A strategy to prevent tracheo-innominate artery fistula in the course of laryngotracheal separation: 9-year experience in a children's hospital.

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.

A Computed Tomographic Assessment of Tracheostomy Tube Placement in Patients with Chronic Neurological Disorders: The Prevention of Tracheoarterial Fistula.

Objective Tracheoarterial fistula (TAF) is a rare but devastating complication of tracheostomy caused by pressure necrosis from the elbow, tip, or over-inflated cuff of the tracheostomy tube. The incidence of TAF is reportedly higher in patients with neurological disorders than in those without such disorders. To evaluate the incidence of and factors contributing to the misalignment of tracheostomy tubes in bedridden patients with chronic neurological disorders. Methods We retrospectively assessed three-dimensionally reconstructed serial computed tomography (CT) images to see if the tip of the tube made contact with the tracheal wall and if the main arteries were running adjacent to the tube's elbow, tip or cuff. Results The tip of the tube was in contact with the tracheal wall in 14 of the 30 patients assessed. Among them, the tip was adjacent to the innominate artery in eight, the aortic arch in three and an aberrant right subclavian artery in one. In one patient with the tube tip adjacent to the aortic arch and the other four patients, the cuff of the tube was adjacent to the innominate artery across the tracheal wall. Patients with the tube tip in contact with the anterior tracheal wall had a significantly greater cervical lordosis angle than those without contact (p<0.05). Conclusion More than half of tracheostomized patients with chronic neurological disorders had a latent risk of TAF. The variability in the location of the innominate artery, anomalies of the aortic arch, and skeletal deformities may therefore be contributing factors.

Recognition and Management of Life-Threatening Tracheovascular Fistulae and How to Prevent Them.

Formation of a fistula between trachea and a major artery or vein in the root of the neck threatens life quickly from combination of major external bleeding and hemorrhagic shock, and asphyxiation from flooding of the proximal airways with blood. This complication can occur after cervical tracheostomy open or percutaneous, tracheal resection, cervical exentration and anterior mediastinal tracheostomy, and laryngectomy. The recognition of its occurrence is clinical based on a high index of clinical suspicion. The life-saving operation for this complication carries potential risk for ischemic stroke. Impairment of arterial perfusion to the right arm and ischemia is another potential complication.

[Experience of 3 successfully treated cases of tracheo-innominate artery fistula and significance of preventive surgery].

Tracheo-innominate artery fistula (TIF) is a rare but fatal complication after tracheostomy. Necessary lifesaving measures include proper ventilation, temporary hemostasis, and surgery. Recently, we successfully managed 3 cases of TIF. Ventilation and temporary hemostasis were secured by a long endotracheal tube and overinflated cuff. Division of the innominate artery, restoration of the tracheal fistula with an autologous pericardial patch or direct closure, and aorto-innominate bypass grafting or extra-anatomical bypass grafting with a polytetrafluoroethylene (PTFE) graft were performed through an emergency median sternotomy. All 3 patients recovered with no problems. After TIF occurs, the patient's condition rapidly worsens, and the risk of bacterial contamination in the operative field may increase. Surgical intervention should be performed for patients with tracheal stenosis who are judged to be at high risk for TIF. This preventive surgery includes bypass grafting to divide the innominate artery and partial resection of the anterior bony thorax(upper sternum, medial part of clavicles, and anterior part of upper ribs if necessary). We believe that this procedure will improve tracheal stenosis and minimize the risk of TIF. Thus far, 10 patients have undergone this operation, and their mid-term results are satisfactory.

Tracheoinnominate artery fistula after laryngotracheal separation: prevention and management.

AIM: Tracheoinnominate artery fistula (TIF) is an often fatal complication of laryngotracheal separation (LTS) for which there has been no systematic therapeutic strategy for prevention or management of TIF. The aim of this study was to establish such a strategy based on our clinical experience. MATERIALS AND METHODS: From 2000 to 2010, 14 patients received LTS. We reviewed these patients to develop a therapeutic approach to prevent or manage TIF. RESULTS: Three patients had major bleeding, and another 3 received preventive treatment before major bleeding. In the major bleeding group, 1 patient died of choking from uncontrollable hemorrhage, but the others were rescued by brachiocephalic trunk separation and/or endovascular embolization. At operation, median sternotomy with its high risk of mediastinitis was avoided. In the preventive treatment group, prophylactic brachiocephalic trunk separation was performed for 2 patients because their severe scoliosis narrowed the mediastinum, compressing the innominate artery on computed tomography. Another avoided major bleeding by converting the tracheostomy tube to a length-adjustable type. CONCLUSION: Tracheoinnominate artery fistula is a dramatic, often lethal complication. The strategic approach should be designed to prevent it and includes evaluation of the spinal deformity on computed tomography, brachiocephalic trunk separation at the same time as LTS, and recognizing the importance of "herald" or warning minor bleeds.

Lymphatic complications after varicose veins surgery: risk factors and how to avoid them.

INTRODUCTION: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoying event with a variable frequency in the literature. METHOD: Retrospective study reviewing all surgeries carried out for VVs from January 2000 to October 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including the minor ones and lymphoedema. RESULTS: During the period studied, 5407 surgical procedures for VVs were performed in 3407 patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118 cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and a lymphoedema in 0.2%. The population with a LC was older (59.6 vs. 53.3 years, P < 0.05), had a higher frequency of C4-C6 (22.0% vs. 6.5%, P < 0.05), a higher incidence of obesity (31.4% vs. 5.4%, P < 0.05) and was more often treated by a redo surgery or a crossectomy stripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P < 0.05). We have observed a dramatic decrease in incidence of LC after January 2004 (1.3% vs. 5.3%, P < 0.05) corresponding to a new surgical practice for the treatment of VVs: stripping, crossectomy and redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and 11.3% vs. 0.1%, respectively, P < 0.05), while isolated phlebectomy was more often performed during this period (78.4% vs. 8.4%, P < 0.05). CONCLUSION: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs. Older age, more advanced clinical stage and obesity were associated with a higher frequency of LC. A mini-invasive and selective surgery has significantly reduced the occurrence of LC.

[Survival analysis for patients with severe motor and intellectual disabilities following tracheotomy].

To investigate the survival rate and causes of death in patients with severe motor and intellectual disabilities (SMIDs) that necessitated tracheotomy, we retrospectively analyzed 90 patients who underwent tracheotomy between 1990 and 2009. Indications for tracheotomy in these patients were upper airway obstruction (44 patients), recurrent aspiration pneumonia (28 patients), retained secretions (23 patients), prolonged mechanical ventilation (18 patients), chronic respiratory failure (9 patients), central respiratory failure (5 patients), and gastroesophageal reflux (8 patients). Most of the patients underwent tracheotomy at the age of 0-5 years or 10-19 years. As of April 1, 2010, 28 patients had died. The survival rate was 0.91 at 1 year, 0.74 at 5 years, 0.59 at 10 years, 0.54 at 15 years, and 0.40 at 19 years after tracheotomy. Massive tracheal bleeding due to development of tracheo-innominate artery fistulas occurred in 5 patients, and 4 of them died. They were thirteen years of age or older when they underwent tracheotomy, and developed fistulas after 2 weeks or later. In contrast, 7 patients at high risk for fistula formation, including those that had developed severe tracheomalacia associated with granulation or warning hemorrhages, underwent preventive resection of the innominate artery, and all of them had survived. It is important to regularly evaluate patients with SMIDs who have undergone tracheotomy by using bronchofiberscopy to identify risk factors for tracheoinnominate artery fistulas, a preventable cause of death.

Computed tomographic analysis of the esophagus, left atrium, and pulmonary veins: implications for catheter ablation of atrial fibrillation.

PURPOSE: The aim of this study was to investigate the anatomic relationship around the left atrium (LA) and to provide clinical information to help avoid the risk of an atrio-esophageal fistula during atrial fibrillation (AF) ablation. METHODS: The multidetector spiral computed tomography images of 77 male patients (mean age, 54 ± 9 years) with drug-refractory AF and 37 male control subjects (mean age, 50 ± 11 years) were analyzed. We measured the following variables: (1) distance between the ostia of the pulmonary veins (PVs) and the ipsilateral esophageal border, (2) presence of a pericardial fat pad around each PV, and (3) contact width/length and presence of a fat pad between the LA and the esophagus. RESULTS: The distance between the esophagus and the ostia of right superior PV, right inferior PV (RIPV), left superior PV, and left inferior PV (LIPV) was 27.2 ± 9.4 mm, 22.9 ± 10.3 mm, 2.7 ± 9.4 mm, and 7.1 ± 8.8 mm, respectively. A fat pad between the esophagus and the superior PV was present in more than 90% of the subjects in both groups. However, the fat pad around inferior PV was present less frequently in the patients than in the control group (p = 0.011, RIPV; p < 0.001, LIPV). The average length of the LA-esophagus contact in the patients and the control group subjects was 26.2 ± 10.4 and 18.5 ± 5.1 mm, respectively (p < 0.001). CONCLUSION: Caution should be exercised when ablating the LIPV because the esophagus is located in close proximity to the left-sided PV and most of the inferior PVs in patients with AF are not covered with fat pads.

Suprasternal approach for impending tracheo-innominate artery fistula.

We report preventive innominate artery division or ligation through a suprasternal approach for impending tracheo-innominate artery fistula (TIF) with recurrent airway oozing in patients with severe neuromuscular disease. Our approach is less invasive and a favorable procedure as preventive surgery for impending TIF.

[Delineation of the anatomical relationship of innominate artery and trachea by respiratory-gated MR imaging with true FISP sequence in patients with severe motor and intellectual disabilities].

Tracheoinnominate artery fistula is a well-known complication that arises on using a cannula. Therefore, routine examination of the anatomical relationship of the innominate artery and trachea should be carried out. We evaluated the usefulness of magnetic resonance imaging in 5 patients with severe motor and intellectual disabilities (SMID) using a combination of true-fast imaging of steady-state precession (true-FISP) sequences and two-dimensional prospective acquisition correction (2D-PACE). For all patients, the trachea and the innominate artery were identified without sedation and contrast media. In one patient, the innominate artery was observed to be pressing on the trachea. In three patients, the trachea and innominate artery were brought very close each other, and in the other patient the anatomical relationship of the trachea and surrounding structure was delineated before tracheotomy. The validity of true-FISP sequences combined with the respiratory-gated technique was confirmed useful for the patients who are difficult to lie quietly and to hold their breath voluntarily.

Recurrence of postoperative aortic fistulas: is there an ideal method of prevention? A case report.

There are very few cases in English literature of recurrent postoperative aortic fistulas (RPAFs). These are neo-communications between the aortic bloodstream and the lumen of contiguous organs which occur after unpredictable periods from surgical treatment of a previous fistula. The supradiaphragmatic aorta may fistulize into the airways, pulmonary circulation, oesophagus, and cardiac chambers; the infradiaphragmatic aorta into the intestine, stomach, and vena cava. According to the etiology, aortic fistulas are categorized as postoperative (or secondary) and spontaneous (or primary), and RPAF may be considered a subgroup of secondary fistulas. They may recur even more times in the same patient, hence the role of prevention is of the utmost importance. The simultaneous respect of different surgical principles is crucial to make the risk of recurrence less likely. Surgical treatment represents a real challenge due to the emergency conditions and redo nature of operations. Mortality rate is very high. In this article, we describe a case of recurrent aorto-duodenal communication, we discuss the principles of prevention both for the supra and infradiaphragmatic aorta, we introduce some modifications to the classic categorization and we present the first RPAF literature review.

Venobronchial fistula: an unusual complication of long-term central venous access.

A venobronchial fistula developed between the azygous vein and the upper aspect of the right main bronchus 12 months after completion of the treatment of a stage IIIB non-small-cell lung cancer in a 54-year-old man. The fistula contained the tip of the catheter placed for chemotherapy perfusion. The reported case presented risk factors previously identified for such a complication. In addition, some clinical particularities were present, suggesting new potent risk factors and some preventive means for safe long-term central venous catheterization.

[Prevention and management of frequent complications after endovascular repair of infrarenal abdominal aortic aneurysm].

OBJECTIVE: To prevent and manage frequent complications after endovascular repair of infrarenal abdominal aortic aneurysm (AAA). METHODS: The data of 71 cases of infrarenal abdominal aortic aneurysm (AAA) treated by endovascular repair were analysed retrospectively. The reasons, managements, results and prognosis of frequent complications were investigated. RESULTS: Seventy-one cases of infrarenal AAA were treated by endovascular repair with 100% success rate. There was no surgical conversion to open aneurysm repair. There were 8 cases of primary endoleak, 1 case of nervous complication and acute thrombosis. An average follow-up period was 26 +/- 5 months. Three persistent endoleaks and 4 secondary endoleaks were found during the follow-up period. The endoleak rate was 9.8% (7/71) within 1 month postoperatively and mortality rate was 1.3% (1/71). Total mortality rate was 4.2% (3/71). Two patients died from acute myocardial infarction and one from acute heart failure. CONCLUSIONS: Endovascular treatment of abdominal aortic aneurysm is technically feasible and can effectively exclude aortic aneurysms from the circulation. Endoleak is a chief complication after endovascular repair of infrarenal AAA.Additional procedures and follow up are very important. Endoleak with enlarged aneurysm should be treated actively.

Venobronchial fistula: an unusual early complication after central venous catheterization.

Venobronchial fistula is a rare complication of long-term central venous catheterization. We present the uncommon occurrence of a venobronchial fistula as an acute complication of central venous catheterization during open heart surgery. The factors responsible for this unusual complication and the methods to prevent it are discussed.