What is the real risk of stent-graft infection in the treatment of aortobronchial fistulas?

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CTSNet classification: 15.2, 26.1

To the Editor:

A recent article by Hacker and colleagues¹ describes a single case report of aortobronchial fistula (ABF) in a patient who was successfully treated (27 years ago) for isthmic posttraumatic pseudoaneurysm by placement of thoracic endoprosthesis. The authors conclude by saying that “endovascular intervention and stent grafting are feasible and should be the first option in the treatment of ABFs.”

We agree that ABF is a rare and fatal disease and most frequently associated with previous cardiac, vascular, or thoracic surgery. Surgical treatment is still characterized by high rates of mortality and morbidity. Our article² showed that it is not possible to identify a half-accurate diagnostic instrument: angiography, bronchoscopy, and transesophageal echocardiography are associated with a high rate of complications, including fatal hemorrhage. Findings suggestive of ABF on computed tomography scan include pseudoaneurysm, aortic anatomy abnormalities, lung parenchyma consolidation, and compression of bronchial tree.

Conventional open surgical correction involves a thoracotomy and has fairly high morbidity and mortality because of difficult operative dissection associated with reoperative surgery; in addition, patients may have severe comorbidities and present in rather poor health. Endovascular stent grafting provides a safe and reliable method to treat ABF.

One potential life-threatening complication is stent-graft infection; however, in our experience, no signs of infections were detected by postoperative scintigraphy with labeled leukocytes.

It is unclear why the infection rate for endovascular repair is minimal, but the stent graft remains in the center of the aneurysm sac well away from the actual fistula and source of contamination. Perhaps because there is minimal tissue trauma associated with the deployment of the stent graft, as opposed to open surgical repair, the excluded aneurysmal or pseudo-aneurysmal cavity is less likely to become contaminated or infected.

Postoperative antibiotic treatment differs completely among the various authors, both with regard to the antibiotic (cephalosporin, vancomycin, antifungal) and the duration of therapy (lifelong antibiotic therapy?).

In our opinion, the open questions remain: (1) Which antibiotic therapy should be performed in patients with ABF treated with thoracic endovascular aneurysm repair? (2) How long should antibiotic therapy be continued?

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References 

1. Hacker S, Langenberger H, Plank C, Gorlitzer M, Ehrlich M, Dolak W, et al. Management of aortobronchial fistula developing 27 years after open aortic surgery by means of endovascular stent grafting. J Thorac Cardiovasc Surg. 27 April 2009;[Epub ahead of print]
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2. Pirrelli S, Bozzani A, Arici V, Odero A. Endovascular treatment of acute haemoptysis secondary to aortobronchial fistula. Eur J Vasc Endovasc Surg. 2006;32:366–368
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