Multidisciplinary Hybrid Management Of Recurrent Tracheo-Innominate Artery Fistula After Open Ligation Of The Innominate Artery
Manda Maley, MD, Nadia Awad, MD, Evan Deutsch, MD, Rashad Choudry, MD, Laurel Hastings, MD, Aaron Ilano, MD.
Einstein Medical Center, Philadelphia, PA, USA.
DEMOGRAPHICS:Tracheoinnominate artery fistula (TIF) is a rare, life-threatening complication of tracheostomy. Even with expedient surgical repair, morbidity and mortality related to TIF remains high. This is a case of recurrent TIF after emergency open ligation of the innominate artery, salvaged with extra-anatomic left subclavian artery (LSCA) to left common carotid artery (LCCA) bypass and endovascular exclusion of the pseudoaneurysm with an aortic stent graft. HISTORY: A 29-year old female struck by an automobile suffered multiple organ system trauma requiring tracheostomy placement after prolonged intubation. On post-operative day 5 after tracheostomy, the patient had massive hemorrhage from the site that was controlled with over-inflation of the tracheal cuff. CT angiography demonstrated TIF without active hemorrhage. The patient underwent median sternotomy with ligation of the innominate artery and tissue coverage of the tracheal defect. Given hemodynamic instability at the time of the procedure, definitive repair with vascular reconstruction was deferred. The patient ultimately suffered a significant stroke with hemorrhagic conversion requiring neurosurgical intervention. However, she recovered well and was following commands. She underwent open tracheostomy placement several weeks later. Ten days after open tracheostomy, the patient had recurrent hemorrhage from her tracheostomy site. Aortography demonstrated a pseudoaneurysm at the innominate artery stump without active extravasation. PLAN:Given the patientís hostile thoracic anatomy, multidisciplinary discussion determined a hybrid procedure would minimize morbidity. A LSCA to LCCA artery bypass was performed with an 8mm Propaten graft (W.L. Gore; Flagstaff, AZ) and the aortic defect was excluded with a Medtronic Valiant Navion 34mm x 52mm aortic endograft (Medtronic; Santa Rosa, CA). The proximal LCCA was ligated due to backfilling of the pseudoaneurysm. Post-operative imaging confirmed successful exclusion of the pseudoaneurysm with good flow into the LCCA (Figure 1). The patient was subsequently discharged to a long-term care ventilator rehabilitation facility. DISCUSSION: TIF is a complex and highly moribund complication rarely seen after tracheostomy placement. In controlled situations, excision of the innominate artery with patch repair may be indicated to prevent pseudoaneurysm. Endovascular and hybrid approaches due to hostile anatomy may offer less morbidity and do not preclude definitive arch reconstruction in the future.
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