Successful management of tracheo-innominate artery fistula with endovascular stent graft repair

A Systematic Review of Mortality Associations in Patients who Develop Tracheoinnominate Artery Fistula Following Tracheostomy

OBJECTIVE

Tracheoinnominate artery fistulas (TIFs) are a rare but deadly complication of tracheostomy. Tracheoinnominate artery fistula cases in the literature were summarized in order to understand mortality associations.

METHODS

MEDLINE was searched for studies reporting individual characteristics of patients with TIFs after tracheostomy, excluding cases without tracheostomy or with additional procedures at the tracheostomy site. This study followed PRISMA guidelines.

RESULTS

121 TIF patients from 18 case series and 46 case reports were included. The median age was 40 years, and 52.9% were male. The overall mortality rate was 64.5%. There were differences in mortality between cases that presented initially with vs without sentinel bleeding (odds ratio [OR] .34; CI [confidence interval] .16-.73; P = .006). The mortality rate also differed in whether or not the tracheostomy cuff was over-inflated for temporary hemostasis during resuscitation (OR 3.57 (CI 1.57-8.09); P = .002). Treatment compared to no treatment had lower mortality rates (OR .11 (CI 0.04-.32); P < .001); no differences were found if treatment was endovascular vs open surgical.

CONCLUSIONS

Mortality is a major concern after detection of a TIF and resuscitation paired with endovascular or open surgical intervention is imperative. Rapidly investigating sentinel bleeds and intervening upon hemorrhage with temporary cuff over inflation may lead to improved outcomes.

A Case of Tracheo-innominate Artery Fistula after Tracheostomy Successfully Treated with a Covered Stent

A 78-year-old man underwent a tracheostomy after embolization for a dural arteriovenous fistula. Seventy days after tracheostomy, arterial bleeding appeared through the tracheal stoma. The bleeding stopped spontaneously. However, two days later, arterial bleeding reappeared, and he was diagnosed with a tracheo-innominate artery fistula (TIF). He then underwent urgent endovascular covered stent placement. After the procedure, there was no bleeding. TIF can be a fatal complication after tracheostomy and it is generally treated with open chest surgery. However, a successful endovascular treatment for TIF has recently been reported and may yield better results.

Prevention of Tracheo-Innominate Artery Fistula Formation as a Complication of Tracheostomy: Two Case Reports

Tracheo-innominate artery fistula (TIF) is a rare complication of tracheostomy and refers to the formation of a fistula between the trachea and innominate artery. Because TIF is fatal, prevention rather than treatment is very important. Here we report the cases of two high-risk patients who underwent tracheostomy, and in whose cases attempts were made to lower the risk of TIF. In the first patient who developed a chest deformity with Duchenne muscular dystrophy, a tracheostomy was performed with a high-level (cricothyroid level) approach compared with the standard tracheostomy. In the second patient, the thoracic cage was relatively small due to a giant omphalocele, and the risk of a fistula forming was decreased by wrapping the innominate artery with an opened polytetrafluoroethylene vascular graft after resolving crowding of the intrathoracic cavity by total thymectomy. There was no TIF occurrence at the outpatient follow-up in either case. We expect that our approaches may be effective intervention measures for preventing TIF.

Successful management of a tracheomalacia patient with active endotracheal bleeding due to intraoperative innominate artery injury: A case report

RATIONALE

Intraoperative innominate artery injury is life-threatening in tracheomalacia patients with prolonged tracheostomy. Anesthetic management is challenging in cases with massive hemorrhage into the endotracheal tube. We report a case in which we successfully managed a tracheomalacia patient with acute endotracheal bleeding due to innominate artery injury.

PATIENT CONCERNS

A 24-year-old patient with tracheomalacia was scheduled to undergo exploratory thoracotomy for the treatment of intermittent bleeding at the tracheostomy site. During exploration, sudden active bleeding due to innominate artery injury was observed in the endotracheal lumen.

DIAGNOSES

The patient was diagnosed with tracheomalacia.

INTERVENTIONS

We immediately used the bronchoscope to place the tip of the endotracheal tube at the bleeding site and hyperinflated the cuff.

OUTCOMES

The ballooned cuff compressed the active bleeding site, so no additional bleeding was detected by bronchoscopy, and no additional massive bleeding was observed in the operative field.

LESSONS

Immediate and appropriate overinflation of the endotracheal tube cuff by an anesthesiologist may provide improved surgical field visibility and time for critical surgical procedures in cases of massive hemorrhaging.

Evaluation of Endovascular Intervention for Tracheo-Innominate Artery Fistula: A Systematic Review

BACKGROUND

While the standard of care for suspected tracheo-innominate artery fistula (TIF) necessitates sternotomy, perioperative mortality remains high. Endovascular interventions have been attempted, but reports have been anecdotal. The aim of this systematic review was to evaluate the outcomes of endovascular management of TIF by pooling the existing evidence.

METHODS

An electronic database search of Ovid MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Controlled Trials Register was performed to identify all studies examining endovascular treatment of TIF. Patients greater than 14 years of age who underwent endovascular intervention for TIF were included. 25 studies consisting of 27 patients met the inclusion criteria.

RESULTS

48.1% (13/27) of patients were male and median age was 39.0 [IQR 16.0, 47.5] years. Tracheostomy was present in 96.3% (26/27) of cases. Median duration from tracheostomy to TIF presentation was 2.2 months [0.5, 42.5]. On presentation, 84.6% (22/26) had tracheal hemorrhage, and 22.8% (6/27) were hemodynamically unstable. 96.3% (26/27) underwent covered stent graft placement while 1 patient (3.8%) had coil embolization. 18.5% (5/27) of patients required repeat endovascular intervention for recurrent bleeding, while 11.1% (3/27) required rescue sternotomy. Median hospital length of stay was 30 days [16.0, 46.5], and overall mortality was 29.6% (8/27) with a median follow-up time of 5 months [1.2, 11.5].

CONCLUSION

While uncommon, endovascular treatment of TIF may be a feasible alternative to sternotomy. The approach may be useful in those who are unable to undergo surgery or are likely to have adhesions from prior chest operations.

Tracheoinnominate Artery Fistula Treated With Endovascular Stent Graft at a Level I Trauma Center

Tracheoinnominate artery fistula could be a fatal complication of tracheostomy. Herein, we present the case of a 59-year-old male with sentinel bleeding around the tracheostomy with subsequent workup revealing a tracheoinnominate fistula. Subsequently, the patient was managed with an endovascular approach with a subsequent favorable outcome. We reported an alternative approach to the management of this catastrophic complication in patients who are at high risk for complications from conventional treatment approach.

Endovascular Treatment of Tracheoinnominate Artery Fistula: A Case Report

Tracheoinnominate fistula is a rare but lethal condition that requires emergent surgical intervention to prevent ensuing exsanguinating hemorrhage. In clinical situations where the risk of open surgery is prohibitively high, endovascular repair may provide a life-saving alternative to control hemorrhage and serve as a temporizing or definitive solution based on a given clinical scenario. The authors report successful endovascular repair of the bleeding tracheoinnominate fistula with a stent in a liver transplant patient with high comorbidities and review the current literature.

Conservative management of trachea-to-innominate artery transfixion with a guidewire during percutaneous tracheostomy: a case report

Background

Tracheostomy is a standard procedure in critically ill patients requiring mechanical ventilation or airway protection for extended periods. The main cause of death is haemorrhage, most commonly owing to a trachea-to-innominate artery fistula, usually requiring surgical treatment.

Case presentation

Here we report the case of an 83-yr-old woman with a subarachnoid haemorrhage, who incurred a trachea-to-innominate artery transfixion following percutaneous tracheostomy, successfully and conservatively managed by interventional radiology.

Conclusions

The use of peri-procedural ultrasound examination of the neck can reduce the risk of complications related to vessel anatomical variants. When the tracheostomy is complicated by bleeding, the procedure should be stopped in order to diagnose the vascular iatrogenic injury and to evaluate the best therapeutic approach by a multidisciplinary team.

Endovascular Treatment of Tracheoinnominate Artery Fistula: Case Report and Literature Review With Pooled Cohort Analysis

To pool data from published cases of tracheoinnominate artery fistula (TIF) treated with surgical or endovascular techniques along with reporting a case of similar presentation. A total of 261 cases in 137 published case reports and case series were identified through a comprehensive systematic literature review. Data regarding patient characteristics, treatment, and follow-up were extracted. A local case of a 14-year-old boy with TIF due to longstanding tracheostomy treated with stent-graft placement was added to the data. Comparison of the complication rates between surgical vs endovascular interventions was done with the chi-square test. Factors associated with longer survival were assessed by the Cox regression analysis. Thirty-three (12.6%) of the reported cases were treated endovascularly, 137 (52.3%) were treated surgically, and 92 (35.1%) were reported with no definitive treatment. Mean age was 34 ± 22 years, and 61% were males. The mean time interval between tracheotomy placement and bleeding was 1 ± 2.5 years. A lower procedure-related complication (30% vs 50%, P = 0.045) and 30-day mortality (9% vs 23%, P = 0.008) rates had been reported with percutaneous approaches compared to surgery. No percutaneous procedure was reported prior to year 2000. In multivariate analysis stratified by publication year, a shorter tracheostomy-to-bleeding time (year) was significantly associated with higher hazards of death (hazard ratio: 1.22, P = 0.017). Type of intervention (percutaneous vs surgery) was not associated with postintervention survival (adjusted hazard ratio: 0.78, P = 0.558). Endovascular stent grafting can have a comparable postprocedural survival and lower complication rates vs open surgical repair in treatment of TIF.

Fatal innominate artery hemorrhage in a patient with tetraplegia: Case report and literature review

Context Hemorrhage is one of the potentially fatal complications of tracheostomy. A rare but lethal cause of tracheostomy related bleeding is hemorrhage from the innominate artery. This occurs following tracheo-innominate artery fistula (TIF) formation, which is associated with a mortality rate of more than 85%. Here, we report the case of an individual with tetraplegia and a tracheostomy who died as a result of innominate artery hemorrhage. This case highlights the possible causes and interventions associated with this complication, and provides insight into tracheostomy related bleeding in patients with spinal cord injury (SCI). Findings A 15-year-old boy with a diagnosis of incomplete SCI at the C5 level was admitted for rehabilitation 4 months after injury. He required a tracheostomy for ventilation, and underwent subglottic stenosis dilatation thrice. Multiple decannulation attempts were performed without success. He received intensive care on several occasions for respiratory failure. During the course of his rehabilitation, a minimal tracheostomy bleed was observed, which became profuse within a few hours and led to hypoxia with loss of consciousness. An urgent sternotomy identified bleeding from a TIF. He suffered severe brain damage following massive tracheal hemorrhage and died. Conclusion/clinical relevance Given the morbidity of TIF-related hemorrhage, it is important to increase awareness of this rare condition among health-care providers, especially those in non-acute settings. Patients with SCI and a tracheostomy pose unique challenges related to respiratory compromise, which may accentuate TIF formation.

Prophylaxis and Treatment of Complications After Tracheal Resection

Tracheal resections are major surgical procedures with a complication rate as high as 44%. Early detection of complications followed by a structured and expedited course of action is critical for achieving a successful outcome. The prevention of complications after tracheal resection starts with a correct indication for resection. A thorough preoperative evaluation, meticulous surgical technique, and good postoperative care in a center that performs airway surgery routinely are important factors for achieving good results.

Endovascular Management of Tracheo-Subclavian Fistula

Tracheoarterial fistula is a rare complication of tracheostomy with an incidence of less than 1%. Survival of this disease entity is low, and it likely results from a major open operation in a high-risk surgical group. In our review of the literature, a tracheoinnominate artery fistula is the most commonly reported arterial fistula. However, we present a rare case of tracheo-left subclavian artery fistula. We have identified 1 previous case of tracheo-left subclavian fistula as a source of massive tracheal bleeding. In our case report, we describe the successful management of this disease by endograft placement. Owing to its rarity, there are no guidelines on the management approach to tracheoarterial fistulas, but given the difficulty of controlling this problem via median sternotomy, the placement of a covered stent may be the best therapy. Initially, case reports showed a role for endograft placement as a temporizing measure, but the risk of infection may be sufficiently low to justify this approach as a definitive therapy. Upon a 6-month follow-up, our patient remains without recurrence of bleeding or infection, and computed tomography angiography of the chest with 3D reconstruction has shown patency of the endovascular stent with resolution of the associated pseudoaneurysm.

Successful Rescue of a Ruptured Tracheoinnominate Fistula with Extracorporeal Membrane Oxygenation, Endovascular Stents, and Debranching Surgical Bypass

We reported a case of ruptured tracheoinnominate fistula in a 14-year-old boy with history of repeated sternotomy. Tracheostomy was performed at age 2 years. Slide tracheoplasty was done at age 13 years. He presented to outpatient clinic with episodic hemosputum. Massive blood emanated from stoma during bronchoscopy evaluation. Venous-arterial extracorporeal membrane oxygenation was installed for resuscitation. A contrast-enhanced computed tomography (CT) and angiography confirmed the diagnosis. Immediate control of bleeding was achieved by an endovascular stent graft deployed at innominate artery. Massive hemorrhage recurred on day 7. An aortic arch stent was inserted and all arch vessels debranching via supraclavicular collar excision was performed. A covered stent was used to fenestrate the aortic stent and establish antegrade blood flow to all neck vessels via left common carotid artery. The patient remained stable at 10-month follow-up. Combination of extracorporeal membrane oxygenation, endovascular intervention, and surgical bypass could be effective in treating critical patients.

Successful Kissing Balloon Expandable Stent Graft Treatment for a Right Common Carotid Pseudoaneurysm Caused by Tracheotomy

BACKGROUND

A rare complication following tracheotomy is common carotid artery (CCA) pseudoaneurysm. Treatment modalities for CCA pseudoaneurysm include surgical repair and single-artery balloon-covered stent graft technique. We describe successful treatment of tracheotomy-related CCA pseudoaneurysm with the "kissing balloon" expandable stent graft technique.

CASE DESCRIPTION

We successfully implemented the kissing balloon expandable stent graft technique for treatment of a large, narrow-necked, bilobed CCA pseudoaneurysm that arose owing to a tracheotomy complication. The pseudoaneurysm was detected while performing a diagnostic angiogram of the aortic arch and surrounding vessels. The stent was deployed while the 2 balloons were introduced in a kissing manner such that they faced one another to avoid occlusion of either branch of the innominate artery coming into contact; 1 balloon was inflated at the origin of the right subclavian artery, and the other was inflated at the right innominate artery simultaneously. The pseudoaneurysm was successfully contained; normal blood flow was restored in the CCA. The balloons were deflated and withdrawn. The patient remained neurologically intact after the procedure.

CONCLUSIONS

The kissing balloon technique is a safe and effective alternative to surgical repair, as it prevents morbidities associated with the surgical procedure. Also, this technique decreases the risk of major side-branch occlusion associated with the single-artery balloon-covered stent graft technique.

Endovascular "neobranching" to manage acute aortic syndrome

Acute aortic syndrome was coined in 2001 to describe a spectrum of acute aortic wall pathologies. The syndrome represents a cluster of aortic conditions such as aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Acute aortic dissection is more common than the latter two pathologies with an incidence of up to 6 cases per 100,000 per year. The following report focuses on an unusual case presentation emphasizing the newest management techniques including "neobranching" whilst dealing with challenging patient anatomy and refractory hypertension. We believe this case report eventually broadens our understanding of acute aortic syndrome whilst addressing an entry tear outside the aorta by placing "neobranches". © 2016 Wiley Periodicals, Inc.

Innominate artery hemorrhage following tracheostomy

OBJECTIVES

To review the clinical presentation, predisposing factors, prevention strategies, management, and outcomes of innominate artery hemorrhage following tracheostomy.

STUDY DESIGN AND SETTING

We report the case of an 80-y-old patient who experienced sudden massive innominate artery hemorrhage 11 days post tracheostomy. We review the literature and present recommendations for management and prevention.

RESULTS

Emergency median sternotomy with ligation and resection of the affected segment was performed with no neurological or vascular sequelae.

CONCLUSIONS AND SIGNIFICANCE

The risk of innominate artery hemorrhage may be minimized with simple measures. Management by ligation and resection of the pathological segment of artery has superior outcomes to primary vascular reconstruction with maintenance of blood flow. Bypass procedures are not routinely required and have not been shown to confer any significant benefit. Resection without reconstruction is associated with a surprisingly low incidence of neurological sequelae.

Aberrant innominate artery may complicate a potentially safe surgery

Surgeries of the anterior neck include thyroid surgery, open or percutaneous dilatational tracheotomy, bronchoscopy, mediastinoscopy and oesophagoscopy. These are potentially safe surgeries with mortality rates less than 1%. Today, the most common cause of death following a tracheotomy is haemorrhage and, following thyroid surgery, the causes are haemorrhage, giant goitres and upper airway complications. Bronchoscopies and mediastinoscopies are almost never fatal. While operating around the trachea, no major vessel is encountered in the surgical field. We report a case in which an aberrant innominate artery was encountered crossing anterior to the trachea just below the thyroid isthmus. As it is an uncommon finding, even minor complacency can lead to torrential bleeding culminating in death. Thus, we recommend surgeons to be vigilant for any aberrant artery in the surgical field rather than finding it accidentally; thereby preventing any complications in a potentially safe surgery.

Tracheoinnominate Fistula: Endovascular Treatment with a Stent Graft in a 4-Year-Old Child

A 4-year-old boy presented with acute and profuse bleeding at the tracheostomy site. An emergency angiography was performed and identified a pseudoaneurysm at the innominate artery. A selective catheterization of the artery was executed and 2 Advanta V12 balloon-expandable covered stents were implanted in an overlapping manner to occlude the pseudoaneurysm. Final angiography demonstrated patency of the innominate artery and no signs of bleeding. The patient had no postoperative complications and no further bleeding during follow-up. A contrasted computed tomography scan was performed after 20 days and demonstrated no signs of pseudoaneurysm or bleeding. After 4 months, the patient was readmitted to tracheal dilatation and change of T-tube and died of respiratory complications.

Recurrent Tracheoinnominate Artery Fistula due to Stent Graft Fracture

Tracheoinnominate artery fistula (TIF) is one of the most dangerous complications after tracheostomy, and fetal even after surgical repair. Recently, endovascular stent has been introduced as an option for the treatment of TIF. Unfortunately, endovascular stent repair could not replace the surgery due to rare clinical reports about the long-term follow-up and complications of stent graft. More collection of clinical data are necessary for the evaluation of long-term results. We report a rare case of recurrent TIF due to stent graft fracture after endovascular stent graft insertion in the treatment of TIF, and reviewed the world literature.

Operative technique for tracheo-innominate artery fistula repair

Tracheo-innominate artery fistula is fatal unless treated surgically. We describe our surgical approach and results in seven patients. The average patient age was 15.7 years; all patients had prior severe neurological deficits. Three of seven patients were in hemorrhagic shock; control of preoperative bleeding was achieved with tracheostomy tube cuff overinflation. The innominate artery and the trachea were exposed through a collar incision and partial upper sternotomy. The innominate artery was divided at the aortic arch and at the bifurcation, with one exception. Cerebral blood flow was monitored by the blood pressure difference in the bilateral upper extremities and by near-infrared spectroscopy. The tracheal fistula was left adherent to the innominate artery in all but one patient. All patients were discharged without new neurologic deficits or severe morbidity. Overall survival was 84% at 37 months, without any vascular, tracheal, or neurological events.

Tracheo-innominate artery fistula after stroke

Tracheo-innominate artery fistula (TIAF) is rare, yet the most fatal complication after tracheostomy. In the absence of immediate diagnosis and surgical management, the mortality rate is very high, because the complication can lead to sudden massive tracheal hemorrhage. Tracheal obstruction and hypovolemic shock are the major life threatening conditions. The 46-year-old woman received tracheostomy tube insertion after stroke. Three months later, there was occurrence of active bleeding at the site of tracheostomy in the patient, who participated in comprehensive rehabilitation program. Immediately, the patient received an endotracheal tube insertion into the tracheostomy site and thus massive bleeding was controlled. The patient was transferred to the intensive care unit, where her breathing was maintained by mechanical ventilation. Based on computed tomography and laryngoscopy, no remarkable findings about TIAF were detected. Nevertheless, transfemoral angiography findings revealed that innominate artery made small luminal outpouching to trachea at the carotid artery and at the subclavian artery bifurcation level, based on which a diagnosis of TIAF was made. She had an operation for TIAF, tracheoplasty with bypass graft. Subsequently, she was discharged after 15 weeks. In the present report, we describe a case of TIAF, which can occur in the patients with tracheostomy tube during rehabilitation.

Tracheoinnominate fistula: successful management with endovascular stenting

Tracheoinnominate fistula is a rare complication of tracheostomy that is associated with high rates of morbidity and mortality. Recently, endovascular stents have been described as a viable treatment option for the management of this condition. We report a case of tracheoinnominate fistula in a 40-year-old man that was successfully managed with endovascular stent placement. Our evaluation included bronchoscopy, arteriography, and computed tomographic angiography. Intraoperative localization of the fistula required selective catheterization of the innominate artery.

Prophylactic ligation of the innominate artery and creation of tracheostomy in a neurologically impaired girl: a case report

Tracheoinnominate artery fistula is known as a potentially fatal complication for patients who depend on tracheostomy or tracheoesophageal diversion. Since the bleeding from a TIF is often difficult to control, preventative procedures are recommended to avoid this complication. An 11-year-old girl with hypoxic-ischemic encephalopathy and scoliosis developed tracheal stenosis caused by compression from the innominate artery. Respiratory control with intubation through the tracheal stenosis was needed, and the patient was at high risk for developing a TIF. She underwent ligation of the innominate artery at tracheostomy. Subsequent tracheostomy revealed a widened tracheal lumen and no further complications. Prophylactic ligation of the innominate artery and creation of tracheostomy might be considered as a valid option for patients at high risk of developing TIF.

Is computerized tomography angiographic surveillance valuable for prevention of tracheoinnominate artery fistula, a life-threatening complication after tracheostomy?

OBJECTIVE

The aim of this study was to evaluate the utility of volume-rendered helical computerized tomography (CT) angiography focusing tracheostomy tube and innominate artery for prevention of tracheoinnominate artery fistula.

METHODS

The authors retrospectively analyzed 22 patients with tracheostomy who had checked CT angiography. To evaluate the relationship between tracheostomy tube and innominate artery, we divided into three categories. First, proximal tube position based on cervical vertebra, named "tracheostomy tube departure level (TTDL)". Second, distal tube position and course of innominate artery, named "tracheostomy tube-innominate artery configuration (TTIC)". Third, the gap between the tube and innominate artery, named "tracheostomy tube to innominate artery gap (TTIG)". The TTDL/TTIC and TTIG are based on 3-dimensional (3D) reconstruction around tracheostomy and enhanced axial slices of upper chest, respectively.

RESULTS

First, mean TTDL was 6.8±0.6. Five cases (23%) were lower than C7 vertebra. Second, TTIC were remote to innominate artery (2 cases; 9.1%), matched with it (14 cases; 63.6%) or crossed it (6 cases; 27.3%). Only 9% of cases were definitely free from innominate artery injury. Third, average TTIG was 4.3±4.6 mm. Surprisingly, in 6 cases (27.3%), innominate artery, trachea wall and tracheostomy tube were tightly attached all together, thus have much higher probability of erosion.

CONCLUSION

If low TTDL, match or crossing type TTIC with reverse-L shaped innominate artery, small trachea and thin TTIG are accompanied all together, we may seriously consider early plugging and tube removal.

[Acute bleeding from the innominate artery after removal of percutaneous tracheotomy]

Percutaneous tracheotomy is a standard procedure in intensive care units. Even though complications associated with this intervention have been described, acute massive bleeding from the innominate artery is rare and necessitates immediate intervention. We report a case with acute bleeding after removal of a percutaneous tracheotomy cannula.

Successful management of a tracheo-innominate fistula in a 7-year-old child

The purpose is to describe the presentation and management of a tracheo-innominate artery fistula in a tracheostomy-dependent child. The study design is case report and the method is retrospective chart review. 7-Year-old female with a history of anoxia at birth, seizure disorder, tracheostomy and ventilator dependency since infancy presented to community hospital after one episode of spontaneous bleeding around and through the tracheostomy tube. The patient was transported to a tertiary pediatric teaching hospital and had more profuse bleeding upon arrival. She was taken emergently to the Operating Room (OR) where the cuff of a 5.0 endotracheal tube (ETT) placed through the existing stoma was used to tamponade the bleeding. The airway was secured proximally with a rigid bronchoscope which also provided photodocumentation during the procedure. The cardiothoracic surgery service performed ligation of the innominate artery and repair of the anterior tracheal wall defect through a midline sternotomy approach. The patient was monitored for 7 days in the ICU sedated and paralyzed and returned the OR for a new airway endoscopy and replacement of the ETT with a 5.0 tracheostomy tube. The patient was discharged after 12 days of hospitalization. Subsequent interval endoscopies revealed well-healed fistulous site and no further complications after 12 months of follow-up. Tracheo-innominate artery fistulae can be successfully managed if recognized and treated early. Special attention should be given to "sentinel events" that often precede more catastrophic bleeds.

[Is emergency revascularization of tracheo-innominate artery fistulae mandatory?]

Tracheo-innominate artery fistulas are a rare but life-threatening complications (incidence between 0.1 and 1 %) occurring in tracheostomy patients. Surgery is the treatment of choice. Most authors recommend ligation of the innominate artery, which provides better results in terms of morbidity/mortality than revascularization surgery. We report here a case of innominate artery revascularization isolated from the trachea by a sternocleidomastoid pediculate interposition graft. The procedure was successful as demonstrated by the 2 years follow-up. Revascularization surgery should be reserved of specific cases. The risk of tracheal-mediated infections developing in contact with the vascular sutures warrants systematic use of an interposition graft isolating the trachea from the innominate artery.

[One case report of tracheo-innominate artery fistula responsible of massive haemoptysis in a tracheotomized patient: which strategy to adopt?]

The tracheo-innominate artery fistula is a rare but life-threatening complication of the tracheotomy. Its care management requires a rapid airway control to allow haemostasis by compression and ventilation. The haemostasis must be immediate and two techniques exist: surgery opencast (sternotomy) or interventional radiology. The choice between the two depends largely on the technical platform available. Our case report describes a tracheo-innomninate artery fistula surgically managed with success. The patient carried an anatomic variant, the two carotids come from innominate artery.

Endovascular repair of tracheo-innominate artery fistula

Innominate arterial wall rupture with pseudoaneurysm formation was found during angiography in a 39-year-old woman 2 days after she had undergone percutaneous dilatational tracheostomy. Endovascular stent surgery and balloon angioplasty were performed but these procedures failed to control the massive bleeding resulting from an endoleak. We report the clinical presentations and describe the treatment of a tracheo-innominate artery fistula in our patient. We also reviewed the algorithms of management and the rescue options for treating a tracheo-innominate artery fistula.

Bleeding around a tracheostomy wound: what to consider and what to do?

All patients with bleeding in and around a tracheostomy must be investigated to exclude a serious cause. The overall incidence is approximately 5 per cent of tracheostomies performed in Adult Intensive Care Units (AICU). When bleeding commences more than 72 hours post-operatively, the possibility of a trachea innominate artery fistula needs to be excluded by endoscopic examination of the trachea in an operating theatre environment, with the facility to proceed to exploration of the neck and possibly to sternotomy to enable ligation of the innominate artery. With appropriate recognition, diagnosis, resuscitation and surgical intervention, the associated high death rate of trachea innominate artery fistula can be reduced.

Endovascular Repair of a Tracheoinnominate Fistula with a Stent Graft

Massive bleeding from a tracheostomy developed in a 65-year-old woman with stroke after successful conservative management of a minor tracheostomy bleeding episode. Temporary hemostasis was achieved, and angiography showed a tracheoinnominate fistula (TIF), a rare complication of tracheostomy. Open surgery was contraindicated in this patient, so endovascular repair using a stent graft was performed. Permanent hemostasis was obtained, and there were no immediate complications from the procedure. The patient never recovered from her stroke and died 2 weeks later. The endovascular approach may be a feasible alternative to surgical repair of TIF, especially in patients unable to tolerate an open procedure.

Hemorrhage due to tracheoarterial fistula with severe motor and intellectual disability

BACKGROUND

Tracheoarterial fistula (TAF) is an unusual but highly lethal complication of tracheostomy, and successful surgical intervention for TAF has been reported. Few investigations are available for TAF in severe motor and intellectual disability (SMID). The aim of the present paper was to analyzed TAF in SMID to clarify which clinical variables might predict the occurrence of TAF, and adequate management for lifesaving.

METHODS

Medical records at Metropolitan Fuchu Medical Center were retrospectively investigated for SMID between 1970 and 2000, and 10 TAF patients verified on operation or autopsy were identified. Details were reviewed including clinical status, emergency treatment at the occurrence of TAF, and operation and/or autopsy recordings.

RESULTS

Four of 10 patients underwent successful operation and survived, while the other six died from hemorrhagic shock. Eight patients had tracheoinnominate artery fistula, the others had tracheocarotid artery fistula. Characteristic features as SMID such as etiology of brain disease, muscle tonus and convulsion were no apparent relevance to occurrence of TAF. All patients suffered from endotracheal granuloma extending to the arterial walls. Seven of 10 patients had re-bleeding after stabilization of the first massive hemorrhage, especially fiber bronchoscopy to confirm the diagnosis of TAF precipitated to fatal re-bleeding. One patient underwent interruption of the artery at relapse of TAF, the other three underwent suturing and had good outcome.

CONCLUSIONS

There were no apparent predictors of TAF in SMID. Tracheal granuloma was recognized and consequent on formation of TAF, so control of granuloma may prevent TAF. Fiber bronchoscopy for suspected TAF is not recommended because it precipitates fatal bleeding.

Exsanguinating tracheoinnominate artery fistula repaired with endovascular stent-graft

BACKGROUND

Tracheoinnominate artery fistula is a relatively rare but life-threatening complication of tracheostomy. Peristomal bleed or hemoptysis may be massive and usually fatal if treatment is not instituted immediately.

CASE DESCRIPTION

We report the case of a 40-year-old woman who sustained surgical evacuation of a brainstem cavernoma and developed a massive hemoptysis 13 days after a percutaneous tracheostomy. Because of the patient's poor clinical condition, endovascular repair of the arterial injury was decided. The innominate artery was successfully repaired by means of urgent stent-graft placement.

CONCLUSIONS

We believe that, if technically feasible, stent-graft placement can be a valuable therapeutic alternative for this dramatic condition. Physicians in charge of tracheostomized patients and neurointerventionalists should be familiar with this management strategy.

The emergency use of endografts in the carotid circulation to control hemorrhage in potentially contaminated fields

We report our experience with the use of endoluminal grafts to control emergency bleeding in two patients with tracheoinnominate fistulas and three patients with carotid blowouts. Systemic infectious complications were not seen. However, rebleeding occurred in one patient, and extensive stent coverage to control bleeding was required in a second. Survival was usually limited by the patient's cancer. There was one long-term survivor without cancer whose tracheostomy was placed for neurologic compromise. A review of the literature for similar cases identified 18 additional endografts placed for carotid blowout and 3 placed for tracheoinnominate fistulas. Overall, infectious complications occurred in only two patients, whereas rebleeding occurred in eight patients. On the basis of these findings, we believe that endografts are useful to control emergency hemorrhage in these two pathologies because treatment is usually palliative, given the poor survival secondary to the underlying disease. However, more extensive graft coverage may be necessary considering the erosive nature of these processes.

Tracheoinnominate Artery Fistula: Combined Endovascular and Surgical Management by Emergency Stent-Graft Placement Followed by Cryopreserved Arterial Allograft Repair

Tracheoinnominate artery fistula is an uncommon but life-threatening complication usually requiring emergency ligation of the artery. The recent introduction of stent-grafts offers a new therapeutic option for emergency management of hemorrhage. Stent-grafts can be used for definitive treatment or as a bridge to surgery. The purpose of this report is to describe a case of hemoptysis due to a tracheoinnominate artery fistula that occurred after a single orotracheal intubation for general anesthesia and was treated by placement of a covered stent followed 12 hours later by surgical revascularization of the innominate artery using a cryopreserved arterial allograft.

Tracheoinnominate artery fistula: a rare and often fatal complication of indwelling tracheostomy tubes

Fistula formation between the innominate artery and the trachea is a rare but potentially catastrophic complication after tracheostomy. Although surgery is the definitive treatment of tracheoinnominate artery fistula, the responsibility for making the proper diagnosis and stabilizing the patient before surgery often falls on the personnel in the emergency department. We describe the emergency department management of a 14-year-old girl with a tracheoinnominate artery fistula. A discussion of the risk factors, diagnostic considerations, and emergency department management strategies of tracheoinnominate artery fistula is presented.

Tracheoinnominate fistula in a Duchenne muscular dystrophy patient: Successful management with an endovascular stent

Tracheoinnominate fistula is a rare but often fatal complication occurring in Duchenne Muscular Dystrophy (DMD) patients with long-term tracheostomy. We report a 16-year-old boy with DMD who developed a fistula causing massive haemorrhage 26 months after tracheostomy. Due to the high risk of perioperative complications, a minimally invasive technique with placement of an endovascular stent grafting the innominate artery was performed. The patient was successfully managed and recovered uneventfully. We believe that endovascular repair of tracheoinnominate fistula by stent grafting may be the treatment of choice in severely compromised patients and that clinicians who treat tracheostomised DMD patients should be familiar with this management strategy.

A case with tracheo-innominate artery fistula

Tracheo-innominate artery fistula (TIF) is known as a fatal complication after tracheostomy. We report a 9-year-old girl with early hypoxic encephalopathy who had a tracheo-innominate artery fistula with exsanguinating hemorrhage from her tracheostoma 10 months after tracheostomy. After temporary control of bleeding, embolization of the innominate artery was performed. The patient has remained well 1 year after the procedure. We reviewed the aetiology, diagnosis and management of the tracheo-innominate fistula, and findings suggest that endovascular embolization of the innominate artery may be an appropriate treatment for patients with tracheo-innominate artery fistula.