Aortobronchial fistula as a late complication of posttraumatic chronic aortic aneurysm.

A 23-year-old man sustained blunt thoracic trauma during a hang gliding accident in 1985. Initial plain films of the chest and thoracic CT scans did not disclose evidence of a thoracic aortic aneurysm, dissection, or mediastinal hematoma. Abdominal CT showed a splenic rupture, for which splenectomy was done immediately. Three years later, a routine chest radiograph showed aneurysmal dilatation of the thoracic aorta. Contrast-enhanced CT scans of the chest confirmed the diagnosis of a marginally calcified 3.5 cm (diameter) x 4.5 cm (length) thoracic aortic aneurysm adjacentto the origin of the left subclavian artery (Fig. 1A). The patient refused to undergo surgical treatment, despite counseling regarding the increased mortality from delay oftreatrnent. Follow-up CT and MR imaging were done at 6-month intervals to monitor the progression of disease. The patient was a recreational bodybuilder, and clinical history revealed anabolic drug abuse during the past 5 years. Eight years after the initial injury, the patient had massive hemoptysis during his daily workout. The patient was admitted to the intensive care unit with hypotension, dyspnea, and ventricular tachycardia. Contrast-enhanced thoracic CT revealed a 5.5-cm (diameter) aneurysm of the thoracic descending aorta near the ligamenturn arteriosurn. The aneurysm was marginally calcified and partially thrombosed, such that the caudal portion of thrombus resulted in partial obstruction of the left main bronchus (Fig. 1 B). Soft tissue strongly suggestive of clot was identified within the bronchial lumen (Fig. 1C), and air trapping resulted in hyperinflation of the left lung. Aortobronchial fistula was diagnosed. The patient underwent emergency repair of the aneurysm with placement of a Dacron graft. At operation, a fistulous connection between the aneurysm and the left main bronchus was confirmed. lntraoperative bronchoscopy confirmed the presence of a clot and bronchomalacia, treated conservatively because of the patient’s poor condition. Despite thorough inflation and ventilation of the left lung, the postoperative course was complicated by left hemopneumothorax, hernomediastinum, and multiresistant Streptococcus faecails pneumonia, requiring tracheotomy. On the sixth postoperative day, the patient had a cardiac arrest and was successfully resuscitated. CT 6 weeks later revealed a perfused aortic lumen of 2.5 cm with marginal thrombus, persistent compression of the left main bronchus with atelectasis of the left lower lobe, and a left pleural effusion. Despite the stormy course, the patient recovered and only had damage of the left recurrent laryngeal nerve, presumably from cornpression due to the aneurysm itself preoperatively, as the patient had complained of hoarseness earlier.