A systematic review of therapies for aortobronchial fistulae

The aim of the study was to summarize epidemiologic data about aortobronchial fistulae and compare outcomes (mortality, recurrence, reoperation) of open, staged, and endovascular repair of aortobronchial fistula.

A systematic literature review was conducted to identify eligible studies published between January 1999 and December 2019. The Cochrane Library, PubMed, and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series, and thus, only descriptive data with data heterogeneity were available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death).

Overall, 214 patients (90 studies) underwent 271 procedures (including redo procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae were located most often in the descending thoracic aorta (zone 3 or 4) (64.6%) and in zone 2 (23.8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43) patients. Recurrences were, to some extent, associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whereas 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61 patients, 3 received lifelong antibiotics and for 58 patients data were not available. Considering outcomes, the mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments.

Literature review has revealed only case reports and small case series, and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease, which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies that have not been conducted till today.

Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and the recurrence process, and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal, and thus, surgeons should feel confident to apply the treatment of their choice, keeping in mind their experience, patient's age, and clinical condition.