Tracheo-innominate artery erosion: Successful surgical management of a devastating complication

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.

Over-Inflating a Tracheostomy Tube Cuff for Tracheo-Innominate Artery Fistula

We report an angiographic image of a 58-year-old woman with profuse bleeding from a tracheo-innominate artery fistula. It may not have been possible to obtain this valuable image if adequate initial resuscitation and an over-inflated tracheostomy tube cuff had not been administered to stop bleeding during an emergency.

Anterior mediastinal tracheostomy for severe tracheal stenosis in a child with severe motor and intellectual disabilities: a case report

BACKGROUND

Owing to recurrent aspiration pneumonia and airway stenosis secondary to thoracic deformities, tracheostomy or laryngotracheal separation are often necessary in children with severe motor and intellectual disabilities. However, these procedures are associated with the risks of tracheal stenosis due to tracheal granulation and tracheoinnominate artery fistula formation. We report a case of a child with severe motor and intellectual disabilities treated with an anterior mediastinal tracheostomy.

CASE PRESENTATION

The patient was a 15-year-old boy with severe motor and intellectual disabilities due to intractable epilepsy. Due to thoracic deformity and tracheomalacia, the patient had a flattened and narrowed trachea. Accordingly, laryngotracheal separation was performed 4 months before admission to avoid aspiration pneumonia. Due to a common cold, the patient required frequent sputum suctioning, which exacerbated the tracheal stenosis. Bronchoscopy revealed tracheal stenosis 4-5 cm caudal to the tracheostomy site, tracheal mucosal ulcers, and pulsation of the innominate artery on the anterior wall of the trachea. We performed an anterior mediastinum tracheostomy to release the tracheal stenosis and prevent tracheoinnominate artery fistula formation.

CONCLUSIONS

Anterior mediastinal tracheostomy has several advantages. Including sufficient release of bony compression, release of tracheal hyperextension, and relief of tracheal and innominate artery contact ensures a cannula-free tracheostomy, and there is no need to dissect the brachiocephalic artery. It is the procedure of choice in cases of head and neck malignancies requiring extensive tracheal resection and could be a good surgical option for severe tracheal stenosis and tracheoinnominate artery fistula in children with severe motor and intellectual disabilities.

Tracheoarterial fistula in a patient with amyotrophic lateral sclerosis successfully managed by overinflation of the tracheostomy tube cuff alone: a case report

BACKGROUND

Tracheoarterial fistula is the most devastating complication after tracheostomy, and its mortality, without definitive treatment, approaches 100%. In general, the combination of bedside emergency management, that is, overinflation of the tracheostomy tube cuff, and definitive treatment such as surgical or endovascular intervention is necessary to prevent the poor outcome. Patients with neuromuscular diseases such as amyotrophic lateral sclerosis are susceptible to tracheoarterial fistula because of long-term mechanical ventilation and muscle weakness.

CASE PRESENTATION

We describe a case of tracheoarterial fistula in a Japanese 39-year-old patient with amyotrophic lateral sclerosis with long-term ventilator management. The patient was clinically diagnosed with a tracheoarterial fistula because of massive bleeding following sentinel hemorrhage. The massive hemorrhage was controlled by overinflation of the tracheostomy tube cuff alone, without definitive treatment.

CONCLUSIONS

This case suggests overinflation of the tracheostomy tube cuff alone plays an important role, semi-permanently, in the management of tracheoarterial fistula, especially in cases where surgical or endovascular intervention is not indicated. Clinicians taking care of patients with tracheostomy undergoing long-term mechanical ventilation should be aware that tracheoarterial fistula might occur following tracheostomy.

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.

Post-tracheostomy tracheoinnominate fistula: endovascular treatment

Objective:

Tracheoinnominate fistula (TIF) is a rare and frequently lethal complication of tracheostomies. Immediate bleeding control and surgical treatment are essential to avoid death. This report describes the successful endovascular treatment of TIF in a preschooler and reviews the literature concerning epidemiology, diagnosis, prophylaxis, and treatment of TIF in pediatric patients.

Case description:

A tracheostomized neurologically impaired bed-ridden three-year-old girl was admitted to treat an episode of tracheitis. Tracheostomy had been performed two years before. The child used a plastic cuffed tube continually inflated at low pressure. The patient presented two self-limited bleeding episodes through the tracheostomy in a 48h interval. A new episode was suggestive of arterial bleeding, immediately leading to a provisional diagnosis of TIF, which was confirmed by angiotomography, affecting the bifurcation of the innominate artery and the right tracheal wall. The patient was immediately treated by the endovascular placement of polytetrafluoroethylene (PTFE)/nitinol stents in Y configuration. No recurrent TIF, neurological problems, or right arm ischemia have been detected in the follow-up.

Comments:

TIF must be suspected after any significant bleeding from the tracheostoma. Endovascular techniques may provide rapid bleeding control with low morbidity, but they are limited to a few case reports in pediatric patients, all of them addressing adolescents. Long-term follow-up is needed to detect whether stent-related vascular complications will occur with growth.

Modified Manikin for Tracheoinnominate Artery Fistula

Audience

This simulator is designed to instruct emergency medicine residents in tracheostomy training that involves bleeding from the tracheostomy site. Any resident, fellow, or attending physician who cares for patients with complications from their tracheostomy might benefit from this innovation.

Introduction

The emergency medicine provider must maintain proficiency in caring for patients with complications from their tracheostomy. In the United States, over 110,000 patients receive tracheostomies per year.1 A rare but catastrophic complication of tracheostomies, usually within the first month of placement, is a tracheoinnominate artery fistula (TIAF). This complication occurs in 0.7% of tracheostomy patients and carries a 50-70% mortality.1,2 We modified a low-fidelity tracheostomy manikin to instruct learners in the stepwise management of hemorrhage from a TIAF.

Educational Objectives

By the end of this educational session, learners will be able to:Perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site.Describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF.Demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver.Verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above.Demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol.

Educational Methods

This modified manikin is a useful training tool for any healthcare provider who is involved in the treatment and stabilization of a variety of tracheostomy emergencies, from bleeding to infection to obstruction or dislodgement. Our case was presented on two separate occasions, to otolaryngology interns (PGY-1), and emergency medicine residents (PGY 1-3). It involved the care of a patient with a sentinel bleed and subsequent hemorrhage from a tracheoinnominate artery fistula (TIAF). This low-fidelity tracheostomy manikin provides the ideal platform for any complex, tracheostomy case, particularly where ongoing bleeding from the tracheostomy site might permanently damage the electrical circuitry of a high-fidelity model. We initially fashioned this modified manikin for tracheostomy training during a simulation "boot camp" for otolaryngology PGY-1 residents. Our use of this modified manikin for tracheostomy training was a useful teaching tool during our otolaryngology intern "boot camp." As a result, we organized a subsequent simulation training session with our PGY 1-3 emergency medicine residents to provide similar instruction in management of a TIAF.

Research Methods

We provided a pre- and a post-simulation survey for the 33 emergency medicine residents who participated in the TIAF simulation with our modified tracheostomy manikin. There were 11 residents from each of the PGY-1, PGY-2, and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-simulation survey, and 33 residents (100%) completed the post-simulation survey. We used a 6-point Likert Scale from "strongly agree" to "strongly disagree" to assess a resident's knowledge of multiple learning objectives within this simulation.

Results

The pre- and post-simulation survey supported this simulation and manikin innovation as a useful teaching tool for tracheostomy emergencies such as a TIAF.

Discussion

This was a useful innovation for emergency provider training in the recognition and management of a TIAF, a rare but emergent tracheostomy complication. In addition to this bleeding complication, this innovation might be useful for a variety of tracheostomy emergencies such as site infection, obstruction, and tube dislodgement. We highly recommend the involvement of both an emergency medicine and otolaryngology content expert in the design and debriefing of tracheostomy cases with this modified manikin. In our experience, a facilitated debriefing by an experienced clinician and educator from both fields provided a diverse perspective for challenging cases such as bleeding from a TIAF.

Topics

Difficult airway, tracheostomy, tracheoinnominate fistula, hemorrhagic shock, tracheostomy complications, Utley Maneuver.

Tracheoinnominate Artery Fistula

AUDIENCE

This simulation provides training for emergency medicine residents in the stepwise management of a patient who presents with bleeding from a tracheoinnominate artery fistula. Additional learners who might benefit from this simulation are otolaryngology and general surgery residents as well as critical care fellows.

INTRODUCTION

Hemorrhage from a tracheoinnominate artery fistula (TIAF) is a rare but life-threatening complication in a patient with a recent tracheostomy. This complication occurs in 0.7% of tracheostomy patients with a mortality of 50-70%.1 Seventy-five percent of patients with a TIAF will present within the first three weeks of surgery and 50% of patients will present with a sentinel bleed that briefly resolves.1 Key elements of a history and exam that should raise a provider's concern for this diagnosis include a recent tracheostomy (within the last 4 weeks), a percutaneous tracheostomy, prior radiation, chronic steroid use, a neck or chest deformity or a sentinel bleed.2 Survival from a TIAF hinges upon emergent, operative repair by an otolaryngologist and cardiothoracic surgeon. Cuff hyperinflation and the Utley Maneuver are critical bedside interventions to temporize this massive bleed and stabilize the patient for definitive, operative repair.

EDUCATIONAL OBJECTIVES

By the end of this simulation, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site, 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF, 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver, 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above, 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol.

EDUCATIONAL METHODS

This case was written with a modified, low-fidelity manikin, traditionally used for training in nasogastric tube placement and tracheostomy care. We modified this manikin to simulate a hemorrhage from the tracheostomy site.3 The patient in our case had a history of laryngeal cancer, and thus we occluded his larynx for this simulation. As a result of this obstruction, he was unable to be intubated from above. We provided confederates, a bedside nurse and family member, to assist the learners throughout the case. We also utilized a simulation technician to operate dynamic vital signs on a simulated cardiac monitor. It would be technically challenging to adapt this case to a high-fidelity simulator due to potential for damage of the internal electrical elements by the large amount of artificial blood from the tracheostomy tube. However, a mechanical pump provided a useful means of active bleeding in this low-fidelity manikin.

RESEARCH METHODS

We provided a pre- and post-simulation questionnaire for the 33 emergency medicine residents who participated in this simulation. There were 11 residents from each of the PGY-1, PGY-2 and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-survey and 33 residents (100%) completed the post-survey. For our questions, we used a 5-point Likert Scale to assess a resident's knowledge of the learning objectives within this simulation.

RESULTS

Responses from our pre- and post- survey indicated a significant improvement in knowledge about a tracheoinnominate artery fistula as well as the general management of tracheostomy complications in the emergency department.

DISCUSSION

This simulation is a useful educational tool for instructing emergency medicine residents on optimal management of tracheostomy emergencies such as a TIAF. The interprofessional teaching by an emergency medicine attending and mid-level (PGY-3) otolaryngology resident allowed for a richer and more detailed discussion during the debriefing. Throughout the case, the emergency medicine attending played the role of a bedside nurse and offered supportive, clinical cues when bleeding recurred. The otolaryngology resident played the role of a family member and offered helpful cues during the history and exam portion of the case. Following the case, both content experts provided useful clinical insight during the debriefing. If staffing availability permits, it might be advantageous to use additional simulation-trained personnel to play the roles of the nurse and family member, thus allowing the emergency medicine attending and otolaryngology content experts to simply view the case from the control room and perform the debriefing.

TOPICS

Tracheostomy, surgical airway, tracheoinnominate artery fistula, bleeding from tracheostomy site, complications with tracheostomies, hemorrhagic shock.

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.

Prophylactic innominate artery transection to prevent tracheoinnominate artery fistula: a retrospective review of single institution experiences

PURPOSE

This study aimed to investigate the optimal indication and availability of prophylactic innominate artery transection (PIAT).

METHODS

We retrospectively analyzed the medical records of the patients with neurological or neuromuscular disorders (NMDs) who underwent PIAT. Meanwhile, we originally defined the tracheal flatting ratio (TFR) and mediastinum-thoracic anteroposterior ratio (MTR) from preoperative chest computed tomography imaging and compared these parameters between non-PIAT and PIAT group.

RESULTS

There were 13 patients who underwent PIAT. The median age was 22 years. PIAT was planned before in one, simultaneously in five, and after tracheostomy or laryngotracheal separation in seven patients. Image evaluations of the brain to assess circle of Willis were performed in all patients. Appropriate skin incisions with sternotomy to expose the innominate artery were made in four patients. All patients are still alive except one late death without any association with PIAT. No neurological complications occurred in any patients. As significant differences (p < 0.01) between two groups were observed for TFR and MTR, objective validity of the indication of PIAT was found.

CONCLUSIONS

PIAT is safe and tolerable in case of innominate artery compression of the trachea with NMDs. TFR and MTR are useful objective indexes to judge the indication of PIAT.

Anesthetic Management for Emergent Repair of Tracheoinnominate Fistula

We present a case of a 30-year-old female, who had tracheostomy revision complicated by false passage into the subcutaneous space and pneumothorax. Six days later, she developed massive bleeding from the mouth, nose, and tracheostomy site. Approximately 2 liters of blood was lost. With high suspicion for tracheo-innominate fistula, she was emergently brought to the operating room for fistula repair. Her anesthetic management was initially focused on maintaining spontaneous ventilation with inhalation agents until surgical exposure was adequate. An endotracheal tube was then placed under guidance of a video-laryngoscope. The tracheostomy tube was then removed over a Cook catheter to maintain secure passage in case of airway collapse. The oral endotracheal tube was then inserted distal to the arterial and tracheal defect. The patient's bleeding was stopped, the fistula was repaired, and she was transferred back to the intensive care unit, but she died several days later due to multi-organ failure.

Tracheo-innominate Artery Fistula in a Complicated Penetrating Neck Trauma: A Successfully Managed Rare Complication of Low Tracheotomy

Tracheo-innominate artery fistula is a rare complication of tracheotomy with very high mortality rate. Only a few patients survive this complication as reported in the literature. Here we report the case of a 54-year-old gentleman who presented to the emergency department with a history of penetrating neck trauma following a road traffic accident. Neck exploration and tracheotomy were done to secure the airway. After two weeks, the patient had an episode of massive stomal bleed for which he was taken to the operating room and re-explored. A tracheo-innominate artery fistula was detected, and right side aorto-carotid and right side aorto-subclavian anastomoses were done using reversed saphenous vein graft with interruption of flow. Following a successful surgery, the patient was decannulated later, and now lives a healthy normal life. Early diagnosis and immediate intervention are the key in managing this complication. Bedside management also plays a vital role.

Critical Care and Postoperative Management of the Head and Neck Patient

Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.

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.

Imaging of the age-related anatomical relationship between the innominate artery and the trachea

PURPOSE

To measure the age-dependent changes of anatomical positions and relations between the trachea, cricoid cartilage (CC), and innominate artery (IA) in adults by computed tomography (CT).

METHODS

A retrospective cohort reviewing images of 127 consecutive adult patients who underwent CT angiography (CTA) of the neck. The trachea-to-IA (T-IA) distance was measured as the minimal horizontal distance between them. The vertical distance between the CC and the IA was measured between the axial section, demonstrating the CC's inferior border to the axial section at the level of the T-IA measurement.

RESULTS

Images of 125 patients (median age 53 years, range 18-89; 74 males) were reviewed. The mean T-IA distance was 2.3 ± 1.1 mm for males and 1.7 ± 0.9 mm for females (P = 0.002). The vertical C-IA distance was 44.2 ± 11.4 mm and 49.5 ± 12.5 mm for males and females, respectively (P = 0.01). Age correlated negatively with the vertical C-IA distance (P < 0.0001) and positively with the T-IA distance (P < 0.0001). The rate of IA variants was 23.2%, with no significant difference between the measurements of distances among patients with or without IA variants.

CONCLUSIONS

This is the first description of the relationships between the trachea, CC, and IA distances in adults as depicted on CTA. The T-IA distance becomes larger while the T-CC distance becomes shorter with age.

A Computed Tomographic Assessment of Tracheostomy Tube Placement in Patients with Chronic Neurological Disorders: The Prevention of Tracheoarterial Fistula

Objective Tracheoarterial fistula (TAF) is a rare but devastating complication of tracheostomy caused by pressure necrosis from the elbow, tip, or over-inflated cuff of the tracheostomy tube. The incidence of TAF is reportedly higher in patients with neurological disorders than in those without such disorders. To evaluate the incidence of and factors contributing to the misalignment of tracheostomy tubes in bedridden patients with chronic neurological disorders. Methods We retrospectively assessed three-dimensionally reconstructed serial computed tomography (CT) images to see if the tip of the tube made contact with the tracheal wall and if the main arteries were running adjacent to the tube's elbow, tip or cuff. Results The tip of the tube was in contact with the tracheal wall in 14 of the 30 patients assessed. Among them, the tip was adjacent to the innominate artery in eight, the aortic arch in three and an aberrant right subclavian artery in one. In one patient with the tube tip adjacent to the aortic arch and the other four patients, the cuff of the tube was adjacent to the innominate artery across the tracheal wall. Patients with the tube tip in contact with the anterior tracheal wall had a significantly greater cervical lordosis angle than those without contact (p<0.05). Conclusion More than half of tracheostomized patients with chronic neurological disorders had a latent risk of TAF. The variability in the location of the innominate artery, anomalies of the aortic arch, and skeletal deformities may therefore be contributing factors.

Tracheo-innominate fistula in children: A systematic review of literature

OBJECTIVE

Tracheo-innominate fistula (TIF) is a rare but fatal complication of tracheotomy. To date, there is a paucity of literature regarding pediatric TIFs. The objectives of this study were to conduct a systematic review of literature on pediatric TIF following tracheotomy and describe three demonstrative cases from our institutional experience.

METHODS

We conducted a systematic review using MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL. All studies with pediatric patients (under 18 years of age) who developed TIF following tracheotomy were included.

RESULTS

Fifty-four publications met inclusion criteria, reporting on 77 cases. The most common indication for tracheotomy was prolonged intubation and the need for ventilatory support (38.6%), with neurological comorbidities being the most common indication (72.7%). The mean time to TIF was 395.7 days (95% confidence interval, 225.9-565.5). Fifty-four patients (70.1%) presented with massive hemorrhage, whereas 18 patients (23.3%) presented with a sentinel bleeding event. The most common diagnostic interventions were computed tomography scan with or without contrast and bronchoscopy (55.8%). A substantial number of patients did not have any investigations (41.6%). Surgical management occurred in 70.1% of patients. Mortality was 38.6% in reported cases with variable follow-up periods.

CONCLUSION

TIF may occur in long-term tracheostomy-dependent children, contrary to the conventionally described 3-week postoperative period. The mortality may not be as high as previously reported with timely intervention. Our results are limited by inherent risks of bias. Further research including well-designed cohort studies are needed to guide an evidence-based approach to TIF.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:217-224, 2020.

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.

Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence

We report a fatal tracheoinnominate artery fistula (TIF) in a 13-year-old female patient with long-term tracheostomy tube dependence due to chronic respiratory failure. Thirteen years after placement of her tracheostomy tube, the patient experienced two separate episodes of sentinel bleeding prior to a fatal hemorrhagic event. Diagnostic evaluation after the sentinel events was mostly nonconclusive. This case highlights the risk of TIF in pediatric age group, even years after initial tracheostomy tube placement, and the need for a high index of suspicion for TIF when children present with unexplained tracheal bleeding.

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.

High-riding brachiocephalic (innominate) artery during surgical tracheostomy

Two cases of a high-riding innominate artery, which were found during routine surgical tracheostomy. A cartilage flap was applied to cover the significant vessel to prevent the life-threatening complications. These two cases were followed up for 2 months without any adverse events. We discussed the related vascular anatomy, imaging studies and brief literature review.

A case of tracheo-innominate artery fistula successfully treated with endovascular stent of the innominate artery

Tracheo‐innominate artery fistula (TIF) is a rare but life‐threatening complication of tracheostomy. We describe a 44‐year‐old man who was admitted for a pressure ulcer infection with a third tracheostomy in place. He showed massive hemoptysis from the TIF, followed by cardiopulmonary arrest. The cuff of the tube was hyperinflated; however, even a slight movement of the tube resulted in recurrent massive hemorrhage. Thus, an endovascular stent graft was placed. Our case shows that sentinel bleeding may be found prior to TIF, and an endovascular repair can be a lifesaving temporizing option, when the hemorrhage was not controlled by hyperinflating the cuff of the tube.

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.

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Avoidance of a potential tracheoinnominate fistula by innominate artery re-implantation in a four year old girl with tracheostomy dependence and Pfeiffer syndrome

A 4 year old tracheostomy dependent girl with Pfeiffer syndrome was noted on bronchoscopy to have a pulsatile tracheostomal mass. CT chest angiography was consistent with the innominate artery crossing anterior to the trachea and superior to the sternal notch. The patient underwent reimplantation of the innominate artery via a median sternotomy approach. Tracheoinnominate fistula is a potentially devastating complication of tracheostomy. We report discovery of a near tracheoinnominate fistula in order to highlight the importance of regular interval surveillance endoscopy in tracheostomy dependent children and to discuss a preventative surgical intervention employed in prevention of this potentially devastating complication.

[The Significance of Resection of the Cricoid Cartilage as a Surgical Procedure in Laryngotracheal Surgery]

The cricoid cartilage has been regarded as an extremely important organ because it plays important role in both of phonation and breathing. We herein report on two different types of surgical procedure for laryngotracheal diseases with aggressive resection of the cricoid cartilage. The first procedure is a tracheostomaplasty by partial resection of the cricoid cartilage. A tracheostoma is made by resection of the cricoid cartilage in the range of approximately a one-third front. This method is effective for such cases having difficulty in tracheostomy owing their backgrounds with such condition as neck stiffness, obesity, higher displacement of the brachiocephalic artery, short neck, thyroid disease and so on. We applied this procedure for eight cases with such difficult backgrounds. In all cases, we were able to make a good tracheostoma and the postoperative courses were uneventful. The second procedure is a glottic closure with resection of the cricoid cartilage and thyroid cartilage. We applied this procedure for six cases with intractable dysphagia. One case had a postoperative bleeding. We were able to make good conditions in all cases with a large tracheostoma and no pharyngeal-tracheal leakage. In conclusion, the surgical procedure involving resection of the cricoid cartilage can be applied to some laryngotracheal diseases.

Prevention and Treatment of Life-Threatening Bleeding After Thyroid Surgery

BACKGROUND Few reports have discussed life- threatening bleeding that occurs postoperatively in patients who have undergone thyroid surgery. In this article, we discuss the causes, treatment measures, and possible ways of preventing this severe complication. MATERIAL AND METHODS From Jan 2002 to Dec 2014 we retrospectively analyzed 7 patients who developed life-threatening bleeding after undergoing thyroid surgery at our center. RESULTS Among the group of 7 patients, there was 1 case of superior thyroid artery hemorrhage (STAH), 5 cases of carotid blowout syndrome (CBS), and 1 case of tracheo-innominate fistula (TIF). The STAH was caused by unreliable ligation. All the cases of CBS and TIF were caused by surgical wound infection. Six patients were transferred to the operating room immediately; open surgical treatment was performed on these 6 patients. Out of these 6 patients, 1 patient did not survive the operation, and hemorrhage was successfully controlled in 3 patients. The remaining 2 patients again experienced bleeding even after undergoing open surgery. Only 1 patient developed long-term neurological complications. CONCLUSIONS Infection is the most common cause of life-threatening bleeding that occurs postoperatively in some patients who have undergone thyroid surgery. Early surgical intervention can save the lives of these patients without causing any severe neurological complications.

Tracheo-innominate artery fistula with severe motor and intellectual disability: incidence and therapeutic management

OBJECTIVE

Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication following tracheostomy or tracheoesophageal diversion (TED). Although successful surgical intervention for TIF has been reported, few studies have been performed in patients with severe motor and intellectual disability (SMID). Therefore, we aimed to analyze TIF in patients with SMID to clarify the clinical variables predicting the occurrence and adequate management for lifesaving of TIF.

METHODS

We retrospectively reviewed the records of patients with SMID undergoing surgical tracheostomy and TED between 2006 and 2012 and identified those with TIF. When TIF occurred, we obtained the clinical status and emergency management.

RESULTS

Of 70 patients who underwent tracheostomy or TED during the study period, three patients had TIFs; in one case, TIF was avoided by ligation of the innominate artery before TED. The incidence of TIF in those undergoing tracheostomy and TED was 2.3% and 7.4%, respectively. The interval between tracheostomy and TIF was 14-50 months.

CONCLUSIONS

Patients with SMID may have an increased risk of TIF. Prompt diagnosis and surgical intervention to control the bleeding is the only effective management at present.

Innominate artery injury: a catastrophic complication of tracheostomy, operative procedure revisited

A patient presented with profuse bleeding from the oronasal cavity following orofaciomaxillary trauma associated with tracheolaryngeal injury and suspected cervical-spine injury due to collapse of a wall on the face, neck and upper chest. The patient was gasping, coughing blood and was unable to speak. Threatened airway was diagnosed. Inability to maintain oxygenation on cricothyroidotomy, forced emergency department surgeons to shift the patient to the operating room for definitive airway. During tracheostomy a major vessel was injured. Application of vascular clamp in the event of achieving haemostasis resulted in disappearance of saturation and pulse in the right upper limb, thus we suspected innominate artery (IA) injury. High tracheostomy performed and endotracheal tube passed into the trachea after removing clot and overcoming compromised narrow tracheal lumen. The injured IA was repaired and the patient survived for 14 days. On postoperative day 14 he died following profound bleeding into the tracheobronchial tree and asphyxia/apnoea. Tracheoinnominate artery fistula was detected at autopsy.

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.

Pathological consideration of tracheo-innominate artery fistula with a case report

OBJECTIVES

Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication of tracheostomy. There are many reports about TIF but the mechanism of TIF formation remains poorly documented. Our objective is to investigate the TIF pathologically and suggest the possible mechanism of TIF formation.

PATIENT AND METHODS

The patient was an 11-year old boy with a history of severe childhood epilepsy, cerebral palsy, and psychomotor retardation who died from TIF. We investigated the TIF histopathologically through his autopsy and reviewed bibliographical considerations.

RESULTS

Autopsy revealed massive blood aspiration from a large TIF and histopathological findings showed the following: (1) fibroepithelial polyps around the fistula; (2) squamous metaplasia of tracheal mucosa; (3) disappearance of tracheal cartilages and tracheal glands; and (4) arteritis (infiltration of neutrophils into the mesarterium and endarterium). Probably, (1) and (2) indicate chronic and repetitive irritations caused by cannula. (3) and (4) indicate intense inflammation caused by local infection. In this case, it is suggested that the chronic damage by cannula and the local infection resulted in the fistula formation and rupture of innominate artery.

CONCLUSION

The present case suggests a pathogenesis in which chronic damage to the anterior tracheal wall by the cannula and consequent infection led to fistulation and rupture of the innominate artery.

Tracheo-innominate artery fistula: Diagnosis and surgical management

BACKGROUND

Tracheo-innominate artery fistula (TIF) is a rare and fatal complication after tracheostomy. The diagnosis, treatment, and possible prevention of this disease are discussed in this study.

METHODS

From 1976 to 2008, 14 patients with TIF were studied retrospectively.

RESULTS

All patients underwent open surgical tracheostomy. Before TIF, herald events occurred in 10 patients (8 had slight hemoptysis and 2 had innominate artery exposure). When TIF occurred, bedside aid was administered, and 5 patients lived long enough to reach the operating room. Four patients accepted median sternotomy and ligation of innominate arteries. After surgery, mediastinal infection caused the rebleeding and death of 3 patients. In conducting follow-up for 11 months, the last patient was still alive without neurological complications. The survival rate was only 7.1%.

CONCLUSION

Prompt diagnosis and surgical intervention can save the life of a patient with TIF. Prevention is vital because of the high mortality of this disease.

Successful treatment of tracheoinnominate artery fistula following tracheostomy in a patient with cerebrovascular disease

Tracheoinnominate artery fistula is a critical complication of tracheostomy. The most important factors influencing patient outcome are prompt diagnosis, immediate control of bleeding with a patent airway, and emergency operation with or without interruption of the innominate artery. Here, we report a case of tracheoinnominate artery fistula in a 40-year-old woman with cerebrovascular accident who was successfully managed with an aorta-axillary artery bypass.

Tracheoinnominate artery fistula after laryngotracheal separation: prevention and management

AIM

Tracheoinnominate artery fistula (TIF) is an often fatal complication of laryngotracheal separation (LTS) for which there has been no systematic therapeutic strategy for prevention or management of TIF. The aim of this study was to establish such a strategy based on our clinical experience.

MATERIALS AND METHODS

From 2000 to 2010, 14 patients received LTS. We reviewed these patients to develop a therapeutic approach to prevent or manage TIF.

RESULTS

Three patients had major bleeding, and another 3 received preventive treatment before major bleeding. In the major bleeding group, 1 patient died of choking from uncontrollable hemorrhage, but the others were rescued by brachiocephalic trunk separation and/or endovascular embolization. At operation, median sternotomy with its high risk of mediastinitis was avoided. In the preventive treatment group, prophylactic brachiocephalic trunk separation was performed for 2 patients because their severe scoliosis narrowed the mediastinum, compressing the innominate artery on computed tomography. Another avoided major bleeding by converting the tracheostomy tube to a length-adjustable type.

CONCLUSION

Tracheoinnominate artery fistula is a dramatic, often lethal complication. The strategic approach should be designed to prevent it and includes evaluation of the spinal deformity on computed tomography, brachiocephalic trunk separation at the same time as LTS, and recognizing the importance of "herald" or warning minor bleeds.

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.

Tracheo-brachiocephalic artery fistula after tracheostomy associated with thoracic deformity: a case report

INTRODUCTION

Tracheo-brachiocephalic artery fistulae are critical long-term complications after tracheostomy, reported in 0.6% of patients within three to four weeks after the procedure. In 30% to 50% of cases there is some bleeding prior to onset. Since the onset involves sudden massive bleeding, the prognosis is poor; the reported survival rate is 10% to 30%. The direct cause of bleeding is the formation of a fistula with the trachea subsequent to arterial injury by the tracheostomy tube. Endo-tracheal factors are movement of the tracheostomy tube due to body movement and seizures, pressure exerted by the cuff of the tracheostomy tube, tracheostomy at lower levels, and the fragility of blood vessels and the trachea due to steroid or radiation therapy, and malnutrition. Extra-tracheal factors include prior surgery and deformity and shifting of the trachea and major blood vessels due to congenital kyphoscoliosis or thoracic deformity. There has been no report of the usefulness of contrast-enhanced computed tomography studies to identify the anatomical relationship between the trachea and brachiocephalic artery.

CASE PRESENTATION

A 27-year-old Mongolian woman with congenital muscular dystrophy who underwent tracheal intubation for airway management due to pneumonia and granulation development developed a tracheo-brachiocephalic artery fistula during the placement of the tracheostomy tube. It was diagnosed by contrast-enhanced chest computed tomography and repaired. About a month later she developed massive airway bleeding during replacement of the tracheostomy tube. Temporary hemostasis was achieved by compression via cuff inflation. A contrast-enhanced chest computed tomography scan demonstrated a narrowed brachiocephalic artery running along and ventral to the tube and a tracheo-brachiocephalic artery fistula was suspected. She underwent brachiocephalic artery resection and aorta, right common carotid artery, and subclavian artery bypass surgery with an innominate vein, tracheoplasty, and partial sternectomy. We noted marked thoracic deformity; the brachiocephalic artery was compressed by the trachea and chest wall resulting in localized wall necrosis and the development of a tracheo-brachiocephalic artery fistula, a fatal complication whose prevention is important.

CONCLUSIONS

We suggest that before tracheostomy, the anatomic relationship between the trachea and brachiocephalic artery must be confirmed by contrast-enhanced chest computed tomography scan.

Tracheostomy care: a clinician's guide

Tracheostomies have become a typical component of the management of patients with prolonged respiratory failure. There are, however, relatively few studies from which to establish an accepted standard of care with regard to the specific features, daily care, and removal of tracheostomy tubes. Consequently, these decisions are sometimes guided by myth and misconception. In this article, we review the different types of tracheostomy tubes with their respective advantages and disadvantages, basic principles of care, recognition of complications, speech with a tracheostomy tube, and the process by which they may sometimes be removed.

Two cases of tracheoinnominate artery fistula following tracheostomy treated successfully by endovascular embolization of the innominate artery

Tracheoinnominate artery fistula (TIF) is a rare but lethal complication of tracheostomy. Treatment has traditionally been surgical, but advances in endovascular technology have led to a few recent reports of therapy with coils. We report 2 cases of TIF with massive hemorrhage that underwent successful treatment with endovascular occlusion. Endovascular repair is less invasive than open surgical repair and usually associated with a shorter recovery period. However, this technique may require multiple coils to inhibit blood flow into the fistula. This procedure should be considered one of the useful treatments for TIF.