ABSTRACT
We report an angiographic image of a 58-year-old woman with profuse bleeding from a tracheo-innominate artery fistula. It may not have been possible to obtain this valuable image if adequate initial resuscitation and an over-inflated tracheostomy tube cuff had not been administered to stop bleeding during an emergency.
ABSTRACT
A 78-year-old man underwent a tracheostomy after embolization for a dural arteriovenous fistula. Seventy days after tracheostomy, arterial bleeding appeared through the tracheal stoma. The bleeding stopped spontaneously. However, two days later, arterial bleeding reappeared, and he was diagnosed with a tracheo-innominate artery fistula (TIF). He then underwent urgent endovascular covered stent placement. After the procedure, there was no bleeding. TIF can be a fatal complication after tracheostomy and it is generally treated with open chest surgery. However, a successful endovascular treatment for TIF has recently been reported and may yield better results.
ABSTRACT
Tracheo-Innominate artery fistula is a rare but devastating complication after tracheostomy. We report a 17-year old man who underwent the transection of the innominate artery and tracheal patch closure (under partial sternotomy) after the endovascular covered stent placement for the recurrent tracheo-innominate artery fistula. Fortunately, his postoperative course was uneventful without any new neurological, bleeding, or infective complication 34 months after the surgery.
ABSTRACT
A 15-year-old girl who had undergone a tracheostomy 4 years earlier because of holoprosencephaly and severe mental and physical disabilities had tracheo-innominate artery fistula with sudden-onset bleeding after endotracheal suctioning. Due to respiratory and circulatory instability, VIABAHN® was implanted in the brachiocephalic artery, and the patient was discharged on postoperative day 33. Three months later, rebleeding from the tracheostomy site was observed, and the patient was transported to our hospital. Although the bleeding stopped spontaneously on arrival, the patient experienced multiple bleeding episodes after admission. Therefore, transection of brachiocephalic artery was performed, after which the patient was discharged on postoperative day 20. Tracheo-innominate artery fistula is a rare complication that occurs after tracheostomy, but it is associated with a poor prognosis, and has a mortality rate of 100% if left untreated. Our case suggests that endovascular treatment using VIABAHN® for tracheo-innominate artery fistula is useful for temporary hemostasis.
ABSTRACT
Tracheo-innominate artery fistula (TIF) is a rare, life-threatening complication of tracheostomy that makes it difficult to secure the airway due to massive bleeding, constituting a medical emergency. Therefore, most successful surgical treatments include innominate artery debridement and tracheal fistula repair. Herein, we report a case of successful surgical treatment of a TIF while maintaining cerebral blood flow through an artificial vascular graft.
ABSTRACT
AIM OF THE STUDY: Laryngotracheal separation (LTS) is known to be the definitive solution for intractable aspiration pneumonia in neurologically impaired children. Postoperatively, a tracheostomy cannula is usually required. However, there are fatal cannula related complications such as a tracheo-innominate artery fistula (TIAF). We present our methods of preventing TIAF. METHODS: A retrospective review in a single center from 2011 to 2019 identified 57 cases treated with LTS. We divided them into three groups: no pre-existing tracheostomy (n = 26), pre-existing tracheostomy with preservation of the pre-existing fistula (n = 20), and pre-existing tracheostomy without preservation of the pre-existing fistula (n = 11). The first group underwent traditional modified Lindeman's procedure. The second received transection of the trachea above the tracheostomy site, while the third had transection of the trachea at the tracheostomy site and creation of a distal end tracheostomy. Proper length and the angle of the cannula were selected to prevent damaging the innominate artery by the tip of the cannula. If the innominate artery compressed the trachea anteriorly, prophylactic arterial transection was considered. RESULTS: Three patients (5.3%) died from causes unrelated to the surgical treatment. Only one patient had a postoperative TIAF followed by LTS (1.8%). Other postoperative complications were: wound infection (8.8%), intratracheal granuloma (12.3%), intratracheal minor bleeding (10.5%), wound granuloma (43.9%), leakage (1.8%). No one required revision of LTS. CONCLUSION: Success rates of LTS were high without major complications in all three groups and implies a safe operation and a definitive solution to intractable aspiration.
Subject(s)
Fistula , Vascular Fistula , Brachiocephalic Trunk/surgery , Child , Fistula/surgery , Hospitals, Pediatric , Humans , Retrospective Studies , Trachea/surgery , Tracheostomy , Vascular Fistula/complications , Vascular Fistula/prevention & controlABSTRACT
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.
ABSTRACT
OBJECTIVES: The present study analyzed surgical outcomes of laryngotracheal separation (LTS) in children with neurological disorders. The purpose of this study was to investigate respiratory impairment and severe complications after LTS in children, and identify the possibility of permanent tracheostomy without a tracheostomy tube as the safest respiratory management method. METHODS: Twenty-eight patients (male:female = 16:12) with neurological disorders (6 months to 32 years) who underwent LTS between January 2012 and April 2018 were reviewed. Tracheal diameter, Cobb angle, and sternocervical spine distance (SCD) were measured to assess the potential risk and possibility of removing tracheostomy tube management. RESULTS: Tracheostomy tube could be removed shortly after LTS in 57% (16/28). However, nine of these patients developed respiratory problems that required tracheostomy tube placement 2 years after LTS. New requirements for a tracheostomy tube as a stent were strongly correlated with SCD (P < .05, odds ratio > 1) as well as tracheal deformity. CONCLUSIONS: Respiratory management in neurologically impaired children after LTS without a tracheostomy tube is challenging because thoracic deformity during physical growth affects tracheal disfiguration. Thoracic deformities and progression of scoliosis should be considered in respiratory management approaches in children with neurological disorders, and long-term follow-up by computed tomography is necessary. LEVEL OF EVIDENCE: IV.
ABSTRACT
An 18-year-old man with hypoxic encephalopathy was admitted because of recurrent minor bleeding a tracheal stoma, which was suspected as a tracheo-innominate artery fistula (TIF). He had undergone tracheostomy and gastrostomy 2 years prior and had mild opisthotonos and scoliosis. Although tracheal endoscopy showed no tracheal mucosal erosion, necrosis, or granulation tissue formation, contrast-enhanced computed tomography (CT) revealed a close contact between the innominate artery and the anterior wall of the trachea, and an equal height between the innominate artery and the tip of the tracheal cannula. Magnetic resonance angiography of the head showed dominant intracranial blood flow from the left internal carotid and vertebral arteries. Preventive innominate artery transection through the supra-sternal approach without sternotomy or reconstruction of the innominate artery was performed for this high-risk case of TIF. The patient's postoperative course was uneventful. Postoperative CT revealed that the innominate artery was transected and isolated from the site of tracheostomy. The preserved connection between the right common carotid and subclavian artery at the distal sutured stump helped maintain blood flow in the right internal and middle cerebral arteries. The patient was discharged on postoperative day 9 without any new neurological complications or bleeding from a tracheal stoma. TIF is a rare but fatal complication after laryngotracheal separation or tracheostomy. It is important to prevent the onset of TIF, however, there are no criteria for preventive innominate artery transection. Our preventive innominate artery transection through the supra-sternal approach is considered as one of the useful surgical treatment for high-risk cases of TIF accompanied by severe neuromuscular disorders.
ABSTRACT
BACKGROUND: Tracheo-innominate artery fistula (TIF) is a life-threatening complication of tracheostomy. We describe perioperative management for innominate artery transection in a case with TIF. CASE PRESENTATION: A 4-year-old Japanese female with Marshal-Smith syndrome presented for management of TIF. She underwent tracheostomy at the age of 3 months and an uncuffed tracheostomy tube was inserted. One month before admission to our hospital, intermittent tracheal bleeding, suggesting TIF, occurred. Although we considered to change to a cuffed endotracheal tube, craniofacial abnormality suggested difficult oral intubation, and there was a possibility of rebleeding. Finally, innominate artery transection was performed under total intravenous anesthesia without changing the tracheostomy tube. Surgery completed uneventfully and she received mechanical ventilation under sedation for a day, followed by weaning without complications. CONCLUSIONS: A cuffed tracheostomy tube should have been inserted before surgery for effective hemostasis against sudden bleeding from TIF even though conversion to oral intubation was difficult.
ABSTRACT
BACKGROUND: Tracheo-innominate artery fistula (TIF) is a rare but fatal complication occurring after tracheotomy. Brachiocephalic trunk transection, one of the surgical treatments for TIF, is mostly associated with a full or partial median sternotomy. We describe a case of TIF with continuous bleeding, which was successfully treated with brachiocephalic trunk transection through a collar incision without the need for median sternotomy. CASE PRESENTATION: Case 1. An 18-year-old man was referred to our hospital with bleeding from a tracheal stoma, which had ceased prior to admission. TIF was suspected after examination. Innominate artery transection was performed through a collar incision. TIF was not revealed when we cut the innominate artery anterior wall open; therefore, we opted for preventive surgical intervention. The post-operative course was uneventful, and the patient was asymptomatic at the 3-year follow-up. Case 2. A 14-year-old male patient was admitted to our hospital with bleeding from a tracheal stoma, and TIF was suspected after examination. There was persistent bleeding when the cuff of the tracheotomy tube was deflated. Brachiocephalic trunk transection was performed through a collar incision using balloon occlusion. The post-operative course was uneventful, and rebleeding has not occurred 2 years later. CONCLUSIONS: Brachiocephalic trunk transection without any median sternotomy may offer the benefits of post-operative infection prevention. In patients with suspected continuous bleeding, using a balloon catheter may be a safe and effective method of treatment.
Subject(s)
Balloon Occlusion , Brachiocephalic Trunk/surgery , Hemorrhage/therapy , Respiratory Tract Fistula/surgery , Tracheal Diseases/surgery , Vascular Fistula/surgery , Adolescent , Hemorrhage/etiology , Humans , Male , Respiratory Tract Fistula/complications , Tracheal Diseases/complications , Tracheostomy , Tracheotomy/adverse effects , Vascular Fistula/complicationsABSTRACT
Tracheo-innominate artery fistula is a rare complication after tracheostomy, but sometimes presents with fatal bleeding. A 10-year-old girl presented with massive bleeding from a tracheostomy that she underwent for prolonged respiratory failure caused by sequelae of mumps encephalitis. Tracheo-innominate artery fistula, complicated by tracheostomy was diagnosed, and she was transferred to our institution. Under general anesthesia, she underwent transection of the innominate artery to exclude the tracheo-innominate artery fistula via median sternotomy. Her postoperative course was uneventful without recurrent bleeding or infection. Considering the risk of tracheo-innominate artery fistula, careful observation is necessary to prevent catastrophic bleeding in patients with mechanical respiratory support via tracheostomy.
ABSTRACT
Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication of tracheostomy. We describe a 44-year-old man who was admitted for a pressure ulcer infection with a third tracheostomy in place. He showed massive hemoptysis from the TIF, followed by cardiopulmonary arrest. The cuff of the tube was hyperinflated; however, even a slight movement of the tube resulted in recurrent massive hemorrhage. Thus, an endovascular stent graft was placed. Our case shows that sentinel bleeding may be found prior to TIF, and an endovascular repair can be a lifesaving temporizing option, when the hemorrhage was not controlled by hyperinflating the cuff of the tube.
ABSTRACT
Objective To explore the cause, clinical feature, rescue measures and prognosis of tracheo-innominate artery fistula (TIF). Methods From January1995 to January 2015, there were 621 patients who were performed tubotomy, and 8 patients had TIF. The diagnosis of TIF were established by surgery exploration or autopsy. Results The interval between tracheostomy and TIF was 8- 78 d. Before TIF, hemoptysis occurred in 4 patients. When TIF occurred, bedside aid was performed and 4 patients quickly died of asphyxia because of massive blood in the trachea. The others lived long enough to reach the operating room. The family of 1 patient refused surgical therapy and he eventually died. Three patients accepted median sternotomy. One patient underwent vascular repair and died after surgery because of infection in repaired area. The other patients accepted ligation of the innominate artery without suction drains in the mediastinum and died after surgery because of re-bleeding due to mediastinal infection. The last one patient underwent ligation of the innominate artery with suction drains in the mediastinum, and was still alive without long-time neurological complications and re-bleeding after a follow-up of 14 months. Conclusion A prompt diagnosis and surgical intervention can save the life of TIF patient. Prevention is very vital because of the high mortality of this disease.
ABSTRACT
OBJECTIVE: Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication following tracheostomy or tracheoesophageal diversion (TED). Although successful surgical intervention for TIF has been reported, few studies have been performed in patients with severe motor and intellectual disability (SMID). Therefore, we aimed to analyze TIF in patients with SMID to clarify the clinical variables predicting the occurrence and adequate management for lifesaving of TIF. METHODS: We retrospectively reviewed the records of patients with SMID undergoing surgical tracheostomy and TED between 2006 and 2012 and identified those with TIF. When TIF occurred, we obtained the clinical status and emergency management. RESULTS: Of 70 patients who underwent tracheostomy or TED during the study period, three patients had TIFs; in one case, TIF was avoided by ligation of the innominate artery before TED. The incidence of TIF in those undergoing tracheostomy and TED was 2.3% and 7.4%, respectively. The interval between tracheostomy and TIF was 14-50 months. CONCLUSIONS: Patients with SMID may have an increased risk of TIF. Prompt diagnosis and surgical intervention to control the bleeding is the only effective management at present.
Subject(s)
Brachiocephalic Trunk/surgery , Intellectual Disability/complications , Postoperative Complications , Quadriplegia/complications , Respiratory Tract Fistula/therapy , Tracheal Diseases/therapy , Vascular Fistula/therapy , Child , Child, Preschool , Embolization, Therapeutic , Esophagus/surgery , Female , Humans , Immobilization , Infant , Ligation , Male , Respiratory Tract Fistula/etiology , Retrospective Studies , Trachea/surgery , Tracheal Diseases/etiology , Tracheostomy/adverse effects , Vascular Fistula/etiologyABSTRACT
Complications in tracheal surgery are not uncommon but generally do not influence the final result. Most patients benefit from tracheal resections and mortality is low. Risk factors for complications are reoperations, preoperative tracheostomy, and lengthy resections. Precise information about the extent of the diseased tracheal part as well as thorough planning of the operative procedure, meticulous dissection, and knowledge of release maneuvers by an experienced thoracic surgeon will diminish the risk of adverse effects. Granuloma formation is the most common event observed postoperatively, whereas dehiscence and restenosis or the potentially fatal bleeding from a tracheo-innominate artery fistula occurs less frequently.
Subject(s)
Postoperative Complications/prevention & control , Thoracic Surgical Procedures , Trachea/surgery , Tracheal Diseases/surgery , Humans , Postoperative Care , Postoperative Complications/epidemiology , Postoperative Complications/therapy , Prevalence , Risk Factors , Tracheoesophageal Fistula/etiology , Tracheoesophageal Fistula/therapy , Tracheostomy/adverse effectsABSTRACT
OBJECTIVES: Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication of tracheostomy. There are many reports about TIF but the mechanism of TIF formation remains poorly documented. Our objective is to investigate the TIF pathologically and suggest the possible mechanism of TIF formation. PATIENT AND METHODS: The patient was an 11-year old boy with a history of severe childhood epilepsy, cerebral palsy, and psychomotor retardation who died from TIF. We investigated the TIF histopathologically through his autopsy and reviewed bibliographical considerations. RESULTS: Autopsy revealed massive blood aspiration from a large TIF and histopathological findings showed the following: (1) fibroepithelial polyps around the fistula; (2) squamous metaplasia of tracheal mucosa; (3) disappearance of tracheal cartilages and tracheal glands; and (4) arteritis (infiltration of neutrophils into the mesarterium and endarterium). Probably, (1) and (2) indicate chronic and repetitive irritations caused by cannula. (3) and (4) indicate intense inflammation caused by local infection. In this case, it is suggested that the chronic damage by cannula and the local infection resulted in the fistula formation and rupture of innominate artery. CONCLUSION: The present case suggests a pathogenesis in which chronic damage to the anterior tracheal wall by the cannula and consequent infection led to fistulation and rupture of the innominate artery.
Subject(s)
Brachiocephalic Trunk , Tracheal Diseases/etiology , Tracheal Diseases/pathology , Tracheostomy/adverse effects , Vascular Fistula/etiology , Vascular Fistula/pathology , Child , Deglutition Disorders/etiology , Deglutition Disorders/pathology , Deglutition Disorders/therapy , Fatal Outcome , Humans , MaleABSTRACT
BACKGROUND: Tracheo-innominate artery fistula (TIF) is a rare and fatal complication after tracheostomy. The diagnosis, treatment, and possible prevention of this disease are discussed in this study. METHODS: From 1976 to 2008, 14 patients with TIF were studied retrospectively. RESULTS: All patients underwent open surgical tracheostomy. Before TIF, herald events occurred in 10 patients (8 had slight hemoptysis and 2 had innominate artery exposure). When TIF occurred, bedside aid was administered, and 5 patients lived long enough to reach the operating room. Four patients accepted median sternotomy and ligation of innominate arteries. After surgery, mediastinal infection caused the rebleeding and death of 3 patients. In conducting follow-up for 11 months, the last patient was still alive without neurological complications. The survival rate was only 7.1%. CONCLUSION: Prompt diagnosis and surgical intervention can save the life of a patient with TIF. Prevention is vital because of the high mortality of this disease.
Subject(s)
Respiratory Tract Fistula/diagnosis , Respiratory Tract Fistula/surgery , Tracheal Diseases/diagnosis , Tracheal Diseases/surgery , Tracheostomy/adverse effects , Vascular Fistula/diagnosis , Vascular Fistula/surgery , Adult , Aged , Asphyxia/etiology , Brachiocephalic Trunk/injuries , Brachiocephalic Trunk/surgery , Bronchoscopy , Female , Follow-Up Studies , Head and Neck Neoplasms/complications , Hemoptysis/etiology , Hemostatic Techniques , Humans , Infections/etiology , Male , Mediastinal Diseases/etiology , Middle Aged , Respiratory Tract Fistula/mortality , Retrospective Studies , Sternotomy , Tracheal Diseases/mortality , Vascular Fistula/mortality , Young AdultABSTRACT
Tracheo-innominate fistula (TIF) is an uncommon life-threatening complication of tracheostomy. We report a 36 year-old man with post-tracheostomy TIF which was successfully repaired. After temporary control of bleeding, he was transported to our hospital by an ambulance helicopter. Emergency surgery was performed. The tracheal fistula was closed by direct suture and it was covered by sternocleidomastoid muscle flap. After sufficient irrigation, ascending aorta-innominate artery bypass was performed using 8 mm Dacron graft through a right pleural cavity. The postoperative course was uneventful. The patient was discharged from our hospital after 30 days of operation. He has been in good condition for 3 years after surgery. Reconstruction of the innominate artery with vascular prosthesis is feasible even is cases of TIF. However, preventive measures are extremely important to avoid long-term complications such as graft infection or recurrence of TIF.
