Fatal Tracheo-innominate Artery Fistula after Tracheostomy in a Patient with Pelizaeus-Merzbacher Disease

Prevention of Tracheo-Innominate Artery Fistula by Using an Adjustable Tracheostomy Tube

Tracheo-innominate artery fistula (TIF) is a severe complication associated with a long-term tracheostomy, and TIF-associated bleeding has a high mortality rate. Here, we report two patients who were considered to be at high risk of developing TIF due to retrocollis after tracheostomy. The patients were an 82-year-old woman with Parkinson’s disease (PD) and a 64-year-old man with multiple system atrophy (MSA). Both patients underwent tracheostomy at an advanced stage and later showed retrocollis. Colored and 3D-reconstructed computed tomography (CT) showed tracheal deformation into a C curve, with the tip of the tracheostomy tube attached to the anterior wall, where the innominate artery transverses. Since they were considered to be at high risk of developing TIF, we used an adjustable tracheostomy tube. Follow-up CT revealed that the tip of the new tracheostomy tube had separated from the tracheal anterior wall. Although retrocollis is rare in PD and MSA, it can develop at the end stage of these diseases. An adjustable tracheostomy tube may be an option for preventing TIF development in cases where surgical intervention would be difficult.

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.