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Letters to the Editor
Fatal Bronchovascular Fistula after a Single Lung Transplantation: A Case Report
Marcos Naoyuki SamanoI, Juliana Akemi SakaI, Marlova Luzzi CaramoriII, Paulo Manuel Pêgo-FernandesI, Fabio Biscegli JateneI
I Thoracic Surgery Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
II Pulmonology Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil., Tel.: 55 113069.5248
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Airway complications following bronchial anastomosis remain an important cause of morbidity and mortality in patients who undergo lung transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> The main complications associated with this procedure are airway stenosis&#44; dehiscence and tissue granulation&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> Bronchovascular fistulas are a very rare but serious and fatal complication of altered bronchial anastomotic healing&#44; which leads to massive hemoptysis and death in almost all cases&#46; We report the first Brazilian case of fatal hemoptysis due to the formation of a bronchial fistula within the pulmonary artery during the early postoperative period of a left single-lung transplantation for idiopathic fibrosis&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE DESCRIPTION</span><p id="para20" class="elsevierStylePara elsevierViewall">A 59-year-old male underwent a left single-lung transplant for idiopathic pulmonary fibrosis after being on a waiting list for 4 months&#46; The operation was uneventful&#44; with a total ischemic time of 170 minutes&#46; Bronchial anastomosis was performed using a telescoping technique and with a continuous suture using 4-0 Prolene &#40;Ethicon&#44; Somerville&#44; NJ&#41; in the posterior membranous portion and invaginating &#8220;U&#8221; stitch sutures in the cartilaginous portion&#46; The venous and arterial anastomoses were made with continuous sutures using 5-0 Prolene&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">The patient was extubated after 12 hours of mechanical ventilation&#46; The patient&#8217;s ICU length-of-stay was 14 days&#44; and the total length-of-stay was 28 days&#46; Initial immunosuppressive therapy included tacrolimus&#44; prednisone and azathioprine&#44; substituted 14 days later with mycophenolate mofetil&#44; due to leukopenia&#46; Prophylaxis against Cytomegalovirus and <span class="elsevierStyleItalic">P&#46; carinii</span> was provided by treatment with ganciclovir and co-trimoxazole&#46; The patient developed significant inflammatory infiltration in the left lung on the 14<span class="elsevierStyleSup">th</span> postoperative day&#46; Transbronchial biopsy showed minimal rejection &#40;grade A1&#41; of the transplanted lung&#44; and the patient was treated with methylprednisolone resulting in total recovery&#46; A bronchoscopic evaluation also showed partial necrosis at the anastomotic site&#44; but no signs of dehiscence &#40;<a class="elsevierStyleCrossRef" href="#f1-cln_64p1031">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="f1-cln_64p1031"></elsevierMultimedia><p id="para40" class="elsevierStylePara elsevierViewall">Ten days after discharge&#44; on the 38<span class="elsevierStyleSup">th</span> postoperative day&#44; the patient had a massive hemoptysis and died of hypovolemic shock in the emergency room&#46; An autopsy revealed a fistula between the pulmonary artery and the left main bronchus&#44; which was identified as the cause of the massive hemoptysis &#40;<a class="elsevierStyleCrossRefs" href="#f2-cln_64p1031">Figures 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="f3-cln_64p1031"></elsevierMultimedia><elsevierMultimedia ident="f2-cln_64p1031"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">Analysis of bronchoalveolar lavage &#40;BAL&#41; fluid obtained shortly after the surgical procedure indicated the presence of <span class="elsevierStyleItalic">Serratia marcescens and Staphylococcus epidermidis&#46;</span> Ten days later&#44; analysis of sputum cultures revealed the presence of coagulase-positive <span class="elsevierStyleItalic">Staphylococcus</span>&#44; <span class="elsevierStyleItalic">Corynebacterium sp&#46;</span> and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#46; Antimicrobial therapy included second&#44; third and fourth generation cephalosporins&#44; amikacin&#44; ciprofloxacin and imipenem&#46; Although several tests for mycobacteria and fungi were performed from BAL and sputum samples&#44; there was no evidence for the presence of such infections&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para60" class="elsevierStylePara elsevierViewall">Fistulas between vascular structures and the tracheobronchial tree are a potentially fatal condition associated with hemoptysis&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;4&#44;5</a> The majority of these types of complications are related to general thoracic surgical procedures&#44; especially aneurysms of the thoracic aorta&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a> The appearance of bronchovascular fistulas after lung transplantation has been previously reported&#44; but mainly in association with the pulmonary artery&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;5&#44;7</a> Knight et al&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a> reported three cases of fatal bronchial fistulas occurring at the azygos vein and the descending aorta&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">The treatment for this condition depends on early diagnosis and the correction of bronchial and vascular communication by restricting bleeding and avoiding hypovolemic shock&#46;<a class="elsevierStyleCrossRefs" href="#bib7">7&#44;8</a> If only one lung is affected&#44; selective intubation is indicated in order to preserve the other lung by avoiding &#8220;blood drainage&#8221; and allowing some ventilation&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">Surgical treatment is based on pneumonectomy or resection of the fistulas with reconstruction of the pulmonary artery and bronchial anastomosis&#59; however&#44; the morbimortality of this emergency procedure is excessively high&#44; and its recommendation depends on the risks&#44; underlying conditions and expected complications&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a> Davidson et al&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a> reported a case of a pulmonary artery-to-bronchial stump fistula after a right upper lobectomy that was successfully treated with endovascular placement of a covered stent&#46; Management by endovascular stent placement has been primarily used for aortobronchial fistulas related to aneurysms or pseudoaneurysms of the descending thoracic aorta with successful occlusion&#46;<a class="elsevierStyleCrossRefs" href="#bib10">10&#44;11&#44;12</a> Unfortunately&#44; urgent treatment of our patient was not possible&#44; and the patient died shortly after arriving in the emergency room&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Abnormal healing of the bronchus is the cornerstone for the occurrence of bronchial anastomotic complications&#44; since deficient vascularization causes ischemia of the bronchial tree after anastomosis&#46; Although bronchial artery anastomosis has been supported by some authors&#44; it is technically complicated and ineffective&#46;<a class="elsevierStyleCrossRef" href="#bib13">13</a> Other techniques&#44; such as using a short donor-derived bronchial stump&#44; reinforcement of the site of anastomosis with an omental flap&#44; donor pericardium or intercostal muscle pedicle&#44; and the use of a telescoping technique&#44; have been shown to be more effective in promoting bronchial healing&#44; improving the coverage of anastomosis and enhancing neovascularization&#46;<a class="elsevierStyleCrossRefs" href="#bib14">14&#44;15</a> The telescoping technique for bronchial anastomosis was introduced in order to minimize the risk of complications&#46; In addition&#44; this technique is especially useful when there are discrepancies in bronchial size between the recipient and donor&#46;<a class="elsevierStyleCrossRef" href="#bib16">16</a> This technique was used in the first reported cases of bronchial anastomosis&#44; including in the case presented here&#59; however&#44; end-to-end anastomosis is more often performed contemporarily&#46; End-to-end anastomosis has been shown to be superior to the telescoping technique with respect to the incidence of complications&#44; such as severe stenosis&#44; ischemia and dehiscence&#46;<a class="elsevierStyleCrossRefs" href="#bib17">17&#44;18</a> However&#44; there are no reports that consider the implications of end-to-end anastomosis on fistula formation&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">Surveillance bronchoscopy allows for the direct evaluation of anastomosis healing and the appearance of related complications&#46; When performed in conjunction with transbronchial biopsy and BAL&#44; surveillance bronchoscopy can be a very important tool for patient follow-up after lung transplantation&#46; This technique is also useful for the early diagnosis of infection by <span class="elsevierStyleItalic">Aspergillus</span> and for the identification of ulcerative and necrotizing defects of the airways&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> Unfortunately&#44; in our patient&#44; cultures of BAL and sputum specimens revealed no signs of fungal infection&#46; Previous bronchoscopy revealed the presence of necrotic and granulated tissue around the site of anastomosis&#44; but bronchoscopy was not able to identify the formation of a fistula&#46; Fungal infection&#44; or aspergillosis&#44; is frequently associated with bronchial complications&#44; such as stenosis&#44; dehiscence and bronchovascular fistulas&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#44;5&#44;7&#44;19</a> This infection increases the risk of morbimortality after lung transplantation&#44; which varies according to the time of onset&#44; the site of infection and the type of transplant procedure&#46;<a class="elsevierStyleCrossRef" href="#bib20">20</a></p><p id="para110" class="elsevierStylePara elsevierViewall">Bronchovascular fistulas are a very dangerous complication of airway anastomoses&#46; The type or form of treatment depends on early diagnosis and is based on re-operation or stent placement&#46; Even though it is a very rare condition&#44; improved evaluation of the factors that contribute to fistula formation must be developed and always considered during follow-up evaluations of lung transplant patients&#46; In addition&#44; surveillance bronchoscopy should be routinely performed in order to identify patients at risk for developing fistulas&#46;</p></span></span>"
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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Posterior view of the fistula orifice in the donor bronchus right below the anastomotic site</p>"
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      "titulo" => "REFERENCES"
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es en pt

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