title: Combined endovascular and surgical approach for aortobronchial fistula.
abstract: OBJECTIVE
  The perioperative outcomes of the endovascular approach to aortobronchial fistula have been favorable. However, it is uncertain whether thoracic endovascular aneurysm repair (TEVAR) alone provides a complete and durable cure for an aortobronchial fistula. TEVAR does nothing to address the issue of the defect in the respiratory tract, leaving the patient at risk of aortobronchial fistula recurrence and/or stent graft infection. The authors believe that the bronchial defect should be addressed.
  
  
  METHODS
  Over the last 10 years, 5 patients were treated for an aortobronchial fistula using a combined endovascular and surgical approach (primary treatment in 3 patients and secondary after TEVAR in 2 patients). All the patients underwent emergency stent graft placement and concomitant (n=1) or staged (n=4) open repair including pulmonary resection with coverage of the stent graft using muscle or pleural flaps. All patients received a 6-week course of broad-spectrum intravenous antibiotics followed by lifelong oral antibiotics.
  
  
  RESULTS
  All patients survived the surgical procedure. After a mean follow-up of 23.2 months, 4 patients are asymptomatic and postprocedure computed tomography scans were unremarkable. One patient treated for an aortobronchial fistula after TEVAR was readmitted 4 months after surgical conversion. Stent graft explantation and silver-coated tube graft replacement of the descending thoracic aorta were performed for severe mediastinitis with associated thoracic stent graft infection. The postoperative course of this patient was uneventful.
  
  
  CONCLUSIONS
  Emergency TEVAR for an aortobronchial fistula is an appealing strategy for this devastating complication. However, to achieve a lasting result, direct contact between the stent graft and the pulmonary tissue should be avoided to prevent further erosive damage. Concomitant or staged repair should entail primary repair or resection and anastomosis of the bronchus and/or pulmonary resection with coverage of the stent graft using muscle or pleural flaps combined with broad-spectrum intravenous antibiotic therapy. Long-term surveillance and continued investigation are warranted.
authors.affiliation: Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, and Unité INSERM U1046, Montpellier, France. Electronic address: ludoviccanaud@hotmail.com.
authors.forename: Ludovic
authors.initials: L
authors.lastname: Canaud
authors.affiliation: Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, and Unité INSERM U1046, Montpellier, France.
authors.forename: Thomas
authors.initials: T
authors.lastname: D'Annoville
authors.affiliation: Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, and Unité INSERM U1046, Montpellier, France.
authors.forename: Baris Ata
authors.initials: BA
authors.lastname: Ozdemir
authors.affiliation: Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, and Unité INSERM U1046, Montpellier, France.
authors.forename: Charles
authors.initials: C
authors.lastname: Marty-Ané
authors.affiliation: Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, and Unité INSERM U1046, Montpellier, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Alric
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001018:Aortic Diseases / Q000175:diagnosis / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis / Q000009:adverse effects; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D001983:Bronchial Fistula / Q000175:diagnosis / Q000601:surgery*; D020878:Device Removal; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D005260:Female; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000209:etiology / Q000601:surgery; D008875:Middle Aged; D011013:Pneumonectomy; D049268:Positron-Emission Tomography; D016459:Prosthesis-Related Infections / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents / Q000009:adverse effects; D013524:Surgical Flaps; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000175:diagnosis / Q000601:surgery*
chemical_list: D000900:Anti-Bacterial Agents