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Tracheo Innominate Artery Fistula
Introduction
Tracheoinnominate fistula (TIF) is a rare but life-threatening complication most frequently associated with tracheostomy, carrying a high risk of massive hemorrhage and mortality. This condition has also been reported following tracheal resection and reconstruction, penetrating neck trauma, and migration of orthopedic hardware, and, rarely, after endovascular stent graft placement.[1][2][3] The innominate artery (brachiocephalic artery or trunk) is 1 of the 3 principal branches of the aortic arch. This artery courses cephalad and anterior to the trachea, deep to the sternum, ultimately bifurcating into the right common carotid and subclavian arteries. The proximity to the trachea makes it vulnerable to injury during tracheostomy and other endotracheal procedures.[4] A fistula may develop from direct intraoperative injury or as a delayed complication due to pressure necrosis from the tracheostomy tube or cuff, resulting in catastrophic hemorrhage.[5][6]
Etiology
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Etiology
Several factors predispose patients to the development of a TIF. The most common mechanism is gradual pressure necrosis of the tracheal and arterial walls, resulting in aberrant communication and massive hemorrhage. TIF most often arises in the setting of a tracheostomy, where cuff pressures exceeding 20 to 30 cm H2O may reduce mucosal perfusion and promote necrosis.[7] Additional risk factors include malposition of the rigid tracheostomy tube, impingement of the solid tracheostomy tube against the manubrium, and repeated mucosal trauma from tube movement, such as in patients with seizure disorders.[8][9]
Anatomical factors may also predispose patients to developing a TIF, with a high-riding innominate artery being the most recognized. This standard anatomical variant occurs when the brachiocephalic trunk (innominate artery) bifurcates more cephalad than usual, sometimes above the sternoclavicular joint.[10] In this position, the vessel lies near the proximal trachea, increasing vulnerability during tracheostomy or prolonged intubation.[11]
Protection of the innominate is crucial regardless of its anatomic position, providing the rationale for placing the tracheotomy incision as proximally as feasible. Tracheostomy placement distal to the third tracheal ring (low tracheostomy) carries an increased risk of TIF, even when the innominate artery occupies its typical anatomic location.[12] More rarely, TIF may arise from unrecognized vascular or tracheal injury during open neck or mediastinum surgical procedures, or from migration of endovascular stents or orthopaedic hardware.[1][13][14] Other common causes include penetrating neck trauma, infection, prior radiation therapy, and direct tumor erosion.[15][16][17]
Epidemiology
TIF incidence ranges from 0.1% to 1% of tracheostomies.[18][19] Most cases (about 70%) occur within the first 3 weeks, with a peak incidence between 7 and 14 days postprocedure. However, delayed presentations have been documented, including cases developed more than 1 year after tracheostomy.[18]
Pathophysiology
The innominate artery typically traverses the trachea between the sixth and ninth tracheal rings. Accordingly, tracheostomy placement below the third tracheal ring increases the risk of TIF. Overinflation of the tracheostomy cuff is another recognized risk, with pressures exceeding 30 cm H2O historically linked to impaired mucosal bloodflow, leading to continued pressure necrosis and erosion into the posterior segment of the innominate artery.[20] Additional risk factors include prior neck irradiation and recurrent hypotension, which compromise mucosal microcirculation and promote necrosis.[1] Systemic corticosteroid use has also been associated with increased risk of TIF, presumably due to impaired wound healing and local tissue repair.[21]
History and Physical
Patients with TIF nearly always have a prior history of tracheostomy, with risk following both percutaneous and open procedures.[22] Up to 35% of patients develop a sentinel or herald bleed, a small volume of bleeding occurring 24 to 48 hours before massive hemorrhage.[21] Clinical presentation often includes sudden, large-volume pulsatile bleeding from the tracheostomy site, hemoptysis with potential airway compromise, or febrile episodes. Patients may rapidly deteriorate, developing hemodynamic instability and hemorrhagic shock owing to the severity of bleeding.[23] Most cases occur within 1 to 6 weeks of tracheostomy placement, with 50 % to 75% presenting between 1 and 2 weeks postoperatively.[24]
Physical examination should begin with assessing vital signs to evaluate hemodynamic stability, followed by a general mental and respiratory status evaluation. Careful inspection of the neck and tracheostomy site is essential, with attention to the amount and character of bleeding. In the setting of active, high-volume, or pulsatile bleeding, immediate consultation with thoracic surgery is arranged while resuscitative efforts are initiated. If bleeding is absent or low in volume, otolaryngocoly consultation should be obtained for endoscopic evaluation of the trachea and formal assessment of the tracheostomy site.
Evaluation
Urgent evaluation and treatment are crucial to improving outcomes in TIF. Diagnostic modalities include bronchoscopy, conventional angiography, and computed tomography (CT) angiography, though all have limited sensitivity in diagnosing the condition. Therefore, maintaining a high index of clinical suspicion, supported by thorough history and physical examination, is critical.
Low-volume or venous-appearing bleeding, particularly from a recent tracheostomy, is more commonly due to surgery-related venous oozing, and often from the thyroid or skin edges, rather than a true TIF.[25] On bronchoscopy, direct visualization of the active bleeding site on the anterior wall of the trachea may be seen. Angiography and CT angiography may reveal contrast extravasation or a vascular blush from the innominate artery into the trachea, though reported sensitivity is only 20% to 30%.[26][27][28]
Treatment / Management
Immediate management is critical and depends on prompt recognition of TIF. Hemorrhage can be temporarily controlled with the Utley maneuver, in which a finger is inserted through the tracheostomy incision to compress the innominate artery against the posterior sternum. A similar tamponade effect can be achieved by overinflating the tracheostomy cuff.[29] Additional assistance should be summoned immediately, as simultaneous control of the airway and bleeding requires multiple providers. The most effective temporizing measure is placement of a cuffed endotracheal tube distal to the bleeding site. Blood products should be made rapidly available in anticipation of massive transfusion.
Currently, most institutions have a massive transfusion protocol that can be quickly activated. Depending on the institution, management of TIF may be spearheaded by trauma and acute care surgery, cardiac surgery, thoracic surgery, or vascular surgery teams. Definitive management can be achieved either through open surgical techniques or endovascular approaches.[30]
The open surgical approach typically involves median sternotomy, or a variation such as a collar incision with a partial sternotomy, followed by ligation and division of the innominate artery.[31] Ligation without division of the innominate artery is contraindicated because the artery can refistulize.[32] Sometimes, the innominate artery may need to be buttressed with a patch of pericardium or vein, though cotton pledgets can also be used. The tracheal defect is usually covered with a local or regional flap, most commonly the pectoralis major muscle.[33] Extensive tracheal resection or reconstruction is rarely necessary. Additional protective materials against infection may include pericardium, thymus, or pleura. Neurologic complications occur in up to 10% of patients following ligation of the innominate artery.[32] Despite the risk, survival depends on rapid hemorrhage control, and the procedure remains the standard lifesaving intervention in most cases.(B3)
Some authors have described revascularization procedures such as innominate-to-carotid, aorta-to-innominate, aorta-to-axillary, or carotid-to-carotid artery bypass. However, these approaches are not considered standard practice due to the heightened risk of infection in the setting of TIF. When performed, both synthetic grafts (eg, polytetrafluoroethylene), cryopreserved arterial allografts, and autologous vein grafts have been successfully utilized. Postoperative complications include mediastinitis, fistulization, and sternal wound infection.[5][27][34](B3)
Endovascular techniques have also been successfully employed, particularly in patients who are prohibitively high-risk for open surgery. They may be preferable in patients with a history of a median sternotomy, thoracotomy, or prior neck or chest irradiation.[35] Successful endovascular stent-graft placement requires selective catheterization of the innominate artery and adequate seal zones.[36](A1)
Some authors have described hybrid procedures employing endovascular and open surgical techniques. In these cases (such as a carotid-subclavian bypass), a surgical bypass is performed along with placement of an endograft stent, as the bypass provides longer landing zones.[37] The stent can be placed via the femoral artery or through direct cutdown on other vessels such as the carotid, brachial, or axillary arteries. Completion angiography is performed after the procedure to confirm technical success. Complications of hybrid procedures include access site complications (such as hematoma), stent migration, maldeployment, or fracture. Recurrent TIF has been reported in the setting of a stent-graft fracture.[38] Additionally, inadequate seal zones may result in endoleak, leading to persistent hemorrhage.
In select cases, endovascular stenting may be used as a bridge to stabilize the critically ill patient, allowing time for resuscitation and eventual definitive open surgical intervention in an elective or semi-elective setting. In critically ill individuals with ongoing bleeding, temporary control can also be achieved by placing an occlusion balloon (eg, Fogarty catheter) in the innominate artery under fluoroscopic guidance, via either transfemoral or transbrachial routes.[39] This maneuver can be lifesaving, providing time to mobilize resources for definitive intervention. Additionally, some authors have described coil embolization of the innominate artery under fluoroscopy combined with selective bypass procedures to preserve cerebral circulation.(B3)
Differential Diagnosis
Bleeding around the tracheostomy site may be mistaken for hemorrhage from stomal granulation tissue. Early postoperative bleeding is more commonly related to inadequate procedural hemostasis or underlying coagulopathy.
Prognosis
Patients should be monitored closely in the intensive care unit after intervention, as rebleeding may occur despite apparently successful procedures. Prognosis remains guarded even with prompt recognition and treatment. Most patients are critically ill and debilitated at the time of the hemorrhagic event, often with multiple comorbidities; perioperative mortality exceeds 50%.[19]
Complications
As TIF itself is a complication, most often of tracheostomy surgery, few additional complications are described. However, if left untreated, TIF is uniformly fatal, with a mortality rate of 100%.[40]
Deterrence and Patient Education
TIF should be prevented through meticulous technique and careful postoperative management. Recommended measures include:
- Limiting the duration of endotracheal intubation to less than 3 weeks.
- Using proper technique during tracheostomy placement.
- Selecting blunt, flexible tracheostomy tubes.
- Positioning the tracheostomy between the second and third tracheal ring.
- Minimizing repetitive head and neck movements to reduce contact between the underside of the tube and the innominate artery.
Pearls and Other Issues
Key facts to keep in mind about TIF include the following:
- Rare, fatal complication of tracheostomy
- Incidence ~0.1% to 1%
- Onset usually 1 to 6 weeks (peak 7–14 days)
- Cause: pressure necrosis between the cuff/tube and the innominate artery
- Herald bleed: Small bleed 24–48 h before massive bleed
- Presentation: Pulsatile bleeding at the stoma, hemoptysis
- Risk factors: Low trach, cuff pressure >30 cm H2O, high-riding innominate, radiation, infection, hypotension, steroids
- Diagnosis: Clinical (imaging sensitivity low)
- Acute management: Utley maneuver, overinflate cuff, secure airway, massive transfusion, call surgery
- Definitive treatment: Innominate artery ligation/division (surgery), or endovascular stent
- Prognosis: Mortality >50% even with treatment
Enhancing Healthcare Team Outcomes
TIF is a rare but often fatal complication if unrecognized. Awareness is essential for physicians, nurses, and respiratory therapists caring for patients with a tracheostomy. Prevention remains the key. A flexible, appropriately long connecter tube should be attached to the tracheostomy to allow mobility and minimize stress on the site.
Any observation of bright red bleeding around the tracheostomy or palpable pulsations of the tracheostomy tube should prompt immediate notification of the surgical team. Tracheal cuff pressures must be monitored regularly, and all bleeding from the tracheostomy site must be reported to the critical care physician. If TIF is suspected, the nurse, respiratory therapist, and physician must promptly secure the airway and control bleeding until thoracic surgical consultation is obtained.[34][41]
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