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Park YJ, Kim E, Jung HS. Successful management of a tracheomalacia patient with active endotracheal bleeding due to intraoperative innominate artery injury: A case report. Medicine (Baltimore) 2022; 101:e30797. [PMID: 36181007 PMCID: PMC9524874 DOI: 10.1097/md.0000000000030797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Yoo Jung Park
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eunji Kim
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hong Soo Jung
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- *Correspondence: Hong Soo Jung, Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea (e-mail: )
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2
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Morimoto N, Maekawa T, Kubota M, Kitamura M, Takahashi N, Kubota M. Challenge for management without tracheostomy tube after laryngo-tracheal separation in children with neurological disorders. Laryngoscope Investig Otolaryngol 2021; 6:332-339. [PMID: 33869766 PMCID: PMC8035946 DOI: 10.1002/lio2.534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/26/2020] [Accepted: 01/20/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The present study analyzed surgical outcomes of laryngotracheal separation (LTS) in children with neurological disorders. The purpose of this study was to investigate respiratory impairment and severe complications after LTS in children, and identify the possibility of permanent tracheostomy without a tracheostomy tube as the safest respiratory management method. METHODS Twenty-eight patients (male:female = 16:12) with neurological disorders (6 months to 32 years) who underwent LTS between January 2012 and April 2018 were reviewed. Tracheal diameter, Cobb angle, and sternocervical spine distance (SCD) were measured to assess the potential risk and possibility of removing tracheostomy tube management. RESULTS Tracheostomy tube could be removed shortly after LTS in 57% (16/28). However, nine of these patients developed respiratory problems that required tracheostomy tube placement 2 years after LTS. New requirements for a tracheostomy tube as a stent were strongly correlated with SCD (P < .05, odds ratio > 1) as well as tracheal deformity. CONCLUSIONS Respiratory management in neurologically impaired children after LTS without a tracheostomy tube is challenging because thoracic deformity during physical growth affects tracheal disfiguration. Thoracic deformities and progression of scoliosis should be considered in respiratory management approaches in children with neurological disorders, and long-term follow-up by computed tomography is necessary. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Noriko Morimoto
- Department of OtolaryngologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Takanobu Maekawa
- Department of General Pediatrics and Interdisciplinary medicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Masaya Kubota
- Department of NeurologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Masayuki Kitamura
- Department of RadiologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Nozomi Takahashi
- Department of OtolaryngologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary medicineNational Center for Child Health and DevelopmentTokyoJapan
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3
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Khanafer A, Hellstern V, Meißner H, Harmening C, Schneider K, Henkes H. Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft. CVIR Endovasc 2021; 4:30. [PMID: 33740143 PMCID: PMC7979846 DOI: 10.1186/s42155-021-00216-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/23/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Ali Khanafer
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - Helfried Meißner
- Klinik für Gefäßchirurgie, Endovaskuläre Chirurgie und Transplantationschirurgie, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Christoph Harmening
- Klinik für Anästhesiologie, Operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Klaus Schneider
- Klinik für Hals-, Nasen-, Ohrenkrankheiten, Plastische Operationen, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
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4
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O'Malley TJ, Jordan AM, Prochno KW, Saxena A, Maynes EJ, Ferrell B, Guy TS, Entwistle JW, Massey HT, Morris RJ, Abai B, Tchantchaleishvili V. Evaluation of Endovascular Intervention for Tracheo-Innominate Artery Fistula: A Systematic Review. Vasc Endovascular Surg 2021; 55:317-324. [PMID: 33529132 DOI: 10.1177/1538574420980625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Thomas J O'Malley
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew M Jordan
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Kyle W Prochno
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Abhiraj Saxena
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Brandon Ferrell
- 12230Georgetown University School of Medicine, Washington, DC, USA
| | - T Sloane Guy
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - John W Entwistle
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - H Todd Massey
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
| | - Babak Abai
- Division of Vascular and Endovascular Surgery, 6529Thomas Jefferson University, Philadelphia, PA, USA
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5
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Suzuki K, Fujishiro J, Ichijo C, Watanabe E, Tomonaga K, Sunouchi T, Watanabe Y. Prophylactic innominate artery transection to prevent tracheoinnominate artery fistula: a retrospective review of single institution experiences. Pediatr Surg Int 2021; 37:267-273. [PMID: 33388953 DOI: 10.1007/s00383-020-04792-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Kan Suzuki
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Jun Fujishiro
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Chizue Ichijo
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Eiichiro Watanabe
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kotaro Tomonaga
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomohiro Sunouchi
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasuo Watanabe
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Anesthetic Management for Emergent Repair of Tracheoinnominate Fistula. Case Rep Anesthesiol 2020; 2020:8865303. [PMID: 32908712 PMCID: PMC7471825 DOI: 10.1155/2020/8865303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/09/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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7
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Wang BR, Bongers KS, Cardenas-Garcia J. Hemoptysis: Rethinking Management. CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-00234-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Abstract
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.
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Affiliation(s)
- M Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - B Reger
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - H-S Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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9
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Tateyama M, Konno M, Takano R, Chida K, Rikimaru H, Chida K. A Computed Tomographic Assessment of Tracheostomy Tube Placement in Patients with Chronic Neurological Disorders: The Prevention of Tracheoarterial Fistula. Intern Med 2019; 58:1251-1256. [PMID: 30626805 PMCID: PMC6543219 DOI: 10.2169/internalmedicine.1158-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Maki Tateyama
- Department of Neurology, National Hospital Organization Iwate Hospital, Japan
| | - Masatoshi Konno
- Department of Neurology, National Hospital Organization Iwate Hospital, Japan
| | - Rina Takano
- Department of Neurology, National Hospital Organization Iwate Hospital, Japan
| | - Koichi Chida
- Department of Neurology, National Hospital Organization Iwate Hospital, Japan
| | - Hiroya Rikimaru
- Department of Radiology, National Hospital Organization Sendai Medical Center, Japan
| | - Keiji Chida
- Department of Neurology, National Hospital Organization Iwate Hospital, Japan
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10
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Chauhan JC, Hertzog JH, Viteri S, Slamon NB. Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence. J Pediatr Intensive Care 2018; 8:96-99. [PMID: 31093462 DOI: 10.1055/s-0038-1672153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022] Open
Abstract
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.
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Affiliation(s)
- Jigar C Chauhan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - James H Hertzog
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Shirley Viteri
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Nicholas B Slamon
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, United States.,Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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11
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Reger B, Neu R, Hofmann HS, Ried M. High mortality in patients with tracheoarterial fistulas: clinical experience and treatment recommendations. Interact Cardiovasc Thorac Surg 2017; 26:12-17. [DOI: 10.1093/icvts/ivx249] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/02/2017] [Indexed: 11/14/2022] Open
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12
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Ulusan A, Sanli M, Isik AF, Celik İA, Tuncozgur B, Elbeyli L. Surgical treatment of postintubation tracheal stenosis: A retrospective 22-patient series from a single center. Asian J Surg 2017; 41:356-362. [PMID: 28412038 DOI: 10.1016/j.asjsur.2017.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/22/2017] [Accepted: 03/02/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND/OBJECTIVE We aimed to present cases of postintubation tracheal stenosis (PITS), all due to long-term intubation and treated surgically in a university hospital, and to discuss them in light of the literature. METHODS In this retrospective study, 22 patients who were treated with tracheal resection and reconstruction due to PITS were included. Demographics, intubation characteristics, localization of stenosis, surgical technique and material, postoperative complications, and survival of patients were recorded. RESULTS The mean intubation duration was 16.95 days with a median of 15.00 days. Collar incision was applied in 19 cases (86.4%); in two cases (9.1%) a median sternotomy incision was used; and in the remaining case (4.5%), a right thoracotomy incision was made. The mean tracheal stenosis length was 2.14 cm (mean excision length, 2.5 cm). In 17 cases (77.3%), the anterior walls were supported with vicryl (polyglactin) suture one by one. No postoperative complications were observed in 12 cases (54.5%). No recurrence developed during the long-term follow-up of 15 of the 22 patients (68.2%). Two patients (9.1%) died in the early stages after surgery, and five patients (22.7%) had a stent inserted due to restenosis. CONCLUSION Tracheal resection and end-to-end anastomosis are the most efficient techniques in cases without medical contraindications, despite emerging stent or endoscopic procedures. Endoscopic interventions can be suggested as an alternative to surgery in patients for whom surgery cannot be performed or who develop recurrence.
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Affiliation(s)
- Ahmet Ulusan
- Department of Thoracic Surgery, Hitit University Corum Education and Research Hospital, Corum, Turkey.
| | - Maruf Sanli
- Department of Thoracic Surgery, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Ahmet Feridun Isik
- Department of Thoracic Surgery, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - İlknur Aytekin Celik
- Thoracic Surgery Clinic, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Bulent Tuncozgur
- Department of Thoracic Surgery, Ankara Guven Hospital, Ankara, Turkey
| | - Levent Elbeyli
- Department of Thoracic Surgery, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
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13
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Do post-tonsillectomy patients who report bleeding require observation if no bleeding is present on exam? Int J Pediatr Otorhinolaryngol 2017; 95:75-79. [PMID: 28576538 DOI: 10.1016/j.ijporl.2017.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 02/01/2017] [Accepted: 02/03/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Three to ten percent of tonsillectomy patients experience post-tonsillectomy hemorrhage. Examination of those patients who return to the Emergency Department (ED) with a history of hemorrhage may be found to have active bleeding, a coagulum within the fossa, or a normal post-operative exam. It is not known if those with a normal postoperative exam require inpatient observation. METHODS This is a retrospective series from 1/1/2010 to 12/31/2014 at a tertiary pediatric hospital. We evaluated outcomes in patients who presented to our ED with a history of post tonsillectomy hemorrhage, but after a thorough inspection failed to demonstrate active bleeding or clot, and were thus deemed to have a normal postoperative exam. This cohort was then evaluated for subsequent active bleeding requiring cauterization. Demographics and clinical data were extracted from the medical record. RESULTS In 337 visits with a history of bleeding, and a normal postoperative exam, 38 (11%) subsequently bled requiring cauterization. 32/38 (84%) bled within 24 h of admission to the ED. No demographic or clinical variables predicted an increased risk of bleeding during observation. CONCLUSIONS Eleven percent of patients who presented to the ED with a history of bleeding at home but a normal postoperative exam subsequently bled and required cautery, usually within 24 h. Aside from the history of bleeding at home, we found no additional predictors of subsequent bleeding and recommend this group of patients should be considered for 24 hour in-hospital observation prior to discharge.
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14
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Abstract
The placement of a tracheostomy has become a routine procedure for intensive care unit patients who are mechanical ventilator dependent for a period of time, usually exceeding 1 or 2 weeks. It is vital for the intensivist to be familiar with all aspects of tracheostomies care including the timing of converting a patient to a tracheostomy, types of procedure, risks and benefits, and issues of daily care including oral feedings, speech, and decannulation. In this article we provide a comprehensive review for the intensivist regarding tracheostomies in the intensive care setting. We specifically review indications, timing, surgical options including percutaneous dilation tracheostomy, complications, decannulation, oral feeding, speaking devises, stomal stents, and routine tracheostomy care.
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Affiliation(s)
- A. Alan Conlan
- From the Division of Cardiothoracic Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Scott E. Kopec
- From the Division of Pulmonary, Allergy, and Critical Care, University of Massachusetts Medical School, Worcester, MA
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15
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Browne GA. Quick Response Tracheotomy: A Novel Surgical Procedure. J Intensive Care Med 2016; 31:276-84. [PMID: 26905541 DOI: 10.1177/0885066615627141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 11/16/2022]
Abstract
Quick response tracheostomy (QRT) is a novel open surgical technique to emergently establish an airway. The method is simple; the skills necessary to perform this procedure are rapidly acquired; and it is expedient, minimally traumatic, and remarkably devoid of complications often encountered with percutaneous dilatational tracheotomies, including those complications seen with cricothyroidotomies. Unlike all other tracheotomies in which considerable blunt dissection is required, QRT avoids tissue crushing because sharp dissection alone is used to acquire surgical access to the trachea. The QRT does not entail inserting a guidewire into the trachea, a standard feature for percutaneous tracheal access; it avoids any risk of unintended laceration of the posterior tracheal wall and proximal subjacent esophagus. The technique averts tracheal ring fracture and tracheoesophageal fistula complications. The QRT has a uniquely low incidence of inducing hemorrhage, and it requires no steps that cause temporary tracheal occlusion and will therefore not facilitate hypoxia. The QRT contributes minimally to conditions favorable for generating subglottic stenosis, and the procedure is swiftly executed with very low probability for external tracheal placement of the tracheostomy tube. The QRT is not a blind procedure. No special instruments are required for its execution nor is concurrent tracheoscopy required at any stage while performing a QRT as is specified for percutaneous tracheotomies.
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Affiliation(s)
- Graeme A Browne
- Department Emergency Medicine, Mayo Health Care System Austin, Austin, MN, USA
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Ise K, Kano M, Yamashita M, Ishii S, Shimizu H, Nakayama K, Gotoh M. Surgical closure of the larynx for intractable aspiration pneumonia: cannula-free care and minimizing the risk of developing trachea-innominate artery fistula. Pediatr Surg Int 2015; 31:987-90. [PMID: 26276429 DOI: 10.1007/s00383-015-3780-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/29/2022]
Abstract
There is a risk of developing a fatal trachea-innominate artery fistula following laryngotracheal separation for the prevention of intractable aspiration pneumonia. We developed a novel technique of surgical closure of the larynx to avoid this complication and provide long-term cannula-free care.
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Affiliation(s)
- Kazuya Ise
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan.
| | - Makoto Kano
- Department of Otorhinolaryngology, Head and Neck, Ohara General Hospital, 6-11 Ohmachi, Fukushima-shi, Fukushima, 960-8611, Japan
| | - Michitoshi Yamashita
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Show Ishii
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Hirofumi Shimizu
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Kei Nakayama
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Mitsukazu Gotoh
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
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Maruti Pol M, Gupta A, Kumar S, Mishra B. Innominate artery injury: a catastrophic complication of tracheostomy, operative procedure revisited. BMJ Case Rep 2014; 2014:bcr-2013-201628. [PMID: 24700033 DOI: 10.1136/bcr-2013-201628] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Manjunath Maruti Pol
- Department of Trauma Surgery, All India Institute of Medical Sciences, New Delhi, India
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Tracheoinnominate artery fistula after laryngotracheal separation: prevention and management. J Pediatr Surg 2012; 47:341-6. [PMID: 22325387 DOI: 10.1016/j.jpedsurg.2011.11.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 11/10/2011] [Indexed: 11/20/2022]
Abstract
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.
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Prophylactic ligation of the innominate artery and creation of tracheostomy in a neurologically impaired girl: a case report. Case Rep Med 2011; 2011:790746. [PMID: 22007237 PMCID: PMC3189477 DOI: 10.1155/2011/790746] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 08/10/2011] [Indexed: 11/17/2022] Open
Abstract
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.
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Hamaguchi S, Nakajima Y. Two cases of tracheoinnominate artery fistula following tracheostomy treated successfully by endovascular embolization of the innominate artery. J Vasc Surg 2011; 55:545-7. [PMID: 21958569 DOI: 10.1016/j.jvs.2011.08.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 07/21/2011] [Accepted: 08/03/2011] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Shingo Hamaguchi
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan.
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Effectiveness of near-infrared spectroscopy during surgical repair of tracheo-innominate artery fistula. J Artif Organs 2011; 14:245-8. [PMID: 21509490 DOI: 10.1007/s10047-011-0565-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 03/31/2011] [Indexed: 10/18/2022]
Abstract
Monitoring regional cerebral oxygen saturation (rSO(2)) by use of near-infrared spectroscopy (NIRS) is a useful method for detecting cerebral ischemia. Tracheo-innominate artery fistula is a rare but life-threatening complication of tracheostomy. The surgical procedures for management of tracheo-innominate artery fistula include direct or patch closure of the fistula, ligation or division of the innominate artery, and anatomical or extra-anatomical reconstruction of the flow of the innominate artery. Division of the innominate artery is the best method to prevent postoperative recurrence of bleeding and infection. However, cutting off the innominate artery flow may cause brain ischemia. We present the case of a patient with tracheo-innominate artery fistula successfully treated by dividing the innominate artery while the rSO(2) was monitored. In this case report, we have shown that NIRS is a useful method for deciding the surgical maneuver for tracheo-innominate artery fistula.
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Shima H, Kitagawa H, Wakisaka M, Furuta S, Hamano S, Aoba T. The usefulness of laryngotracheal separation in the treatment of severe motor and intellectual disabilities. Pediatr Surg Int 2010; 26:1041-4. [PMID: 20623128 DOI: 10.1007/s00383-010-2649-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Intractable aspiration is a life-threatening medical problem in patients with severe motor and intellectual disabilities (SMID). Laryngotracheal separation (LTS) is a surgical procedure for the treatment of intractable aspiration which separates the upper respiratory tract from the digestive tract. We performed LTS for 14 patients with SMID to prevent intractable aspiration, performing two types of operation. The standard diversion procedure connected the upper trachea to the esophagus. The modified diversion includes closure of the proximal trachea and a high tracheostomy, avoiding a tracheoesophageal anastomosis. LTS was performed on 14 patients. Operations performed before the LTS included tracheostomy in four patients, fundoplication in six and gastrostomy in two. A standard diversion was performed in 11 patients and a modified diversion in 3. There were no operative complications. Eleven patients were safely transferred to home-care after their LTS. Twelve patients are still alive and two died some months after operation. One patient died from their primary disease and the other died a tracheo-innominate artery fistula (TIAF). We recently experienced a patient who was at high risk of developing a TIAF. LTS is an effective operation, preventing intractable aspiration in patients with severe motor and intellectual disabilities. The results are similar for the standard or modified diversion procedure with the procedure chosen being related to the initial tracheostomy site. The most serious complication is a lethal TIAF.
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Affiliation(s)
- Hideki Shima
- Division of Paediatiric Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
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Tracheotomy bleeding from an unusual tracheo-arterial fistula: involvement of an aberrant right subclavian artery. The Journal of Laryngology & Otology 2010; 124:1333-6. [PMID: 20537208 DOI: 10.1017/s0022215110001362] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The development of a tracheo-arterial fistula is a rare but severe complication of tracheotomy. The reported patient presented with such a fistula involving an aberrant right subclavian artery, termed an arteria lusoria, an aortic arch abnormality which is usually asymptomatic. CASE REPORT A 30-year-old man was admitted to our institution for bleeding through his tracheotomy. He had been treated for advanced Duchenne muscular dystrophy, involving invasive assisted ventilation, since the age of 10 years. Surgical exploration and computed tomography scanning revealed a tracheo-arterial fistula involving an aberrant right subclavian artery, associated with severe scoliosis. Emergency, transient haemostasis was achieved by over-inflation of the tracheostomy tube cuff. Aneurysm ablation was successfully achieved as the result of an endovascular interventional radiology procedure. DISCUSSION Arteria lusoria is one of the most common aortic arch abnormalities. The occurrence of an aneurysm of this artery in a tracheotomised patient has not previously been described. In Duchenne muscular dystrophy patients, spinal deformities may result in thoracic compression, which may alter the anatomical relations of mediastinal vessels. Such deformities are slowly progressive. Thus, vigilance is required in the long term management of Duchenne muscular dystrophy patients with a tracheostomy.
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Abstract
Tracheostomy has gained importance due to recent developments in critical care medicine. This procedure is the most frequent surgical intervention on intensive care wards. Indications for tracheostomy (conventional versus dilatational) should consider the duration of the need for a tracheal cannula. The decision for one of the types of tracheostomy may have a relevant impact on the airway management and the rehabilitation of swallowing, because these are dependent on state of the tracheostoma and its subsequent maintenance. Selection of the appropriate cannula helps to avoid complications and improve patient comfort. To minimize the risks during tracheostomy, skills and expertise on the management of life- threatening complications are necessary. Early and late complications can be detected by regular examination of the tracheostoma which may help to repress complications in an early stage and can improve the long term outcome.
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Jonker FH, Indes JE, Moll FL, Muhs BE. Management of Iatrogenic Injuries of the Supra-aortic Arteries. J Cardiothorac Vasc Anesth 2010; 24:322-9. [DOI: 10.1053/j.jvca.2009.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Indexed: 11/11/2022]
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Wang PK, Yen PS, Shyr MH, Chen TY, Chen A, Liu HT. Endovascular repair of tracheo-innominate artery fistula. ACTA ACUST UNITED AC 2009; 47:36-9. [PMID: 19318299 DOI: 10.1016/s1875-4597(09)60019-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Po-Kai Wang
- Department of Anesthesiology, Buddhist Tzu Chi General Hospital, Tzu Chi University School of Medicine, Hualien, Taiwan, R.O.C
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When percutaneous dilation tracheotomy may be hazardous: abnormal course of the brachiocephalic trunk. Neurocrit Care 2009; 10:336-8. [PMID: 19301153 DOI: 10.1007/s12028-009-9210-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 03/02/2009] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Percutaneous dilatational tracheotomy (PDT) is becoming increasingly popular in present day critical care medicine. In contrast to the surgical approach, PDT involves a blind puncture and dilation of the pretracheal space, which may predispose to dangerous complications in the case of anatomical, in particular vascular, anomalies. METHODS AND RESULTS We report on two patients, in whom an abnormal pulsation was detected when the infracricoid region was palpated in preparation for PDT. An immediately performed ultrasound scan revealed an arterial blood vessel in front of the upper part of the trachea. A subsequent CT-angiography showed an anomalous course of the brachiocephalic trunk. While too dangerous for PDT, the local department of cranio-maxillofacial surgery was consulted for surgical tracheotomy. CONCLUSION To avoid hazardous bleeding complications in PDT we recommend at least an ultrasound scan in case of an abnormal pulsation and an enlarged thyroid gland.
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Hamano K, Kumada S, Hayashi M, Uchiyama A, Kurihara E, Tamagawa K, Enomoto S, Chou H. Hemorrhage due to tracheoarterial fistula with severe motor and intellectual disability. Pediatr Int 2008; 50:337-40. [PMID: 18533948 DOI: 10.1111/j.1442-200x.2008.02573.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Kimiko Hamano
- Department of Pediatrics, Tokyo Metropolitan Fuchu Medical Center for Disabled, Tokyo, Japan.
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29
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Kato K, Suzuki N, Aoki M, Warita H, Jin K, Itoyama Y. [Massive bleeding from tracheoarterial fistula in an amyotrophic lateral sclerosis patient treated with long-term invasive ventilation: an autopsy case report]. Rinsho Shinkeigaku 2008; 48:60-2. [PMID: 18386635 DOI: 10.5692/clinicalneurol.48.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 43-year-old woman with familial amyotrophic lateral sclerosis (FALS) who died of massive bleeding from a tracheoarterial fistula. Four years after the onset of the disease, she received invasive ventilation by tracheostomy because of respiratory failure. Four years and 7 months later, she showed an abrupt hemorrhage from the tracheostomy and died. The postmortem examination revealed a fistulous tract between the tracheal mucosal ulcer and the brachiocephalic trunk. The ulcer was in close proximity to the tracheostomy tube. In order to avoid such unexpected complications, we should observe the contact site between the tracheal mucosa and the tracheal tube in chronic tracheostomy patients.
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Affiliation(s)
- Kazuhiro Kato
- Department of Neurology, Tohoku University School of Medicine
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Johnson PE, Tabaee A, Fitz-James IA, Pass RH, de Serres LM. Major aorto-pulmonary collateral arteries (MAPCAs)--Bronchial fistula presenting as tracheotomy bleed. Int J Pediatr Otorhinolaryngol 2006; 70:1109-13. [PMID: 16297452 DOI: 10.1016/j.ijporl.2005.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 10/01/2005] [Accepted: 10/06/2005] [Indexed: 10/25/2022]
Abstract
Tracheal hemorrhage is a common occurrence in pediatric patients with long-term tracheotomies. The majority of these events are related to self-limited etiologies, such as granulation tissue or suction trauma. Tracheo-arterial fistula, however, represents a frequently fatal form of tracheal hemorrhage that may initially be difficult to distinguish from other causes. Previous reports have described the pathophysiology, presentation and management of tracheo-arterial fistula involving the innominate artery. We describe a case of a 21-month-old male with a history of significant congenital cardiac malformations and chronic tracheotomy tube dependence who presented with intermittent, brisk bleeding from the tracheotomy tube. He was ultimately diagnosed with and treated for an arterio-bronchial fistula from a major aorto-pulmonary collateral artery. We review the etiology and management of this disorder.
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Affiliation(s)
- Paul E Johnson
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Bruzzi JF, Rémy-Jardin M, Delhaye D, Teisseire A, Khalil C, Rémy J. Multi-detector row CT of hemoptysis. Radiographics 2006; 26:3-22. [PMID: 16418239 DOI: 10.1148/rg.261045726] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hemoptysis is symptomatic of a potentially life-threatening condition and warrants urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. Multi-detector row computed tomographic (CT) angiography is a very useful noninvasive imaging modality for initial assessment of hemoptysis. The combined use of thin-section axial scans and more complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be the source of hemorrhage and that may require embolization. Conditions such as bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis, and chronic fungal infection are some of the most common underlying causes of hemoptysis and are easily detected with CT. "Cryptogenic" hemoptysis is common among smokers and warrants subsequent follow-up imaging to exclude possible underlying malignancy. The bronchial arteries are the source of bleeding in most cases of hemoptysis. Contributions from the non-bronchial systemic arterial system represent an important cause of recurrent hemoptysis following apparently successful bronchial artery embolization. Vascular anomalies such as pulmonary arteriovenous malformations and bronchial artery aneurysms are other important causes of hemoptysis. Multi-detector row CT angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of hemorrhage into the airways and helps guide subsequent management.
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Affiliation(s)
- John F Bruzzi
- Department of Radiology, Hospital Calmette, University Center of Lille, Blvd Jules Leclercq, 59037 Lille, France
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Atlas GM. A mathematical model of differential tracheal tube cuff pressure: effects of diffusion and temperature. J Clin Monit Comput 2006; 19:415-25. [PMID: 16437293 DOI: 10.1007/s10877-005-1626-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2005] [Accepted: 08/01/2005] [Indexed: 10/25/2022]
Abstract
The tracheal tube cuff performs an important function during anesthesia and critical care situations by allowing positive pressure ventilation and isolating the lungs from aspiration. Other maneuvers, such as pressure support ventilation and positive end-expiratory pressure, are also cuff-dependent. However, excessive cuff pressure, as well as long-term intubation without excessive cuff pressure, have been associated with significant morbidity and mortality. A straightforward mathematical model of differential tracheal tube cuff pressure has been developed. This model incorporates compliance, temperature variation, and net molar diffusion in determining differential tracheal tube cuff pressure. In addition, temperature and diffusion are modeled as separate processes which effect differential cuff pressure independently. Support for the validity of this model is based upon an analysis of existing data from prior studies.
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Affiliation(s)
- Glen M Atlas
- Department of Anesthesiology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ 07103, USA.
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Scalise P, Prunk SR, Healy D, Votto J. The Incidence of Tracheoarterial Fistula in Patients With Chronic Tracheostomy Tubes. Chest 2005; 128:3906-9. [PMID: 16354862 DOI: 10.1378/chest.128.6.3906] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE The incidence of tracheoarterial fistula (TAF) in patients with short-term tracheostomy tubes has been reported between 0.6% and 0.7%. The purpose of this study was to determine the incidence of TAF in patients with long-term tracheostomy tubes used for the management of chronic respiratory failure. SETTING Long-term ventilator facility. DESIGN Retrospective. METHODS Medical records of 544 patients admitted to our institution between January 1981 and December 2002 were reviewed. All patients underwent tracheostomy prior to admission to our facility. Patient age, length of stay (LOS), duration of tracheostomy, and serum albumin levels were compared between patients with and without TAF; p values were obtained using the Student unpaired t test for equal variances. RESULTS TAF was diagnosed in five patients. The incidence of TAF in our population was 0.7%. The average age of these patients was significantly less than the study population (31.20 years vs 68.27 years). When one patient outlier was eliminated, LOS was not significant. CONCLUSION TAF is an uncommon complication of tracheostomy tubes. The incidence of TAF in patients with long-term tracheostomy tubes is similar to that reported in short-term tracheostomy tubes.
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Affiliation(s)
- Paul Scalise
- Department of Pulmonary Medicine, Hospital for Special Care, 2150 Corbin Ave, New Britain, CT 06053, USA.
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Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. Br J Anaesth 2005; 96:127-31. [PMID: 16299043 DOI: 10.1093/bja/aei282] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Tracheo-innominate artery fistula (TIF) is an uncommon yet life threatening complication after a tracheostomy. Rates of 0.1-1% after surgical tracheostomy have been reported, with a peak incidence at 7-14 days post procedure. It is usually fatal unless treatment is instituted immediately. Initial case reports of TIF resulted from surgically performed tracheostomies. We present three fatalities attributable to TIF, confirmed by histopathology, after percutaneous dilatational tracheostomy (PDT). The use of PDT has resulted in tracheostomies being performed by specialists from different backgrounds and the incidence of this complication may be increasing. Pressure necrosis from high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, radiotherapy and prolonged intubation are all implicated in TIF formation. Massive haemorrhage occurring 3 days to 6 weeks after tracheostomy is a result of TIF until proven otherwise. We present a simple algorithm for management of this situation. The manoeuvres outlined will control bleeding in more than 80% of patients by a direct tamponade effect. Surgical stasis is obtained by debriding the innominate artery proximally, then transecting and closing the lumen. Neurological sequelae are few. Post-mortem diagnosis of TIF may be difficult, but specific pathology request should be made to assess innominate artery abnormalities.
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Affiliation(s)
- C A Grant
- Critical Care Unit, University Hospital, Aintree, Liverpool, UK.
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Thorp A, Hurt TL, Kim TY, Brown L. Tracheoinnominate artery fistula: a rare and often fatal complication of indwelling tracheostomy tubes. Pediatr Emerg Care 2005; 21:763-6. [PMID: 16280953 DOI: 10.1097/01.pec.0000186433.82085.f6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Andrea Thorp
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA 92354, USA.
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Takasaki K, Enatsu K, Nakayama M, Uchida T, Takahashi H. A case with tracheo-innominate artery fistula. Auris Nasus Larynx 2005; 32:195-8. [PMID: 15917179 DOI: 10.1016/j.anl.2004.11.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Accepted: 11/26/2004] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Kenji Takasaki
- Department of Otolaryngology, Sasebo City General Hospital, Sasebo, Japan.
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Sawamura Y, Takase K, Higuchi N, Kikuchi S, Ito T, Tabayashi K. Surgical repair for tracheo-innominate artery fistula with a muscle flap. ACTA ACUST UNITED AC 2003; 51:630-3. [PMID: 14650597 DOI: 10.1007/bf02736707] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A 70-year-old woman was quickly diagnosed as having tracheo-innominate artery fistula by three-dimensional computed tomography. Immediate surgical exploration was performed to control the bleeding using a temporary shunt. After the damaged artery was excised, vascular reconstruction was performed to preserve the connection between the proximal and distal ends of the innominate artery with the interposition of a saphenous vein graft. A pedicled sternocleidomastoid muscle flap was successfully used for the tracheal reconstruction.
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Affiliation(s)
- Yoshihiro Sawamura
- Department of Cardiovascular Surgery, Ishinomaki Red Cross Hospital, Ishinomaki, Japan
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Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax 2003; 58:814-9. [PMID: 12947147 PMCID: PMC1746797 DOI: 10.1136/thorax.58.9.814] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- J L Lordan
- Department of Respiratory Medicine, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
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Abstract
Massive hemoptysis accounts for a minority of all patients with hemoptysis but poses a major challenge for the acute and long-term treatment. Massive hemoptysis can lead to asphyxiation and airway obstruction, shock, and exsanguination. Bronchoscopy plays an integral part in managing massive hemoptysis in diagnosis and treatment (Table 5). Specifically, bronchoscopy allows lateralization and more specific localization of bleeding that is critically important for effective management. Furthermore, acute control of bleeding can sometimes be achieved with instruments and catheters placed through the bronchoscope or by agents instilled into the airways through the bronchoscope.
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Affiliation(s)
- R A Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA
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