Endovascular Treatment Of Trachea-left Subclavian Fistula
Matthew Pergamo, MD, Naveed Rahman, MD, Caron Rockman, MD, Joanelle Lugo, MD.
New York University School of Medicine, New York, NY, USA.
DEMOGRAPHICS While trachea-innominate fistula is a well-known entity after tracheostomy placement, there are only three reports in the literature regarding fistulas to the left subclavian artery. Emergent open resection or ligation has been considered the standard approach but can be technically challenging with high morbidity. HISTORY This 80-year-old male with history of Crohn's disease initially presented with a perforated sigmoid colon adenocarcinoma requiring exploratory laparotomy and bowel resection. Due to prolonged hospital course, the patient underwent tracheostomy placement. Four weeks later, he began bleeding from his tracheostomy site with associated hypotension. CT angiogram demonstrated a 3mm focal out-pouching of the left subclavian artery adjacent to the trachea concerning for trachea to left subclavian artery fistula formation. Given inability of the patient to tolerate an open repair, the decision was made to proceed with endovascular coverage of the fistula. PLAN Diagnostic aortogram was performed via left upper extremity brachial access using an 8Fr sheath. With the tracheostomy balloon inflated, there was no evidence of active extravasation or pseudoaneurysm on initial imaging. Given the patient’s hemodynamic status, we did not attempt to deflate the tracheal cuff. The proximal left subclavian artery was covered using two 11mm x 29mm Gore VBX stents starting at the origin of the artery and landing just proximal to the take-off of the left internal mammary artery and left vertebral artery (Figure 1). Balloon angioplasty of the stents was then performed using a 12mm balloon. Postoperatively, the patient experienced complete resolution with no further episodes of tracheostomy bleeding. He was maintained on suppressive antibiotics. DISCUSSION There are only three cases in the literature of fistula formation between the trachea and left subclavian artery. The first patient died in the operating room after attempted open repair. The other two underwent successful endovascular stenting to cover the fistula with no evidence of recurrence or infection at follow up. As the left subclavian is difficult to reach with open technique, this case further highlights the role of endovascular treatment for a trachea to left subclavian artery fistula in select patients who cannot tolerate an open repair.
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