Tracheo-Innominate Artery Fistula: Two Case Reports and a Clinical Review

Abstract

Tracheo-innominate artery fistula (TIF) is a surgical emergency with high mortality rates. Reported incidence is 0.1%-1.0% after tracheostomy with peak incidence 3 days to 6 weeks post procedure. TIF is usually fatal once it bleeds. For the successful management of TIF, treatment should be initiated immediately with the special considerations kept in mind. We describe two cases of TIF, and its clinical characteristics are reviewed in accordance with relevant literature.Keywords: tracheo-innominate artery fistula (TIF), tracheostomy, high-lying innominate artery source of bleeding, we performed flexible bronchoscopy that showed no active bleeding distal to the cannula tip. However, bleeding occurred again inside the tracheal tube. With the cuff of the tube maintained in the maximum hyperinflated state and the tracheostomy wound digitally compressed, the patient was immediately transferred to the operating room for surgical hemostasis. Unfortunately, we had no time to perform a computed tomography (CT) scan for this patient because this was an emergency case. A review of the CT scan, which had been taken about a year before, suggested that the TIF was probably above the sternal notch (Fig. 1). Therefore, unlike in the standard procedure, herein we made a suprasternal incision. After identifying the trachea and the overriding innominate artery, we successfully encircled the artery proximally and distally to the trachea and found the fistula posterior to the high-lying innominate artery. We debrided the fistulous segment of the innominate artery and reconstructed the artery in end-to-end fashion. Finally, the fistula of the trachea was repaired by suturing and the sternocleidomastoid flap was positioned between the trachea and artery to provide a mechanical barrier (Fig. 2). After controlling the blood flow of the fistulous segment of the artery, intra-tracheal bleeding was not observed. The amount of intra-operative bleeding was about 300 mL, and the operative time was 93 min. The post-operative course was uneventful with no sign of rebleeding. However, according to the findings of the CT

Endovascular stenting of tracheoinnominate fistula after tracheostomy in a 14-year-old boy

“…This is due to the mechanical force generated by the cuff or tip of the tracheostomy tube. The necrosis of the trachea can occur by a low-lying tracheostomy tube below the 3rd to 4rd trachea rings, overinflated cuffs, high-riding innominate artery, local infections by the tracheal defects, prolonged tracheostomy, or neck and chest deformities41112). In our case, the tracheostomy site was located below the 4th tracheal ring, and the innominate artery was located at midtrachea.…”

“…When unexpected bleeding occurs around a tracheostomy site between 3 days and 6 weeks following the tracheostomy, the clinician should consider that the bleeding could be associated with TIF. Sentinel bleeding is reported in more than 50% of patients who develop massive hemorrhage in TIF12). Thus, even a small amount of fresh bleeding should not be ignored.…”

Airway management in a patient with a deep neck abscess and tortuous brachiocephalic artery: Case report and review of the literature

“…There is a slight risk of large vessels being injured during tracheotomy, although this is a rare event. Injury to a large vessel most frequently causes a delayed tracheo-brachiocephalic artery fistula [18]. On the other hand, injury to a large vessel may occur at the time of tracheotomy.…”

Hemorragia masiva por traqueostomía: caso clínico

“…Su incidencia es baja (0,1-1%), con un pico de presentación entre el día 7 y el 14, hasta la sexta semana [14][15][16]. El sangrado ocurre en las primeras tres semanas después de la traqueostomía, en el 72% de los casos [17].…”

“…Los factores de riesgo para el desarrollo de fístula traqueo-innominada (fti) son la traqueostomía baja (debajo del tercer o cuarto anillo traqueal), el balón de la cánula de traqueostomía sobre-inflado, una traqueostomía prolongada, deformidades del cuello, la localización alta de la arteria innominada y malformaciones de la pared torácica [16]. Algunos han diseñado otras técnicas quirúrgicas para minimizar el sangrado, como la incisión transversal en la tráquea, en lugar de longitudinal, y evitar la traqueostomía por debajo del tercer anillo traqueal [20,21].…”