Interact CardioVasc Thorac Surg 2008;7:654-655. doi:10.1510/icvts.2007.174656
© 2008 European Association of Cardio-Thoracic Surgery
Negative results - Vascular general |
Graft repair of tracheo-innominate artery fistula following percutaneous tracheostomy
Hassan Jamal-Eddinea,
Adel K. Ayeda,b,
Ahmed Al-Moosaa and
Nael Al-Sarrafa,*
a Department of Thoracic Surgery, Chest Disease Hospital, Kuwait
b Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait
Received 30 December 2007;
received in revised form 12 March 2008;
accepted 14 March 2008
*Corresponding author. Al-Deya, P.O. Box 15179, Code number 35452, Kuwait. Tel.: +(965) 6600543; fax: +(965) 4741504.
E-mail address: trinityq8{at}hotmail.com (N. Al-Sarraf).
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Abstract
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Tracheo-innominate fistula (TIF) is a rare complication following percutaneous dilatational tracheostomy (PDT), occurring in  1% of cases. It usually develops three days to six weeks after the procedure and is fatal in the majority of cases, even after successful initial repair. We present a successfully treated case of TIF using a Goretex graft to replace the severely destroyed segment of the innominate artery.
Key Words: Tracheostomy; Tracheoinnominate artery fistula; Graft; Sternotomy
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1. Case report
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A 21-year-old man had a motorcycle accident. On admission, he had right-sided decerebrate rigidity, frequent seizures and Glasgow Coma Scale of 4. Following resuscitation and intubation, a CT brain scan was performed which showed depressed fracture of the right parietal region with an extradural haematoma which was evacuated. There were no other significant injuries. Two weeks later, PDT [Ciaglia Blue Rhino®, Cook Company, Denmark] was performed. Nine days later he had initial, self-limiting bleeding from the tracheostomy site, mouth and nose. Bronchoscopy (performed by ENT surgeons) was normal and CT of the neck with contrast was inconclusive. Two days later, bronchoscopy was repeated in the operating room, being prepared for an emergency procedure. After deflation of the cuff, massive bleeding occurred. A tracheostomy tube was replaced by an orotracheal tube with the cuff hyper inflated. Bleeding was controlled by digital compression of the innominate artery (a finger was inserted in the pretracheal fascia to compress the artery) while an emergent median sternotomy was done. The innominate artery was dissected and the fistula identified (very close to the take-off of the innominate artery from aorta – Fig. 1a) and side-biting clamp applied proximal to the origin of the innominate artery. PDT site (located at the level of the 5th tracheal ring) was closed using 4-0 Vicryl. The tracheal fistula site (located at the level of the 10th tracheal ring) was closed with a purse-string suture and buttressed with a sternohyoid muscle flap (Fig. 1b). The innominate artery was resected from its origin up to 3 mm before branching. The origin of the innominate artery was oversewn. An 8-mm PTFE graft (Goretex) was interposed between the ascending aorta and the division of the innominate artery to the right common and subclavian artery, anterior to the innominate vein, thus avoiding to place the graft in the vicinity of the fistula (Fig. 1b). The patient's general condition and his neurological function gradually improved. He was discharged home three months later following a rehabilitation programme, and he returned to work six months later. A Doppler ultrasound study of the vascular reconstruction was normal, with insignificant difference in arterial systolic pressures (right arm 124 mmHg, left arm 138 mmHg).
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Fig. 1. Tracheo-innominate fistula located at the origin of innominate artery (a). Tracheal fistula closed with purse-string suture and buttressed with a sternohyoid muscle flap, innominate artery resected from its origin up to 3 mm before branching, the origin of the artery oversewn. An 8-mm Goretex graft interposed between ascending aorta and division of the innominate artery, anterior to the innominate vein (vein omitted from drawing to aid clarity) (b).
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2. Discussion
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Tracheo-innominate fistula (TIF) is a rare complication of tracheostomy with an estimated incidence of 0.1–1% [1, 2]. TIF results in a high mortality, even in cases where successful initial surgical repair was accomplished [1]. Besides prompt diagnosis and surgical repair, the outcome following TIF largely depends upon the strategy of repair. Various approaches were reported, including direct suture, resection and ligation of innominate artery, graft interposition (using autologous or prosthetic materials), anatomical and extra anatomical bypasses [3, 4]. The majority of authors are reluctant to use any synthetic materials in proximity of possibly infected area, advocating simple ligation of the damaged artery [4–6]. We present a case where a Goretex graft was successfully used to replace the severely damaged artery, with good long-term outcome.
Since 10% of all instances of post-tracheostomy bleedings could be due to TIF, high index of suspicion must be present, particularly if PDT was done 7–14 days earlier [1]. Once it develops, it is often fatal, even if initial surgical repair was successfully accomplished. This is partly due to the fact that the majority of these patients were in a grim general condition before. However, there are reports of fatal outcomes due to re-bleeding after attempts to preserve the flow in the innominate artery, using direct sutures or prosthetic material in an infected area [4, 5]. On the other hand, many authors claim that interruption of flow through the innominate artery yields no, or only minimal neurological sequel, and they advocate the ligation of the innominate artery as the treatment of choice [1, 4, 5]. However, careful literature review reveals that there is a place for concern. Some of the patients reported never regained consciousness, and it is not clear what the main cause was (i.e. whether due to the previous resuscitation or due to the innominate artery ligation itself). In addition, in some cases subclavian steal syndrome may develop.
Being aware of all implications, we decided to restore the flow using prosthetic material, since our patient had an existing clear neurological deficit with an uncertain prognosis. We assumed that it was worthwhile trying to restore the flow, thus avoiding any uncertainty regarding his brain damage in case his neurological deficit remains stable or worsens. By displacing the graft away from the site of fistula, and bringing the sternohyoid muscle over the repaired trachea, we tried to reduce the possibility of graft infection.
The best preventative and treatment strategies are to avoid placing PDT below the 4th tracheal ring, avoiding hyperextension of the neck, keeping the pressure in the tracheal cuff to <20 mmHg and early suspicion of presence of TIF. In addition, a Goretex graft when used should be interposed between the ascending aorta and division of the innominate artery to right common carotid and right subclavian, thus avoiding placing the graft in the fistula area. The use of endovascular stent technology is evolving [7] but the risk of infection is still present with potentially catastrophic results including re-bleeding. The use of a stent can be either as a definitive treatment or as a temporizing measure before a more definite procedure is carried out such as surgery [7]. Due to the lack of experience in our unit with endovascular stent insertion for TIF and the emergent nature of our case, we proceeded with surgical intervention directly. Previous papers have stated that there is no evidence of a significant neurological or vascular complication associated with innominate artery ligation and the general belief is that restoration of blood flow through the innominate is not crucial [3–5]. EEG can be useful in this setting whenever ligation is contemplated to monitor any EEG changes. However, there is no measure available to prevent cerebral injury during management of this potentially fatal complication.
Despite prompt diagnosis and an emergency management, TIF remains a fatal complication in the majority of cases. Optimal surgical strategy remains controversial, particularly for patients with neurological deficits. Advanced age or known peripheral artery disease, with potential devastating complication after innominate artery ligation is another case for concern. Even in young patients without atherosclerotic peripheral artery disease, malformation or the anomaly of the arterial supply to the brain may make innominate artery ligation a hazardous manoeuvre.
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Acknowledgements
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We would like to thank Dr. Velimir Stojanovic for performing an outstanding drawing of the Fig. 1.
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References
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Abstract
1. Case report