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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 7-9

Tracheoinnominate fistula due to high-riding innominate artery: A rare but potentially life-threatening complication following long-term tracheostomy


1 Department of Surgical Intensive Care, Rashid Hospital, Duba, UAE
2 Department of Cardiothoracic Surgery, Dubai Hospital, Duba, UAE

Date of Submission20-Oct-2020
Date of Acceptance09-Feb-2021
Date of Web Publication23-Apr-2021

Correspondence Address:
Bhushan Sudhakar Wankhade
Surgical Intensive Care Unit, Rashid Hospital, Oud Metha, P.O. Box: 4545, Dubai
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_58_20

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  Abstract 

Tracheoinnominate fistula (TIF) is a rare but potentially life-threatening complication after tracheostomy. TIF was mostly observed within 7–21 days after tracheostomy but can present even years after tracheostomy. The risk factors for TIF are high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, excessive neck movement (hyperextension), radiotherapy, prolonged intubation, and high-riding innominate artery (HRIA). HRIA is also a rare anatomical variation of the innominate artery (IA) whereas IA bifurcates above the sternoclavicular joint. We report a rare case of TIF in a patient with HRIA, who presented with airway bleeding 2 months after percutaneous tracheostomy (PT) and was successfully managed with aggressive resuscitation and midline sternotomy. Knowledge of anatomical variation of the aortic arch and its major branches is essential for the physician who is routinely performing or managing tracheostomy. All the health-care workers involved in the management of tracheostomy should bear this complication in mind while dealing with any airway bleed. We recommend the routine use of bedside neck ultrasonography before all PTs to locate any aberrant vessel within the vicinity of tracheostoma to prevent this complication.

Keywords: igh-riding innominate artery, percutaneous tracheostomy, tracheoinnominate fistula


How to cite this article:
Wankhade BS, Abdel Hadi AM, Alrais ZF, Kumar Naidu GA, Eid H. Tracheoinnominate fistula due to high-riding innominate artery: A rare but potentially life-threatening complication following long-term tracheostomy. Saudi Crit Care J 2021;5:7-9

How to cite this URL:
Wankhade BS, Abdel Hadi AM, Alrais ZF, Kumar Naidu GA, Eid H. Tracheoinnominate fistula due to high-riding innominate artery: A rare but potentially life-threatening complication following long-term tracheostomy. Saudi Crit Care J [serial online] 2021 [cited 2021 May 14];5:7-9. Available from: https://www.sccj-sa.org/text.asp?2021/5/1/7/314442


  Introduction Top
Tracheoinnominate fistula (TIF) refers to the formation of a fistulous tract between the innominate artery (IA) and the trachea. TIF is a rare but potentially fatal complication following tracheostomy.[1] High-riding innominate artery (HRIA) is another rare anatomical variation of IA which increases the risk for development of TIF.[2] We report a rare case of TIF due to HRIA 2 months after percutaneous tracheostomy (PT). [TAG:2]Case Description [/TAG:2] A 58-year-old male underwent uneventful PT for low Glasgow Coma Scale (8/15) following surgically managed spontaneous subdural hemorrhage. He was also known as the case of obesity, hypertension, diabetes mellitus, dyslipidemia, old stroke-left middle cerebral artery territory infarction, and major neurocognitive disorder. He was on antiplatelet: aspirin 75 mg milligrams (mg) once a day (OD) and enoxaparin 40 mg OD in addition to other medications for his underlying comorbid condition. Two months after tracheostomy, the patient started complaining of hemoptysis (bleeding from tracheostomy) and bleeding around tracheostomy stoma. The suctioning frequency was reduced, and antiplatelet and prophylactic enoxaparin was stopped. After 2 days, the patient developed an acute massive hemorrhage with spurting flow from the tracheostomy, with an estimated blood loss of around 400–500 mL in a few minutes. The patient was admitted to the intensive care unit (ICU) with tachycardia and shock. His investigations were hemoglobin 8.1 g/dL with normal platelet count and coagulation profile. He was connected to a ventilator and resuscitated with crystalloid fluid and packed red blood cells. Tracheostomy tube cuff was inflated to cuff pressure of 80 cm of water, as an attempt to stop bleeding by tamponade effect, but the attempt was unsuccessful. The patient was then referred to an otorhinolaryngologist, tracheostomy stoma was examined by an otorhinolaryngologist, and local control of bleeding was attempted but unsuccessful. Subsequently, computed tomography (CT) carotid angiography was done which suggestive of abnormal fistula tract between the HRIA and the trachea [Figure 1] and [Figure 2]. He was immediately taken for surgery by a cardiothoracic surgeon, sternotomy with dissection of the fistulous tract between the IA at its bifurcation to the anterior tracheal wall and closure of the fistula done. Bleeding is controlled after surgical procedure. The patient was weaned from the ventilator and shifted out of ICU in stable condition.
Figure 1: CT carotid angiography (coronal view) showing CT: Computed tomography, HRIA: High-riding innominate artery, F: Tracheoinnominate fistula, and TT: Tracheostomy

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and
Figure 2: CT carotid angiography (cross-sectional view) showing CT: Computed tomography, HRIA: High-riding innominate artery, F: Tracheoinnominate fistula, and TT: Tracheostomy

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  Discussion Top
Tracheostomy is one of the common procedures done in the ICU for various indications. PT by a single-step dilational technique is a preferred technique over open surgical technique because of several advantages.[3] PT in ICU is usually a safe procedure, with minimal immediate or long-term complications.[4] Airway bleeding is the most feared but rare complication after tracheostomy. The most common source of airway bleeding after tracheostomy is IA.[5] Classical left aortic arch and its three major branches (IA, left common carotid artery, and left subclavian artery) are observed in 70% of the population.[6] Various anatomical variations of the aortic arch and its branches have been described in the literature.[6] Knowledge of this anatomical variation is important because these aberrant vessels can act as a potential source of bleeding during neck surgeries such as tracheostomy, thyroidectomy, neck dissection, or mediastinoscopy.[2],[7] Classically, IA is a first branch arch of the aorta; it lies anterior to 6th–10th tracheal rings and divides behind the right sternoclavicular joint (RSCJ) into the right common carotid artery (RCCA) and right subclavian artery (RSCA).[1] The HRIA is defined as an anatomical variation of IA whereas IA bifurcates into RCCA and RSCA anything superior to RSCJ.[8] The HRIA is a rare anatomical variation with a reported incidence of 0.3%.[2] The HRIA developed due to the persistence of a portion of the proximal segment of the right fourth aortic arch during development.[8] The HRIA can be observed as high as up to the thyroid lobe (second or third tracheal ring).[8] Clinically, HRIA can present as a pulsatile anterior neck mass, or during neck examination, it can be palpated in suprasternal notch, but it is often difficult to find or palpate HRIA in an obese patient or individual with a short neck.[7],[8] Sometimes, HRIA can only be detected incidentally during neck surgeries or radiology.[7] Catastrophic hemorrhagic complication due to injury to HRIA has been reported in various neck surgeries including a tracheostomy.[7] The exact incidence of TIF due to HRIA is not known, but the overall incidence of TIF following tracheostomy is 0.1%–1%, and it carries a high risk of mortality without appropriate management.[1] Risk factors for TIF are high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, excessive neck movement (hyperextension), radiotherapy, prolonged intubation, and HRIA.[1],[9] These risk factors are capable of producing sufficient pressures that can lead to ischemia, inflammation, ulceration, and transmural necrosis in the tracheal wall and adjacent IA to form TIF.[1],[9] TIF was mostly observed within 7–21 days after tracheostomy but can present even years after tracheostomy.[1],[9] Clinically, any airway bleeding in a patient with a tracheostomy should be thought of as TIF unless proven otherwise.[1] Bleeding generally triggers after coughing or manipulation of the trachea such as dilatation and routine cannula changes.[9] In 35%–50% of TIF patients first present as self limiting bleeding with spontaneous resolution known as “sentinel bleeding” which can later progress to copious bleeding or sometimes patient may present as massive hemorrhage with the pulsation of the tracheal cannula without warning signs.[9] The diagnosis of TIF can be confirmed with bronchoscopy, CT angiography, and digital subtraction angiography, but sometimes, a detailed investigation is not possible in an emergency.[9] Management: the principle of management in TIF are maintaining an airway, adequate oxygenation, aggressive resuscitations, and control of bleeding. The first step is to overinflate the tracheostomy cuff. If this maneuver is unsuccessful then proceed to endotracheal (ET) intubation with cuff positioned distal to tracheostomy stoma and digital compression. The tracheostomy tube should only be withdrawn to facilitate simultaneous ET intubation. Digital compression consists of inserting the finger into the pretracheal space to tamponade the IA against the posterior surface of the manubrium. If this is also unsuccessful, then the only option is to manipulate the ET tube and cuff to produce a tamponade effect.[1],[10] Definitive management of TIF includes two options: first, open surgical procedure (OSP); standard median sternotomy, by an experienced surgeon. The mainstay of surgical treatment is to terminate flow within the fistulous tract by debriding the IA proximally until healthy tissue is obtained, then transecting and closing the fistula lumen. Advantages of OSP are it's a definitive treatment modality, can be done in infective TIF.[1],[11] The second option is endovascular management: either embolization, covered stent placement, or temporary occlusion with balloons. Advantages of endovascular treatment are can be done rapidly in appropriate clinical settings, can act as a bridge to the surgical procedure in case of emergency, reduction of morbidity and mortality associated with OSP, particularly in a patient with underlying morbidities.[9] Prevention of TIF; In addition to the use of tracheostomy with high volume low-pressure cuff, maintaining cuff pressure below 20 cm of water, avoiding low tracheostomy.[1],[9],[12],[13] The routine use of bedside neck sonography is recommended before all PTs to locate any aberrant vessel within the vicinity of tracheostoma.[14] When HRIA is clinically suspected, surgical tracheostomy with Bjork flap is recommended after appropriate neck imaging.[12],[13] This flap consists of suturing an inverted U-shaped flap of the trachea to the skin edge to create the space between the trachea and the artery and to protect the artery from tracheostomy tube pressure.
  Conclusion Top
TIF is a rare but life-threatening complication of tracheostomy. All the health-care workers involved in the management of tracheostomy should bear this complication in mind while dealing with any airway bleed. We recommend the routine use of bedside neck ultrasonography before all PTs to locate any aberrant vessel within the vicinity of tracheostoma to prevent this complication. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

 
  References Top

1.
Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: Three case reports and a clinical review. Br J Anaesth 2006;96:127-31. Moubayed SP, Ayad T. High-riding innominate artery encountered during neck surgery. Otolaryngol Head Neck Surg 2014;151:888-9. Sasane SP, Telang MM, Alrais ZF, Alrahma AH, Khatib KI. Percutaneous tracheostomy in patients at high risk of bleeding complications: A retrospective single-center experience. Indian J Crit Care Med 2020;24:90-4. Cheung NH, Napolitano LM. Tracheostomy: Epidemiology, indications, timing, technique, and outcomes. Respir Care 2014;59:895-915. Joseph MM, Benjamin R, Padmanabhan A, Bal D, Nair S. Successful management of a life-threatening endotracheal bleed with angiographic stenting. Indian J Crit Care Med 2020;24:210-1. Vučurević G, Marinković S, Puškaš L, Kovačević I, Tanasković S, Radak D, et al. Anatomy and radiology of the variations of aortic arch branches in 1,266 patients. Folia Morphol (Warsz) 2013;72:113-22. Upadhyaya PK, Bertellotti R, Laeeq A, Sugimoto J. Beware of the aberrant innominate artery. Ann Thorac Surg 2008;85:653-4. Wong BL, Gopalan S, Abu Bakar MN, Wong MH. High riding of brachiocephalic artery: A rare case of pulsatile anterior neck mass. Egypt J of Ear Nose Throat Allied Sci 2017;18:291-3. Machado AT, Barroso MC. Endovascular management of tracheo-innominate artery fistula: A case report and literature review. J Vasc Bras 2018;17:348-52. Keçeligil HT, Erk MK, Kolbakir F, Yildirim A, Yilman M, Unal R. Tracheoinnominate artery fistula following tracheostomy. Cardiovasc Surg 1995;3:509-10. Courcy PA, Rodriguez A, Garrett HE. Operative technique for repair of tracheoinnominate artery fistula. J Vasc Surg 1985;2:332-4. Dalati HA, Jabbr MS, Kassouma J. High-riding brachiocephalic (innominate) artery during surgical tracheostomy. BMJ Case Rep. 2018;2018:bcr2017221802. doi: 10.1136/bcr-2017-221802. Kinley CE. A technique of tracheostomy. Can Med Assoc J 1965;92:79-81. Rees J, Haroon Y, Hogan C, Saha S, Derekshani S. The ultrasound neck imaging for tracheostomy study: A study prompting ultrasound screening prior to percutaneous tracheostomy procedures to improve patient outcomes. J Intensive Care Soc 2018;19:107-13.   Back to cited text no. 1
    


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