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.

Important Variations of Aortic Branches: Imaging Case Series

Various anatomical variations are known to occur in branches of the aorta. Some of these variations are common while others are quite uncommon. However, these variations carry significant implications when the patient is diseased and some intervention or surgical procedure is to be done. Most of these variations are usually incidentally detected. This imaging case series illustrates some clinically important variations of aortic branches including branches of the aortic arch and abdominal aorta, with a review of the literature. All cases illustrated here were detected incidentally.

[Tracheal Tumours]

Malignant primary tracheal tumours are rare. The most common histological subtypes are squamous cell carcinoma and adenoid cystic carcinoma. These two entities have different prognoses and growth patterns. Tracheobronchoscopy and thoracic sectional imaging are standard diagnostic tools for tumour staging and local evaluation. Complete surgical resection of the affected tracheal segment is the treatment of choice for limited disease without distant metastases. Incomplete gross tumour resection with additional irradiation is an acceptable therapeutic option for adenoid cystic carcinoma. Interventional endoscopy with tumour debulking or tracheal stenting and/or definitive mediastinal radiotherapy are treatment alternatives in either a locally advanced or palliative setting.

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.

Too big to fail?-An aggressive strategy for a dire problem

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.

Advantage of a higher position of the tracheostoma with glottic closure for preventing complications related to tracheostomy tube: a retrospective cohort study

Background

Surgery to prevent aspiration has complications related to tracheostomy tube, such as the trachea-brachiocephalic artery fistula. Glottic closure procedure makes tracheostoma at a position higher than the first ring of the trachea and theoretically has a potential to prevent such complications owing to a longer distance between the tip of tracheostomy tube and the tracheal membrane adjacent to the brachiocephalic artery. Our aim is to evaluate the safety of glottic closure in neurologically impaired patients by comparing outcomes with laryngotracheal separation.

Methods

This study is a single-center retrospective study from 2004 to 2019, using data of 15 and 12 patients who underwent glottic closure (GC) and laryngotracheal separation (LTS). The primary outcome was the incidence of postoperative complications induced by tracheostomy tube placement and adjustment of the tracheostomy tube position to prevent these complications, such as by converting to a length-adjustable tube and/or placing gauze between the skin and tube flange. Additionally, we analyzed the anatomical relationship between the tracheostomy tube tip and brachiocephalic artery and measured the distance between them using postoperative CT images.

Results

No patients in either group had trachea-brachiocephalic artery fistula. Erosion or granuloma formation occurred in 1 patient (7%) and 4 patients (33%) in the GC and LTS groups, respectively. Adjustment of the tracheostomy tube was needed in 2 patients (13%) and 6 patients (50%) in the GC and LTS groups. CT revealed a higher proportion of patients with the tracheostomy tube tip superior to the brachiocephalic artery in GC than LTS group. The mean tracheostoma-brachiocephalic artery distance was 40.8 and 32.4 mm in the GC and LTS groups.

Conclusions

Glottic closure reduces the risk of postoperative complications related to a tracheostomy tube. This may be due to the higher position of the tracheostoma at the level of the cricoid cartilage, increasing the distance between the tracheostoma and brachiocephalic artery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01505-2.

Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft

Background

A tracheo-innominate fistula is a rare but life-threatening complication of tracheostomy and has a mortality rate of 100% without therapy. The underlying cause is an acquired fistula between the brachiocephalic trunk and the trachea, induced by a tracheostomy cannula’s mechanical impact.

Case presentation

A 25-year-old female was admitted with pulsatile bleeding from a tracheostomy. The cause of the bleeding was a tracheo-innominate artery fistula, which was difficult to recognize. Said fistula was treated with implantation of a self-expanding stent-graft. The bleeding stopped immediately after the implantation of the stent-graft. Dual antiplatelet medication with aspirin IV and ticagrelor PO, bridged with a bolus of eptifibatide IV, was started right after the stent deployment.

Conclusions

Endovascular self-expanding stent-graft implantation is a viable treatment option for tracheo-innominate artery fistulae, especially in hemorrhagic emergencies.

Innominate Artery Ligation: A History From Mott to Matas

Innominate artery ligation emerged in the 19th century as an early operation for right subclavian aneurysm. Clinical outcomes were often dire, but undeterred surgeons believed that ligation represented an opportunity that outweighed the risks of nonoperative aneurysm management. Valentine Mott of New York performed the procedure in 1818; his patient died 26 days later. Variations on Mott's approach were undertaken 13 more times from 1822 to 1861 by surgeons in the United States and abroad, all of which proved fatal. Andrew Woods Smyth of New Orleans was the first to successfully control a subclavian artery aneurysm with innominate ligation in 1864. The Charity Hospital house surgeon used a series of ligations on the innominate, common carotid, vertebral, and internal mammary arteries to prevent collateral and recurrent blood flow to the aneurysmal sac. These physiologically-oriented operations kept Smyth's patient alive and functional for ten years. New Orleans became an internationally-recognized hub for advancements in aneurysm surgery. One of Smyth's students, Rudolph Matas, went on to revolutionize vascular surgery. Along his path to becoming the Father of modern vascular surgery, Matas documented his own performance of Smyth's operation at Charity 4 times over the course of his career. Although later supplanted by primary vascular anastomosis and grafting, the first successful innominate ligation was a collaborative effort between New York and New Orleans that served as a foundation for the development of modern aneurysm repair.

A novel reconstruction technique of a tracheal defect in the emergent setting using a thymus flap in a patient with tracheoinnominate artery fistula

Background

There is a very high mortality associated with a tracheoinnominate artery fistula; however, when patients survive, they often require reconstruction of the eroded tracheal defect after the bleeding has been controlled.

Case presentation

This is the case of an 83-year-old male with a tracheoinnominate artery fistula who was stabilized in the operating room and underwent repair of his trachea. A novel technique of using the thymus gland as a pedicled flap to repair a large tracheal defect was executed after achieving hemostasis. The patient’s defect was repaired successfully following control of the fistula.

Conclusions

We have shown that the thymus gland can be used successfully as a pedicled flap for repair of a tracheal defect in the setting of a tracheoinnominate artery fistula.

[Surgical treatment of tracheoarterial fistulas]

BACKGROUND

A tracheoarterial fistula (TAF) is an uncommon but life-threatening complication after tracheostomy. Only an immediate and targeted treatment provides a chance to survive.

OBJECTIVE

Surgical treatment of TAF.

METHODS

Selective review of the literature and case description.

RESULTS

A TAF leads to an acute bleeding complication with displacement of the respiratory tract. The mortality rate is nearly 100% without a surgical intervention. In the literature various interventional and surgical treatment procedures are described. Rapid control of bleeding via manual compression and overinflation of the tracheal cuff are the most important steps of treatment. Subsequent emergency surgery with ligation or resection of the TAF and covering of the tracheal lesion should be performed. Extracorporeal membrane oxygenation (ECMO) and a heart-lung machine can sometimes be necessary.

CONCLUSION

Despite all treatment options the mortality rate of TAF remains high. The critical steps are a quick diagnosis of TAF, securing the airway and immediate bleeding control.