Two Cases of Successful Treatment of Tracheo-Innominate Artery Fistula

(Department of Cardiovascular Surgery, Kagawa Childrenfs Hospital, Zentsuji, Japan)

Homare Yoshida Yoshiyasu Egawa Tomohisa Kawahito
Tracheo-innominate artery fistula (TIF) is a relatively rare, highly lethal complication after tracheostomy. We report two cases of successfully managed TIF with relatively long-term survival after a massive hemorrhage from the tracheostomy site. Different approaches were employed for the temporary control of bleeding and in the subsequent surgery in these two cases, thus we examined the pros and cons of each approach. In Case 1, the bleeding was temporarily controlled using a long tracheostomy tube and orotracheal tube and by applying digital compression to the tracheostomy site. The right common iliac-to-right axillary artery bypass was then performed, followed by a median sternotomy to resect the injured innominate artery and to directly close the tracheal fistula. In Case 2, an over-inflated cuff was used after inserting the long tracheostomy tube to its full extent from the tracheostomy site, which was able to stop the bleeding for a while. This resulted in massive rebleeding when the cuff was remored while the patient was being transferred to the operation room. The patient underwent median sternotomy followed by anatomic innominate artery reconstruction using an ePTFE graft, and closure of the tracheal fistula was performed using autologous pericardium patch. In the treatment of TIF, prevention must be the greatest priority. If premonitory bleeding occurs (in the form of minor fresh bleeding), the patient must be evaluated immediately using bronchoscopy and CT imaging, and surgical intervention should be considered depending on the condition. If the bleeding is severe, the airway should be maintained and the bleeding should be temporarily controlled. We were able to control the bleeding in Case 1; however, in Case 2, we were unable to so since the tracheostomy tube was not long enough. After the surgery, we thought that the outcome might have been different if we had used the orotracheal tube instead of the tracheostomy tube and we believe this is one point that should be carefully considered. As for the procedures chosen for the TIF surgeries, anatomic revascularization of the innominate artery and closing the tracheal fistula are the procedures of choice when the operation field is not contaminated. However, when the field is contaminated (for example, in the case of a large fistula), extra-anatomic revascularization may be the only choice. This indicates that early evaluation and intervention of TIF are also important in terms of preventing infections and long-term prognosis.
@Jpn. J. Cardiovasc. Surg. 36: 265-268 (2007)