(1125) A Rare Cause of Hemoptysis, Masqueraded by Pulmonary Embolism

Introduction: Aortobronchial fistula remains a rare condition characterized by an acute presentation such as hemoptysis sustained by massive endobronchial bleeding. While in most cases the underlying cause of hemoptysis is quickly identified, there are times when the real etiology of bleeding may be misdiagnosed with a dramatic delay in treatment.

Description: 41-year-old male with history of car accident complicated by aortic transection requiring open repair with graft who presented with hemoptysis, fever, and sweats. He presented to multiple hospitals for evaluation of these symptoms and was recently diagnosed with a pulmonary embolism. During his most recent admission, he was started on anticoagulation therapy with apixaban. He required intubation and mechanical ventilation due to syncope during these episodes of hemoptysis. He was given prothrombin complex concentrate for apixaban reversal. Patient underwent flexible fiberoptic bronchoscopy that showed large amounts of blood mainly in the left lower lobe. CT angiography of the chest with intravenous contrast was completed and significant for a dissection flap in the descending thoracic aorta with postsurgical changes of the descending aorta with a focal aneurysmal dilation of the descending thoracic aorta. Patient developed degeneration of his prior aortic graft causing an aortobronchial fistula and massive hemoptysis. He underwent a percutaneous endovascular repair of the descending thoracic aortic aneurysm with a Gore cTAG device. His hemoptysis resolved and the patient was transferred to the step-down unit and discharged home with a 6-week antibiotic course for graft infection prophylaxis.

Discussion: Aortobronchial fistula represents a misdiagnosed disease especially in patients with coexistent clinical complaints or conditions. It is mostly associated with a history of aortic surgery and can follow after an unpredictable period of time. Once the fistula presence has been established, a rapid multidisciplinary decision regarding management should be made considering comorbidity, risk factors, and clinical stability. In the past, open surgery was the only available option, however with newer thoracic endovascular techniques, this has created a simpler and less invasive approach with less morbidity and mortality.