Redo Aorta to Pulmonary Fistula and Femoral Cannulation
Technical Challenges & Surgical Strategy
Background
•Aorto–pulmonary fistula is a rare but life-threatening complication
•Common in redo cardiac surgery
•Frequently associated with:
•Prior aortic valve/root procedures
•Infective endocarditis
•Pseudoaneurysm rupture
•Leads to:
•Continuous left-to-right shunt
•Pulmonary overcirculation
•Progressive LV & RV dysfunction
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Objective
To outline a systematic surgical approach for redo repair of aorta–pulmonary fistula with concomitant aortic valve insufficiency, emphasizing intraoperative decision-making.
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Preoperative Assessment
•CT Angiography
•Defines fistula anatomy
•Evaluates relation to sternum (critical in redo)
•Transesophageal Echo (TEE)
•Severity of AI
•Shunt magnitude
•Root involvement
•Coronary Assessment
•Rule out active infection
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Operative Strategy
1. Cannulation & Re-entry
•Prefer peripheral cannulation:
•Femoral ± Axillary artery
•Consider:
•Cooling before sternotomy
•High-risk entry (pseudoaneurysm adherence)
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2. Exposure
•Careful adhesiolysis (sharp dissection)
•Identify:
•Aortic root / prior graft
•Main pulmonary artery
•Fistula tract (commonly NCC → PA)
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3. Myocardial Protection
•Challenging in severe AI
•Strategies:
•Retrograde cardioplegia
•Direct ostial delivery
•Avoid sole antegrade approach
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4. Fistula Repair
Principles:
•Aggressive debridement
•Closure of both sides if feasible
Techniques:
•Patch closure (preferred):
•Bovine pericardium
•Dacron (if structural support needed)
Dr.Sam Zeraatian Nejad Davani, Cardiovascular and Transplant surgeon. Advanced Fellow of Thoracic Organs Transplantation Chicago Illinois.