Back to 2025 Abstracts
Successful, Definitive In-situ Surgical Repair Of Tracheo-innominate Artery Fistula Initially Temporized With Endovascular Intervention
Alley E. Ronaldi, MD, Todd E. Rasmussen, MD, Manju Kalra, MBBS, Bernardo C. Mendes, MD, Alberto Pochettino, MD, Jill J. Colglazier, MD.
Mayo Clinic, Rochester, MN, USA.
DEMOGRAPHICS: 57-year-old man status post resection of intracranial hemangioblastoma.
HISTORY: The patient’s post-operative course was complicated by intraventricular hemorrhage resulting in prolonged intubation. Percutaneous tracheostomy was placed. 10 days later there was acute blood loss from the tracheostomy which was controlled with cuff inflation. CT angiogram was concerning for tracheoinnominate fistula (TIF).
PLAN: Diagnostic investigation was performed in the hybrid OR with plan to stent the innominate artery as a temporizing measure to prevent exsanguination if TIF was confirmed. Bronchial blockers were positioned, and femoral artery access obtained. Tracheostomy cuff was deflated resulting in airway hemorrhage and angiographic evidence of TIF. The TIF was covered with 11x39mm Viabahn VBX deployed in the innominate artery and extended with 6x39mm and 8Lx39mm Viabahn VBX into the common carotid and subclavian arteries, respectively, in ‘kissing stent’ configuration resulting in exclusion of the fistula. Given communication of stents with the trachea, infection was assumed. At this time the patient’s respiratory status was tenuous from significant blood loss into the airway so definitive reconstruction was deferred. He returned to the OR two weeks later, once respiratory function was optimized. A median sternotomy with cervical extension onto the anterior border of the right sternocleidomastoid was performed. A large tracheal defect was identified abutting the innominate artery defect (Image 1a), through which the stent was visualized. The trachea was repaired with AlloDerm patch reinforced with thymic flap. Once controlled, the innominate artery and stented portion of the proximal carotid and subclavian arteries were resected. The innominate stump oversewn. A Rifampin-soaked 14x7 bifurcated Dacron graft was used for reconstruction. The proximal anastomosis was completed with a side-biting clamp on the lateral ascending aorta. The graft limbs were tunneled under the innominate vein. The carotid, followed by subclavian anastomoses were performed (Image 1b). The graft was wrapped with thymic flap (Image 1c) prior to closure. Later, open tracheostomy was performed. He was slowly weaned from the ventilator and discharged.
DISCUSSION: TIF represents an uncommon but lethal pathology. This case demonstrates a staged approach to temporize the fistula allowing controlled, staged reconstruction of the innominate artery with concomitant tracheostomy repair.
Back to 2025 Abstracts
