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Tracheoinnominate fistula: successful management with endovascular stenting.

Introduction

Tracheoinnominate fistula is a rare complication of tracheostomy. Its incidence was historically reported to be about 0.7%, (1) but that figure is believed to have declined since the introduction of low-pressure cuffs and high tracheostomies. In a 2000 review of 1,130 tracheostomies over 10 years, Goldenberg et al found that the incidence was only 0.2%. (2)

Tracheoinnominate fistulas typically arise as a result of pressure necrosis on the anterior tracheal wall caused by high tracheostomy cuff pressures or malpositioning of the cannula against the tracheal wall mucosa. Although tracheoinnominate fistula is classically considered an early complication, late fistulas clearly occur, as well.

We describe a case of tracheoinnominate fistula that was successfully managed with endovascular stent placement.

Case report

A 40-year-old man presented to the emergency department with a sudden massive hemorrhage from his tracheostomy tube. Tracheostomy had been performed 23 years earlier to help manage C3 ventilator-dependent quadriplegia. Three days earlier, the patient had presented with a small amount of tracheal hemorrhage, but a tracheoinnominate fistula had not been recognized at that time.

The patient was resuscitated, and tamponade was achieved with overinflation of the tracheostomy tube cuff. He was emergently brought to the operating room, where flexible bronchoscopywas performed and the lungs were cleared of blood to allow for adequate ventilation. The tracheostomy tube was replaced with a flexible endotracheal tube, and bronchoscopy identified the source of the hemorrhage as the anterior right wall of the midtrachea (figure 1). A tracheoinnominate fistula was suspected, and the vascular surgery team performed transfemoral arteriography. Catheterization of the aortic arch did not locate the fistula, but upon selective catheterization of the innominate artery, the fistula was clearly visible near the origin of the common carotid artery (figure 2). A 9 x 38-mm balloon-expandable covered endovascular stent (iCAST; Atrium Medical Corp.; Hudson, N.H.) was placed across the innominate artery up to the origin of the common carotid artery. Control of the fistula was confirmed by bronchoscopy, arteriography, and computed tomographic angiography (CTA) with three-dimensional (3D) reconstruction (figure 3). Adequate perfusion of the central nervous system and the right upper extremity was demonstrated by arteriography and Doppler ultrasonography, and no evidence of neurologic insult was noted postoperatively.

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Follow-up bronchoscopy 2 weeks after stent placement showed a well-healing, mucosalized fistula site (figure 4). The patient was discharged to home at 3 weeks. At 12 months, he exhibited no evidence of graft infection or erosion, and 4 years later, he continued to do well.

Discussion

Bronchoscopy and arteriography can be helpful in diagnosing tracheoinnominate fistula, but a high index of suspicion clinicallyis most important. A sentinel bleed often precedes a massive hemorrhage, and early recognition may prevent death. In our case, arteriography allowed for confirmation of the tracheoinnominate fistula, but selective catheterization of the innominate artery was required. In general, the sensitivity of arteriography is probably not high enough to rule out a tracheoinnominate fistula, but the sensitivity may be improved with selective catheterization of the innominate artery.

Tracheoinnominate fistula is a universally fatal complication if it is not treated urgently with definitive management. In order to achieve hemostasis emergently, a variety of temporizing measures can be performed. The tracheostomy cuff can be repositioned and overinflated, or digital pressure can be applied to the anterior tracheal wall from within the tracheal lumen. Definitive treatment options have traditionally been surgical, including ligation or reanastomosis of the innominate artery, both of which require a sternotomy.

More recently, endovascular stent placement has been used because it is considered a less invasive option. The first case of endovascular repair of a tracheoinnominate fistula with stent grafting was reported in 2001 by Deguchi et al, who described the successful treatment of an adult with a long-term tracheostomy tube. (3) The authors noted neither graft infection nor rejection at 14 months of follow-up. Subsequently, 5 successful, 1 unsuccessful, and 1 temporarily successful endovascular stentings of tracheoinnominate fistulae have been reported. (4-10) In 2 of these cases, stenting was part of a combined treatment or a temporizing measure. (8,10)

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Our current knowledge regarding the long-term outcomes of endovascular management of tracheoin-nominate fistula is limited by the small number of reported cases and the limited duration of follow-up. Potential long-term complications include neurologic injury, stenosis, infection, and graft erosion leading to a recurrence of the fistula. The reported complications of endovascular stenting for tracheoinnominate fistula repair include 2 failures, 1 of which occurred in the setting of an invasive neoplasm, which led to erosion and infection after a few weeks. (9,10) To minimize the risk of infection, prophylactic antibiotics have been recommended. (3) No complications were observed in our patient after 4 years of follow-up.

Despite the potential complications of endovascular stent placement, we believe that the high mortality rate associated with tracheoinnominate fistula and the morbidity of open surgical management justify its use. Indeed, it may become the treatment of choice as further knowledge is gained regarding success rates and long-term outcomes.

References

(1.) Jones JW, Reynolds M, Hewitt RL, Drapanas T. Tracheo-innominate artery erosion: Successful surgical management of a devastating complication. Ann Surg 1976;184(2):194-204.

(2.) Goldenberg D, Ari EG, Golz A, et al. Tracheotomy complications: A retrospective study of 1130 cases. Otolaryngol Head Neck Surg 2000;123(4):495-500.

(3.) Deguchi J, Furuya T, Tanaka N, et al. Successful management of tracheo-innominate artery fistula with endovascular stent graft repair. J Vasc Surg 2001;33(6):1280-2.

(4.) Vianello A, Ragazzi R, Mirri L, et al. Tracheoinnominate fistula in a Duchenne muscular dystrophypatient: Successful management with an endovascular stent. Neuromuscul Disord 2005;15(8):569-71.

(5.) Palchik E, Bakken AM, Saad N, et al. Endovascular treatment of tracheoinnominate artery fistula: A case report. Vasc Endovascular Surg 2007;41(3):258-61.

(6.) Cohen JE, Klimov A, Rajz G, et al. Exsanguinatingtracheoinnominate artery fistula repaired with endovascular stent-graft. Surg Neurol 2008;69(3):306-9.

(7.) Joshi AS, Tanna N, Elmaraghy CA, et al. Nonsurgical treatment of tracheoinnominate fistula in the pediatric population. Arch Otolaryngol Head Neck Surg 2007;113(3):294-6.

(8.) Sessa C, Costache V, Porcu P, et ai. Tracheoinnominate artery fistula: Combined endovascular and surgical management by emergency stent-graft placement followed by cryopreserved arterial allograft repair. Ann Vasc Surg 2006;20(6):731-5.

(9.) Wang PK, Yen PS, Shyr MH, et al. Endovascular repair of tracheoinnominate artery fistula. Acta Anaesthesiol Taiwan 2009;47 (1):36-9.

(10.) Wall LR Gasparis A, Criado E. Endovascular therapy for tracheoinnominate artery fistula: A temporizing measure. Ann Vasc Surg 2005;19(1):99-102.

Peter M. Shepard, MD; Jeffrey M. Phillips, MD; Girma Tefera, MD; Gregory K. Hartig, MD

From Southwestern Ear Nose & Throat Associates, Santa Fe, N.M. (Dr. Shepard); the Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport (Dr. Phillips); and the Vascular Surgery Section (Dr. Tefera) and the Otolaryngology Division (Dr. Hartig), Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison. The case described in this article occurred at the University of Wisconsin.

Corresponding author: Peter M. Shepard, MD, Southwestern Ear Nose & Throat Associates, 1620 Hospital Dr., Santa Fe, NM 87505. Email: peteshepard@hotmail.com
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Title Annotation:ORIGINAL ARTICLE
Author:Shepard Peter M.; Phillips, Jeffrey M.; Tefera, Girma; Hartig, Gregory K.
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Jul 1, 2011
Words:1198
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