Tracheoarterial Fistula: An Unusual Complication of Tracheostomy

Abstract

The tracheoarterial fistula is an unusual but devastating complication of tracheostomy. It occurs with a frequency of approximately 0.7%, and it is uniformly fatal if not recognized and surgically corrected. Mucosal damage from the tracheal cannula, pressure necrosis from high cuff pressure, or mucosal trauma from an improperly positioned cannula tip results in erosion through the tracheal wall into the vascular structures that lie in the pretracheal space. Bleeding from this complication almost always occurs late (> 48 hours postprocedure). It is often preceded by sentinel hemoptysis. A paucity of signs and symptoms that precede or are associated with this complication require a high index of clinical suspicion to make the diagnosis. In addition to bleeding, other potential clues include a low-lying tracheostomy tube, pulsation of the tracheostomy tube, and the presence of infection, hypotension, malnutrition, and corticosteroid use. Unfortunately, there are no consistently useful diagnostic tools for tracheoarterial fistula. Fiberoptic bronchoscopy and angiography have been performed with mixed results. Should no other cause be found to explain the hemorrhage from or around the tracheostomy, or from disease distal to the primary carina, the patient must be taken to the operating room for a more definitive examination and possible vascular repair. Management is divided into acute stabilization and support, with protection of the airway and restoration of circulating blood volume, followed by definitive repair should the patient survive. Measures to prevent tracheal damage by the tracheostomy tube, such as proper surgical technique and proper inflation of the tracheostomy tube cuff, may go a long way to avoid this potentially lethal complication. Early consideration of this entity may be what saves the life of its victim.

Major aorto-pulmonary collateral arteries (MAPCAs)—Bronchial fistula presenting as tracheotomy bleed

“…Tracheal hemorrhage is relatively common in patients with tracheotomy with a reported incidence of up to 37% [1]. The majority of these cases Summary Tracheal hemorrhage is a common occurrence in pediatric patients with long-term tracheotomies.…”

Tracheoinnominate artery fistula after laryngotracheal separation: prevention and management

“…In the bleeding group, 3 (1 male) children had major bleeding at mean age 10.3 (range, [4][5][6][7][8][9][10][11][12][13][14][15][16] years. This occurred at a mean time of 3.6 (range, 1-5) years after LTS.…”

“…The frequency of this fistula in conventional LTS is relatively high compared with that in tracheostomy [14]. The pathophysiologic mechanisms causing TIF is considered to start from erosion of the anterior tracheal mucosa extending through to the posterior wall of the innominate artery with resulting necrosis owing to pressure from the edge of the endotracheal tube, the endotracheal balloon, mechanical ventilation, and focal infection [9,10,14]. The major risk factors contributing to the formation of the TIF are (1) a low tracheostomy, (2) overinflated cuffs, and (3) thoracic deformities such as scoliosis [15,16].…”

When Percutaneous Dilation Tracheotomy Maybe Hazardous: Abnormal Course of the Brachiocephalic Trunk

“…Acute bleeding due to the injury of the brachiocephalic trunk is reported to occur in 0.1-1.0% of cases after surgical tracheotomy [8,9], while there are no comparable data concerning PDT. This complication is frequently fatal, even if treated immediately [10].…”