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\begin{document}

\title{Aortic Arch Replacement and Autologous Pericardial Tracheal Patch for an
Aorto-Tracheal Fistula}



\author[1]{Kelsey A. Musgrove}%
\author[1]{Daniel McCarthy}%
\author[1]{Andreas de Biasi}%
\affil[1]{Division of Cardiothoracic Surgery University of Wisconsin Department of Surgery Madison WI USA}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\selectlanguage{english}
\begin{abstract}
Aorto-tracheal fistulas are rare and highly lethal, with few reports of
successful surgical intervention. We present a 48 year old man with
aorto-tracheal fistula induced by radiation therapy for tracheal
squamous cell carcinoma. He presented with hemoptysis and chest pain and
workup revealed the aorta-tracheal fistula between the posterior aortic
arch and anterior distal trachea. He was emergently taken to surgery. To
our knowledge, this is the first report of an aorto-tracheal fistula
successfully treated with a transverse aortic arch replacement and
complex tracheal repair using autologous pericardium with an omental
buttress.%
\end{abstract}%



\sloppy


\textbf{Aortic Arch Replacement and Autologous Pericardial Tracheal
Patch for an Aorto-Tracheal Fistula}

Kelsey A. Musgrove, M.D.\textsuperscript{1}, Daniel McCarthy, M.D.,
M.B.A.\textsuperscript{1}; Andreas R. de Biasi, M.D.\textsuperscript{1}

1. Division of Cardiothoracic Surgery, University of Wisconsin
Department of Surgery, Madison, WI, USA

Disclosures: None

Abstract:

Aorto-tracheal fistulas are rare and highly lethal, with few reports of
successful surgical intervention. We present a 48 year old man with
aorto-tracheal fistula induced by radiation therapy for tracheal
squamous cell carcinoma. He presented with hemoptysis and chest pain and
workup revealed the aorta-tracheal fistula between the posterior aortic
arch and anterior distal trachea. He was emergently taken to surgery. To
our knowledge, this is the first report of an aorto-tracheal fistula
successfully treated with a transverse aortic arch replacement and
complex tracheal repair using autologous pericardium with an omental
buttress.

\textbf{Case Report}

A 48-year-old man with history of tracheal squamous cell carcinoma and
completion of definitive chemoradiotherapy nine months prior presented
to an outside hospital with a three-day history of small-volume
hemoptysis and chest pain. Subsequent workup with computed tomography
revealed an aorto-tracheal fistula between the posterior aortic arch
(zone 1) and anterior surface of the distal trachea, with concomitant
tracheal stricture (Figure 1). His vital signs were within normal limits
and he was directly transferred to an operating room for emergency
surgical intervention.

The patient was intubated with a single-lumen endotracheal tube
following sedation and direct laryngoscopy. With bronchoscopic guidance
the endotracheal tube was positioned proximal to the stenosis to avoid
instrumenting the fistula. Flexible fiberoptic bronchoscopy then
demonstrated an irregular stricture involving the mid-distal
cartilaginous trachea with preservation of the membranous airway.
Immediately distal to the stenosis, a pit in the anterior trachea was
identified approximately 2 cm from the carina with associated bloody
mucoid secretions. Following placement of additional arterial monitoring
lines, central line, Swan-Ganz catheter, Foley catheter, and brain
function monitor (Masimo Corp., Irvine, CA, USA), an 8 mm right axillary
artery chimney graft was placed (Getinge AB, G\selectlanguage{ngerman}öteborg, Sweden) via right
axillary cutdown. Placement of a transesophageal echocardiography probe
was attempted but resulted in extremely poor ventilation, likely
secondary to extrinsic compression from the probe onto the narrowed
trachea at the level of the stricture. Therefore, it was removed and
later re-introduced after initiating cardiopulmonary bypass. A median
sternotomy was then made; the incision was extended inferiorly into a
partial upper laparotomy. A two-stage venous cannula was inserted into
the inferior vena cava via the right atrial appendage. Following
systemic heparinization, the patient was placed on cardiopulmonary
bypass and cooled; an aortic root cannula, retrograde cardioplegia
cannula, and left ventricular vent were then placed. Simultaneously, a
pedicled omental flap was harvested.

The ascending aorta and aortic arch were next mobilized as the patient
was cooled to 24 degrees Celsius (bladder temperature). The aorta was
cross-clamped and the heart arrested with 1 L of antegrade Del Nido
cardioplegia. Selective antegrade cerebral perfusion was initiated at 10
cc/kg/min by clamping the innominate artery. The aortic cross-clamp was
removed and the proximal and mid~aortic arch were~excised, most
aggressively along the lesser curve and slightly posteriorly into the
arch, so that the fistula defect was incorporated into the resected
specimen. ~The tracheal defect thereby came into view immediately
posterior to the resected transverse arch. At this point only a
peninsula of greater curve remained, which contained the innominate and
left common carotid artery takeoffs. ~The distal extent of the
lesser-curve resection was between the level of the left common carotid
and left subclavian arteries. To fully visualize the tracheal defect,
the innominate artery was sharply detached from the remaining greater
curve.

The trachea was carefully inspected. There was extensive fibrosis
related to prior therapy, as well as fibrinous material consistent with
a subacute inflammatory process. After limited debridement of scar and
devitalized tissue, a 3 mm airway defect was defined. Primary repair was
not possible due to tissue loss and fibrosis, thus an overlay patch
repair was performed. Horizontal mattress sutures were placed
circumferentially around the defect using 4-0 PDS. A portion of
autologous pericardium, harvested earlier in the case and placed in
saline, was folded and trimmed to form a double-layer pericardial patch.
This patch was then parachuted-down using the horizontal mattress
sutures to rapidly provide an initial scaffold for repair before
replacing the aorta and compromising exposure (Figure 2).

An open distal, zone-1, anastomosis was then performed using a 26 mm x
10 mm x 8 mm x 8 mm x 10 mm multi-branch graft (Getinge AB, Göteborg,
Sweden). Antegrade flow was then reestablished via sidearm perfusion;
the proximal graft-to-native ascending-aorta anastomosis was then
performed, after which the aortic cross-clamp was removed and the
innominate artery was anastomosed to one limb of the multi-branch graft
(the unused limbs were ligated) (Figure 3).

The tracheal repair was completed during rewarming. The aortic graft was
carefully retracted, the field was flooded with saline, and ventilation
commenced to assess air leak. The edge of the patch was reinforced with
a continuous running 4-0 PDS suture and several targeted horizontal
mattress sutures until complete pneumostasis was achieved. Progel
sealant (BD, Franklin Lakes, NJ, USA) was applied to reinforce. Once the
patient had rewarmed to 36 degrees Celsius, he was successfully weaned
from cardiopulmonary bypass and hemostasis achieved. The greater omentum
was liberated from the transverse colon, rotated on the gastroepiploic
pedicle, and secured to the repair to provide vascularized tissue
between the tracheal repair and the aortic graft.

The patient was extubated on post-operative day 1; the remainder of his
hospitalization was notable for reintubaton for aspiration pneumonitis
on post-operative day 6, as well as gastric outlet obstruction
necessitating open revision of his omental flap on post-operative day
22. He was ultimately discharged to a rehabilitation facility on
post-operative day 38. He made a satisfactory recovery thereafter and
was alive and neurologically intact as of 13 months post-operatively.

\textbf{Comment}

Fistulas between the aorta and tracheobronchial tree are rare and
uniformly fatal if not surgically treated (1,2). More than 95\% of
patients present with hemoptysis and greater than 50\% with massive
hemoptysis (\textgreater{}400 mL); dyspnea and cough were also common
(1). These fistulas most commonly involve the left bronchial tree (3).
Macintosh et al noted 92\% of cases involved the descending thoracic
aorta to left bronchial tree and 87\% involved a thoracic aortic
aneurysm after graft repair (2).

Aorto-tracheal fistulas are very rarely described, with most cases
likely being lethal prior to any intervention (3,4). Allende et al
described a fistula between the trachea and aortic arch found on autopsy
in a patient with tracheal squamous cell carcinoma two years after
completing radiation therapy. He presented in cardiac arrest after
massive hemoptysis (3). Two cases of aorto-tracheal fistula following
repair of pulmonary artery sling and tracheoplasty in children are
reported, both successfully repaired via cardiopulmonary bypass and
repair with pericardial patch of the aortic arch. One tracheal defect
was also repaired with pericardial patch and the other with tracheal
reconstruction with cadaveric tracheal homograft (4,5).

To our knowledge, this is the first report of an aorto-tracheal fistula
successfully treated with a transverse aortic arch replacement and
complex tracheal repair using autologous pericardium with an omental
buttress.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Piciche M, De Paulis R, Fabbi A, Chiariello L. Postoperative aortic
  fistulas into the airways: etiology, pathogenesis, presentation,
  diagnosis, and management. Ann Thoracic Surg. 2003; 75(6):1998-2006.
\item
  MacIntosh EL, Parrott JCW, Unruh HW. Fistulas between the aorta and
  tracheobronchial tree. Ann Thorac Surg. 1991; 51:515-5199.
\item
  Allende DS, Rodriguez R, Tan CD. Aortotracheal fistula secondary to
  bacterial aortitis. Arch Pathol Lab Med. 2009; 133(6):983-986.
\item
  Ricci M, Cohen GA, Roebuck D, Elliott MJ. Management of complex
  trachea-aortic fistula following neonatal tracheal reconstruction. Ann
  Thorac Surg. 2003; 75(4):1325-1328.
\item
  Chien Y, Chao Y, Lee K, Hsu K. Aortotracheal fistula after slide
  tracheoplasty in a patient with dextrocardia, left pulmonary artery
  sling and tracheal stenosis: a case report. J Cardiothorac Surg. 2021;
  16(1):62.
\end{enumerate}

Figures:

Figure 1 -- Pre-operative CT scan showing the aorto-tracheal fistula
between the posterior aortic arch (zone 1) and the anterior surface of
the distal trachea

Figure 2 -- Autologous pericardial patch being parachuted onto the
tracheal defect with vessel loop around the innominate vein and drop
sucker in the open aortic arch

Figure 3 -- Aortic arch replacement with multi-branch graft with
anastomosis to the innominate artery\selectlanguage{english}
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