title: Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications.
abstract: OBJECTIVE
  To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR).
  
  
  METHODS
  Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres).
  
  
  RESULTS
  Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively).
  
  
  CONCLUSIONS
  ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy.
authors.affiliation: Department of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland martin.czerny@usz.ch.
authors.forename: Martin
authors.initials: M
authors.lastname: Czerny
authors.affiliation: Department of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Diana
authors.initials: D
authors.lastname: Reser
authors.affiliation: Cardioangiological Center Bethanien, Frankfurt, Germany.
authors.forename: Holger
authors.initials: H
authors.lastname: Eggebrecht
authors.affiliation: Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
authors.forename: Karin
authors.initials: K
authors.lastname: Janata
authors.affiliation: Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
authors.forename: Gottfried
authors.initials: G
authors.lastname: Sodeck
authors.affiliation: Heart Center Leipzig, Leipzig, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Etz
authors.affiliation: Heart Center Leipzig, Leipzig, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Luehr
authors.affiliation: Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, Perugia, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Verzini
authors.affiliation: Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, Perugia, Italy.
authors.forename: Diletta
authors.initials: D
authors.lastname: Loschi
authors.affiliation: Department of Vascular Surgery, Scientific Institute H San Raffaele, Milan, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Chiesa
authors.affiliation: Department of Vascular Surgery, Scientific Institute H San Raffaele, Milan, Italy.
authors.forename: Germano
authors.initials: G
authors.lastname: Melissano
authors.affiliation: Department of Vascular Surgery, Scientific Institute H San Raffaele, Milan, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Kahlberg
authors.affiliation: Department of Interventional Radiology, AP-HM-Hôpital Nord, Marseille, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Amabile
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Braunschweig, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Harringer
authors.affiliation: Department of Cardiology, West-German Heart Center Essen, Essen, Germany.
authors.forename: Rolf Alexander
authors.initials: RA
authors.lastname: Janosi
authors.affiliation: Department of Cardiology, West-German Heart Center Essen, Essen, Germany.
authors.forename: Raimund
authors.initials: R
authors.lastname: Erbel
authors.affiliation: Department of Cardiovascular Surgery, Inselspital, University Hospital Berne, Berne, Switzerland.
authors.forename: Jürg
authors.initials: J
authors.lastname: Schmidli
authors.affiliation: Department of Cardiac Surgery, CHUV, Lausanne, Switzerland.
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Tozzi
authors.affiliation: University, Division of Cardiovascular Surgery, Kobe University, Kobe, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Okita
authors.affiliation: Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
authors.forename: Ludovic
authors.initials: L
authors.lastname: Canaud
authors.affiliation: Division of Cardiothoracic Surgery Cedars Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Khoynezhad
authors.affiliation: The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Maritati
authors.affiliation: San Camillo Hospital, Rome, Italy.
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Cao
authors.affiliation: Universitäres Herzzentrum Hamburg, Hamburg, Germany.
authors.forename: Tilo
authors.initials: T
authors.lastname: Kölbel
authors.affiliation: IRCCS Policlinico San Donato, Thoracic Aortic Research Center, Milan, Italy.
authors.forename: Santi
authors.initials: S
authors.lastname: Trimarchi
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000453:epidemiology / Q000601:surgery*; D001018:Aortic Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D001983:Bronchial Fistula / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D057510:Endovascular Procedures / Q000009:adverse effects; D005060:Europe / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008171:Lung Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012042:Registries; D016156:Respiratory Tract Fistula / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery
keywords: Aorto-bronchial fistulation; Complications; Thoracic endovascular aortic repair; Treatment