diameter of the landing zone and length of the endoskeleton. The procedure has been described in detail in a previous report [10]. Briefly, the patient was placed on a radiolucent operating table under general anesthesia in the operating room. The handmade stent graft was manually loaded into the proximal end of an 18F to 20F long sheath (Cook Inc). A minimal amount of heparin (generally 2,000 to 3,000 U) was administered to the 26 patients having TEVAR to keep activated coagulation time at approximately 200 seconds. No heparin was given for patients with an activated coagulation time of more than 250 seconds. The delivery system was advanced to the target region using a brachial guidewire technique. After digital subtraction angiography to confirm the appropriate position for the stent graft, systemic arterial blood pressure was lowered to 80 mm Hg during deployment to prevent graft migration. Digital subtraction angiography was performed to confirm complete exclusion of an aneurysm after placement of the stent-graft. Endoprostheses (Tag; W.L. Gore & Assoc, Flagstaff, AZ, or Talent; Medtronic AVE, Santa Rose, CA) were used in the last 3 years for treatment of thoracic aortic diseases. Devices were selected from hospital stocks on the basis of measurements derived from preoperative CT scans. The patients stayed in the intensive care unit overnight. Postoperative CT scan of the chest was performed on the operative day or first postoperative day.

Results Between February 2001 and May 2011, 386 patients were successfully treated with endoluminal grafts to the distal arch or descending thoracic aorta. Among them, 26 patients with ABF underwent endovascular repair. Patient demographics and preoperative risk factors are listed in Table 1. Of the 26 patients whose age and sex were reported, the mean age was 71 years and 85% were men. Etiologies of the ABFs included 9 (35%) atherosclerotic aneurysms, 13 (50%) anastomotic pseudoaneurysms, 2 (8%) chronic dissections, and 2 (8%) mycotic aneurysms. Mycotic aneurysm is associated with a high mortality rate. One of the 2 patients with mycotic aneurysm had persistent fever. The increase in white blood cell count and C-reactive protein was confirmed. The levels were highly elevated at 2 months, which coincided with the development of hemoptysis. The patient was then referred to our hospital. Pathogens were undetectable in this patient because intravenous antibiotics (vancomycin, meropenem) were administered in the several weeks before he was referred to our hospital. However, the aneurysm was diagnosed as a mycotic aneurysm based on the clinical course. After TEVAR, the mycotic aneurysm was ligated and shrunk (Fig 1). Postoperative oral antibiotics (faropenem sodium) were used for 3 months. A CT scan was performed in all patients who presented to the hospital with a history of recurrent hemoptysis. Although all studies demonstrated associated thoracic aortic disease, none directly demonstrated a fistula. Thir-

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Table 1. Demographics and Comorbidities of Patients With Aortobronchial Fistula ABF (n ⫽ 26)

Characteristics Age, (y) Range Male sex, n (%) Comorbidities, n (%) Coronary artery disease Diabetes mellitus Hypertension Cerebrovascular disease Chronic obstructive pulmonary disease Renal failure (hemodialysis) Arteriosclerosis obliterans Atrial fibrillation Liver cirrhosis Presentation, n (%) Hemoptysis Dyspnea Hypovolemic shock Etiology of fistula, n (%) Atherosclerotic aneurysm Anastomotic pseudoaneurysm Mycotic aneurysm Chronic dissection Previous aortic surgery, n (%) Interval between last thoracic aneurysm surgery and onset of symptoms (y) Range TEVAR within 24 hours of diagnosis, n (%) ABF ⫽ aortobronchial fistula; repair.

71 ⫾ 8.7 52–87 22 (85) 4 (15) 2 (8) 15 (58) 4 (15) 5 (19) 4 (15) 2 (8) 3 (12) 1 (4) 26 (100) 4 (15) 4 (15) 10 (38) 13 (50) 2 (8) 1 (4) 16 (62) 6.5 ⫾ 5.5 0.3–20.7 23 (88)

TEVAR ⫽ thoracic endovascular aortic

teen of the 26 patients (50%) presented with pseudoaneurysms associated with prior surgery of the thoracic aorta with graft interposition or endoluminal grafts before the onset of hemoptysis. Median interval between the last thoracic aneurysm surgery and onset of symptoms was 67 months (range, 4 to 252 months; interquartile range, 84 months). All patients experienced varying degrees of hemoptysis, which ranged from intermittent bloody expectoration to massive hemorrhage. After establishing the diagnosis of ABF, all procedures were performed as soon as possible under general anesthesia in an operating room equipped for prompt open surgical conversion. Stent grafts used are reported in Table 2. Mean stent graft proximal diameter was 34.0 ⫾ 4.2 mm. A mean number of 1.5 ⫾ 0.6 devices per patient were implanted. Proximal landing zone was classified as zone 1 in 4 patients, zone 2 in 7 patients, zone 3 in 8 patients, zone 4 in 4 patients, zone 5 in 1 patient, zone 6 in 1 patient, and zone 7 in 1 patient. Thoracic endovascular repair with fenestrated endoluminal grafts was performed for zone 1 or zone 2 cases. Mean duration of the operation was 154 ⫾ 66 minutes with a mean length of stent-graft deployed of 6.1 ⫾ 2.0 zone numbers from the proximal zone to the distal zone. Assisted primary

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Fig 1. (A) Preoperative three-dimensional computed tomography (panel 1) and postoperative three-dimensional computed tomography at 7 days (panel 2) demonstrating complete exclusion of aortobronchial fistula and correct stent-graft placement. (B) Preoperative computed tomography scan showing a saccular aneurysm of the descending thoracic aorta with fissured thrombus (panel 1). Postoperative (7 days, panel 2; 3 months, panel 3) computed tomography scan after successful endovascular exclusion of the aortic aneurysm. Arrows indicate the process of shrinkage of the aneurysm.

technical success was 100%. No intraoperative deaths were recorded. Complete exclusion of the fistula was successfully achieved during initial TEVAR in 22 of 26 patients (85%). In the remaining 4 patients, open surgical conversion was successfully performed in 1 patient on the first postoperative day because of considerable type 1 endoleak, and the other 3 patients died after 11, 14, and 23 days as a result of massive hemoptysis, which was probably caused by endoleak type 1. Median hospital length of stay was 12 days (range, 1 to 164 days; interquartile range, 14.5 days). Thirty-day mortality was 15% (n ⫽ 4) owing to multiple organ failure (n ⫽ 1) and massive hemoptysis (n ⫽ 3). Median time interval until death was 13 days (range, 3 to 23 days; interquartile range, 7.3 days). No cases of paraplegia, paraparesis, or stroke were observed. Postoperative complications included acute renal dysfunction in 1 patient (4%), respiratory failure in 3 patients (12%), and injury of access vessel in 3 patients (12%). Median follow-up period of surviving patients was 15 months (range, 0 to 102 months; interquartile range, 26 months). Additional vascular interventions for a repeat TEVAR were performed in 2 survivors during this period. Overall survival at 5 years was 39%, and long-term freedom from aneurysm-related death was 83% at 5 years (Fig 2). Because the study period spanned the era before and after thoracic endograft

approval in Japan, the devices used included approved thoracic devices and homemade devices. Most patients (65%) received thoracic endografts of homemade devices (Table 2). Commercially manufactured thoracic endograft devices made up approximately 35%, of which TEVAR was predominantly performed in earlier reports or from countries with limited endograft availability.

Comment Aortobronchial fistula is a rare disease that usually arises after conventional thoracic aortic surgery as a result of tracheobronchial compression necrosis [8, 11–13]. Presenting as either intermittent or massive hemoptysis, mortality is 100% if intervention is not pursued aggressively [7]. In addition to hemoptysis, additional signs and symptoms of ABF are dyspnea and cough, chest or back pain, pulmonary rales, or hypoxia. Prompt diagnosis and expedient operative management are key prognostic factors in the survival of patients with ABF [14]. Aortobronchial fistula has been reported after the surgical repair of aortic aneurysms, coarctation of the aorta, patent ductus arteriosus, aortic dissection, valvular heart disease, and other thoracic procedures, with aneurysm repair being the most common culprit [8, 11, 12]. In the presence of an aortic graft, the fistula is associated with a pseudoaneu-

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Table 2. Operative Details of Patients With Aortobronchial Fistula Variable Operation time (min) Range Stent-graft (manufacturer), n (%) Homemade Tag (W.L.Gore & Assoc) Talent (Medtronic AVE) Vascular access, n (%) Femoral artery Iliac artery Left subclavian artery covered, n (%) Proximal landing zone, n (%) Z0 Z1 Z2 Z3 T4 T5 T6 T7 Distal landing zone, n (%) T5 T6 T7 T8 T9 T10 T11 T12 L1

ABF (n ⫽ 26) 154 ⫾ 66 69–285 17 (65) 5 (19) 4 (15) 17 (65) 9 (35) 3 (12) 0 4 (15) 7 (27) 8 (31) 4 (15) 1 (4) 1 (4) 1 (4)

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management of ABF has entailed open surgical repair of both the aortic and pulmonary components to the fistula [7, 8]. Once the diagnosis is established, definitive treatment of ABF should be expeditious. Open surgical repair is usually a formidable challenge. The traditional approach involves thoracotomy, aortic cross-clamping, possible cardiopulmonary bypass with concomitant anticoagulation, aorta repair, graft replacement or bypass of the aortic defect, and pulmonary tissue dissection in the face of dense adhesions. Bronchial or lung surgical repair may consist of primary closure or partial resection of lung tissue. Open surgery of ABF is associated with respiratory insufficiency, stroke, paralysis, acute renal failure, myocardial infarction, cardiac failure, hemorrhage, and secondary graft infection. In the literature, despite advances in surgical techniques, published reports estimate the operative mortality of open ABF repair to range from 15% to 41% [7, 8, 11, 15–17]. The majority of this mortality may be attributable to the need to perform reoperative thoracic exposures in patients who have previously un-

1 (4) 1 (4) 2 (8) 8 (31) 3 (12) 5 (19) 4 (15) 1 (4) 1 (4)

ABF ⫽ aortobronchial fistula.

rysm at the anastomotic site as a result of atherosclerotic disease progression and weakening of the aortic wall. The diagnosis of ABF should be given serious consideration in any patient with hemoptysis after a thoracic aortic operation. Chest radiograph, CT angiography, magnetic resonance imaging, contrast aortography, bronchoscopy, and transesophageal echocardiography have all been shown to be successful in demonstrating ABF, but each has its individual limitations. Computed tomographic angiography may demonstrate disease of the thoracic aorta and adjacent lung tissue, but a fistulous communication is rarely ever visualized. Although thoracic diagnoses of hemothorax, pleural effusion, or atelectasis were identified adjacent to the aforementioned vascular diseases, no definitive fistula tracts were visualized on CT angiography. Bronchoscopy is particularly useful in ruling out other pulmonary sources of the hemoptysis but should be pursued with caution because of the risk of dislodging any clot and potentially reactivating bleeding. Hemoptysis in a patient with thoracic aorta disease is highly suggestive of ABF and should lead the clinician to pursue urgent operative repair. Historically, definitive

Fig 2. (A) Overall survival (39%) is shown to reach 100 months after endovascular stent-graft repair of aortobronchial fistula. (B) Long-term freedom from aneurysm-related death (83%) is shown to reach 100 months after endovascular stent-graft repair of aortobronchial fistula.

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dergone thoracic aortic surgery. Treatment of a fistula between the thoracic aorta and an adjacent organ by means of TEVAR was first reported in 1996 by Chuter and colleagues [18] and in the same year by Campagna and associates [19]. Subsequently, several cases were published describing the feasibility of endovascular treatment of ABF. Because endovascular treatment is simpler, faster, and safer than open surgery in unstable patients, TEVAR is considered by most authors as first-line treatment to obtain immediate control of aortic bleeding. Spinal cord protection with cerebrospinal fluid drainage was not used in any of the patients in this study. In addition, motor evoked potential monitoring was not conducted for thoracic endografting procedures. There were no perioperative or postoperative neurologic complications, such as paraplegia or paraparesis. However, if any patient experiences postoperative paraplegia or paraparesis, cerebrospinal fluid drainage would be contemplated. Vascular access is an important consideration for thoracic endografting procedures. Introduction and removal of large-bore delivery sheaths in small, calcified, or tortuous access vessels can be associated with rupture of the iliac artery and subsequent patient mortality. If the access vessels will not accept the large-bore delivery sheath, then a 10-mm retroperitoneal conduit must be sewn to the proximal common iliac artery to make the vascular access portion of the procedure safe. Commonly, 15% of patients who are treated with a thoracic endoluminal graft require a retroperitoneal conduit or cannulation [20]. In this study, 9 of 26 patients (35%) required the use of the iliac artery for the vascular access portion to safely deliver the sheath. This rate is significantly higher than most series for thoracic endografting. Prosthetic graft infection is a significant concern after repair of ABF. In open surgical repair, it is recommended that the prosthetic graft and fresh suture line be protected from the repaired bronchial fistula by either wrapping the graft with aneurysmal wall or interposing viable tissues, such as the pleura, intercostal muscle pedicle flap, omentum, or pericardial fat pad [7, 15]. In this study, no infection of endoprosthesis occurred during hospitalization. It is unclear as to why the infection rate for endovascular repair is minimal, but the endoluminal graft remains in the center of the aneurysm sac, far from the actual fistula and source of contamination. All patients without mycotic aneurysm received two or three intravenous doses of perioperative cephalosporin antibiotics and were administered intravenous antibiotics for 3 days postoperatively. Subsequently, no routine postoperative antibiotic regimen was followed. In fact, a subtotal of patients received no postoperative antibiotics; they were discharged home without any oral antibiotics. In this limited cohort, no association between postoperative antibiotic administration and freedom from graft infection was observed. However, the possibility of long-term antibiotic use is suggested in the presence of mycotic aneurysm and overt infection before surgery of ABF by TEVAR. In this experience, 1 patient treated for ABF had mycotic aneurysm as a result of a bronchopulmonary fistula after left upper lobectomy of lung carcinoma. After TEVAR, the mycotic

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Table 3. Outcomes of Thoracic Endovascular Aortic Repair for Aortobronchial Fistula ABF (n ⫽ 26)

Variable Primary technical success of TEVAR, n (%) Recurrent hemoptysis, n (%) Additional surgical intervention, n (%) Open surgery TEVAR Complication, n (%) Renal failure (hemodialysis) Respiratory failure Injury of access vessel In-hospital mortality, n (%) Recurrent hemoptysis Multiple-organ failure ABF ⫽ aortobronchial fistula; repair.

26 (100) 4 (15) 1 (4) 3 (12) 1 (4) 3 (12) 3 (12) 4 (15) 3 (12) 1 (4)

TEVAR ⫽ thoracic endovascular aortic

aneurysm was ligated and shrunk. Because Mycobacterium avium and Staphylococcus aureus as pathogens were detected in this patient’s sputum during hospitalization, postoperative oral antibiotics (trimethoprim/ sulfamethoxazole) were used for 3 months. Although surgical repair of the bronchopulmonary fistula was warranted, the patient’s complicated general condition was considered to be a high risk for surgery based on the assessment of the general thoracic surgeon. As a result, this patient died of sepsis after TEVAR in 16 months. The other patient with mycotic aneurysm, as has been mentioned previously, was given oral antibiotics for 3 months once the symptoms of infection were resolved after surgery. This patient is still alive. Consequently, postoperative long-term antibiotic use is unnecessary in the absence of symptoms of infection before surgery or resolution of symptoms with postoperative antibiotic use. Cases of mycotic aneurysm with clear symptoms of infection before surgery indicate the use of postoperative long-term antibiotic administration. This study has several limitations. This is a retrospective study. The results reflect the clinical outcomes of a small series of a single center and have associated limitations for making broader generalizations. However, the results indicate promising outcomes for the endovascular approach to ABF (Table 3). To better understand the risks and benefits of an endovascular approach, prospective, randomized-controlled trials that will compare open repair with endovascular repair are needed. However, it is unlikely that such a study can be conducted owing to the rarity of ABF and the limited number of cases. Most likely, any conclusions that will be drawn will be based on a meta-analysis of the literature and from large-scale multicenter national research trials for endovascular devices in general. Attempts were made to contact the patients in this study, and our presented data reflected the best follow-up we could obtain. Our series and the results of other studies of a similar scope show very promising early or mid-term results, although little is known of the long-term durability of TEVAR for this condition.

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10. Morishita K, Kurimoto Y, Kawaharada N, et al. Descending thoracic aortic rupture: Role of endovascular stent-grafting. Ann Thorac Surg 2004;78:1630 – 4. 11. Favre JP, Gournier JP, Adham M, Rosset E, Barral X. Aortobronchial fistula: report of three cases and review of the literature. Surgery 1994;115:264 –70. 12. Ishizaki Y, Tada Y, Takagi A, et al. Aortobronchial fistula after an aortic operation. Ann Thorac Surg 1990;50:975–7. 13. Kazerooni EA, Williams DM, Abrams GD, Deeb GM, Weg JG. Aortobronchial fistula 13 years following repair of aortic transection. Chest 1994;106:1590 – 4. 14. Liu SF, Chen YC, Lin MC, Kao CL. Thoracic aortic aneurysm with aortobronchial fistulas: a thirteen-year experience. Heart Lung 2004;33:119 –23. 15. Eren E, Keles C, Toker ME, et al. Surgical treatment of aortobronchial and aortoesophageal fistulae due to thoracic aortic aneurysm. Tex Heart Inst J 2005;32:522– 8. 16. Wheatley GH 3rd, Nunez A, Preventza O, et al. Have we gone too far? Endovascular stent-graft repair of aortobronchial fistulas. J Thorac Cardiovasc Surg 2007;133:1277– 85. 17. Thompson CS, Ramaiah VG, Rodriguez-Lopez JA, et al. Endoluminal stent graft repair of aortobronchial fistulas. J Vasc Surg 2002;35:387–91. 18. Chuter TA, Ivancev K, Lindblad B, Brunkwall J, Arén C, Risberg B. Endovascular stent-graft exclusion of an aortobronchial fistula. J Vasc Interv Radiol 1996;7:357–9. 19. Campagna AC, Wehner JH, Kirsch CM, et al. Endovascular stenting of an aortopulmonary fistula presenting with hemoptysis. A case report. J Cardiovasc Surg (Torino) 1996;37: 643– 6. 20. Wheatley GH 3rd, Gurbuz AT, Rodriguez-Lopez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses: single center experience. Ann Thorac Surg 2006;81:1570 –7.

DISCUSSION DR BURKHART ZIPFEL (Berlin, Germany): Congratulations on your excellent study. If you treat aortobronchial fistula with a stent-graft, there is always concern of inadequate closure or of secondary infection. I have two questions. One, you reported 7 recurrent aortobronchial fistulas. Was this due to inadequate occlusion of the aneurysm by the stent-graft, was there a leak, or did they occur despite successful exclusion of the aneurysm? Two, did you observe any secondary infection of the stent-graft? DR KAWAHARADA: We checked the lesion of endoleak with a CT (computed tomography) scan for follow-up patients. So we know they are completely excluded. But patients with recurrent aortobronchial fistulas have endoleak during follow-up period. Second question? DR ZIPFEL: Did you see any infections of the stent-grafts? DR KAWAHARADA: No, I didn’t have experience of graft infection after TEVAR (thoracic endovascular aortic repair). DR THOMAS E. MACGILLIVRAY (Boston, MA): Were these patients maintained on any kind of suppressive antibiotics? DR KAWAHARADA: Pardon? DR MACGILLIVRAY: Were these patients maintained on antibiotics indefinitely? DR KAWAHARADA: Yes, it is very difficult for us using antibiotics after surgery. We don’t have a routine postoperative

antibiotic regimen. In fact, a subtotal of patients received no postoperative antibiotics after surgery. These patients were discharged home without any oral antibiotic administration. Therefore, all patients without mycotic aneurysm received two or three intravenous [doses] of cephalosporin of antibiotics during the perioperative period and for up to 3 days postoperatively. But cases of mycotic aneurysm with clear symptoms of overt infection before surgery indicate the use of postoperative long-term antibiotics administration. DR SHINICHI TAKAMOTO (Tokyo, Japan): Congratulations for your excellent results for this very severe disease, aortobronchial fistula. The same as the aortoesophageal fistula, sometimes the lesion is infected, relating to the first question. If the infection is vivid and clear as evidenced by the CRP (C-reactive protein) level and high fever, do you do this endograft as first choice or do you do surgery at first? DR KAWAHARADA: Aortoesophageal fistula is a different etiology. Endovascular surgery is not the complete treatment for aortoesophageal fistula. We need esophagectomy for patients of aortoesophageal fistula after TEVAR. But although aortobronchial fistula is maybe an emergency operation, so mortality is 100% if intervention is not done aggressively, we are able to do treatment by only TEVAR. So we think the first choice is endovascular stent-grafting. If this patient has infections in aneurysm before TEVAR, we maybe change the strategy. DR TAKAMOTO: Do you change to surgery? DR KAWAHARADA: If the patient is tolerant of open surgery, we try the open surgery.

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