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

Abstract

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

Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review

“…Through the literature search, 614 articles were found in Pubmed, 488 in Medline, 869 in Embase, and 5 by searching the references in publications included in the analysis (Figure 1). The following subgroups were created based on the bleeding conditions: 1 patient with tracheal injury, 13 11 patients with postpartum or cesarean delivery hemorrhage, 14–19 7 patients with intracranial hemorrhage, 20–25 53 patients with pulmonary hemorrhage, 5,26–66 13 patients with postpulmonary endarterectomy bleeding, 67–72 and 96 patients with bleeding trauma 51,73–96 (Table 1; see Supplementary Tables 1–5, Supplemental Digital Content, http://links.lww.com/ASAIO/A515). Overall, 183 patients were identified in 86 included publications, namely, 74 case reports, 4 case series, 7 retrospective database observational studies, and 1 preliminary results of ongoing study.…”

“…A hybrid form of ECLS was applied in two patients. 13,77 The number of conversions to a different mode was 15 (Supplemental Figure 1, Supplemental Digital Content, http://links.lww.com/ASAIO/A515).…”

“…During the use of heparin in the complete ECLS, activated clotting time (ACT) targets were reported in 35 patients, 13,17,27,31,37,42,45,47,54,55,58,59,61,62,66,73,79,82,89,90,92,93 and activated partial thromboplastin time (aPTT) targets were reported in 10 patients. 20,21,26,40,73,95 In the subgroup with different anticoagulation other than heparin, ACT targets were defined in four patients, 36,38,48,52 whereas no specific mention of anticoagulation assessment was available in the other studies.…”

“…6,70 Even in exceptional situations such as tracheal bleeding in a fistula or stent migration, ECLS appears to be useful in supplying hemodynamic stability until further treatment such as surgery can take place. 13,60 A prediction model for hemorrhage risk is expected to be a useful addition for deciding the most suitable protocol or alteration. Lonergan et al developed the hypertension, age, ECLS type (HAT) score, which shows promising validation.…”

Aortotracheal Fistula after Slide Tracheoplasty in a Patient with Dextrocardia, Left Pulmonary Artery Sling and Tracheal Stenosis: A Case Report

“…In terms of pathophysiology, catastrophic bleeding from stulas between great vessel and major airway often involves pressure necrosis or chronic infection / in ammation of tracheal mucosa [6,7]. Congenital anomalies that change the anatomic relationship between trachea and aorta had been reported to be associated with ATF, such as double aortic arch, and left pulmonary artery sling [1,8,9].…”