Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft

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.

A Case of Tracheo-innominate Artery Fistula after Tracheostomy Successfully Treated with a Covered Stent

“…This involves having a median sternotomy, cutting the innominate ar-tery, and achieving hemostasis, and sometimes, it requires revascularization by bypass surgery. 1,2) Although the direct repair of the artery provides reliable hemostasis, it must be performed under general anesthesia, and open surgery is difficult to perform on unstable patients in emergency situations. 1,6) The post-surgical mortality rate is reported to be over 50%, 7) and complications such as cerebral ischemia and ischemia of the right upper extremity can be problematic.…”

“…1,2) Although the direct repair of the artery provides reliable hemostasis, it must be performed under general anesthesia, and open surgery is difficult to perform on unstable patients in emergency situations. 1,6) The post-surgical mortality rate is reported to be over 50%, 7) and complications such as cerebral ischemia and ischemia of the right upper extremity can be problematic. Previous reports indicate that cranial nerve complications after the ligation of the innominate artery occur in approximately 10% of patients.…”

“…TIF occurs in 0.1%-1% of post-tracheostomy cases, and once it occurs, the prognosis is poor, with a mortality rate of almost 100% if no surgical treatment is provided. 1,2) Traditionally, TIF is treated by median sternotomy and ligation of the innominate artery, but recently, the development of endovascular treatment has been reported.…”

Percutaneous tracheostomy: Comparison of three different methods with respect to tracheal cartilage injury in cadavers—Randomized controlled study

“…If the tracheostomy tube is positioned under the 4th tracheal cartilage the risk of the development of the tracheoinominate artery fistula is higher. These late complications cannot be investigated on cadavers (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27).…”

Prevention of Tracheo-Innominate Artery Fistula Formation as a Complication of Tracheostomy: Two Case Reports

“…To date, research on TIF has mainly focused on its management [ 9 , 10 , 11 , 12 , 13 , 14 ], with studies on its prevention being limited. In a previous document, it was reported that prophylactic brachiocephalic trunk separation was performed as a method to prevent the occurrence of TIF [ 15 ].…”