RESUMO
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.
RESUMO
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.