Patricia Leung 5.26.2013

Department of Surgery SUNY Downstate Medical Center

Management of Tracheo-Innominate Fistulas

Case presentation

• SM - 52 year old male • PMH: HTN, DM, Afib, no PSH • 11/2012 – transferred to KCHC from Woodhull

for evaluation of right temporal mass • 11/20/12 – biopsy c/w high grade glioma • 12/5/12 – right temporal craniotomy with

debulking, pathology c/w glioblastoma multiforme

Case presentation • 12/24/12 – acute decline in mental status requiring

intubation, imaging c/w tumor recurrence, mass effect with midline shift

• Per discussion with family – no radiation or chemotherapy; steroid therapy initiated

• Persistent poor neurological status, malnutrition, pneumonia with respiratory failure requiring vent dependence

• 1/4/13 – Percutaneous tracheostomy and PEG placement

• 3/31/13 - transferred back to SICU for presumed sepsis, started on IV antibiotics for total of 7 day course

Case presentation

• 4/11/13 7:10 PM – Code called after patient found pulseless with massive bleeding from oropharynx and tracheostomy

• Cuff was hyperinflated • ACLS protocol initiated • Anesthesia unable to orally intubate patient

secondary to poor visualization; % O2 saturation remained in 70s

• Despite several rounds of ACLS, the patient expired

History

• 1897 - Korte reported a fatal TIF in 5-year old child with diphtheria after tracheostomy

• 1924 - Schlaepter reviewed 115 cases of fatal hemorrhage after tracheostomy and documented that the innominate artery was involved in most cases

• 1964 - Silen reported the first short-term survivor • 1968 - Reich reported the first long-term survivor of TIF

Introduction

• Pressure necrosis of anterior tracheal wall from cuff or tip causing erosion of trachea and innominate artery

• Rare complication of tracheostomy • Incidence 0.7% • Survival rate 14.3% • Mortality rate 100% without operative

intervention • ~75% of TIF develop within first 3 weeks after

tracheostomy

Anatomy

• Trachea is 11.8 cm long with 18-22 cartilaginous rings

• Innominate artery traverses trachea at level 9th tracheal ring

• Ranges between 6-13th tracheal rings

• Anatomical variants

A & A April 1999 vol. 88 no. 4 777

Contributing factors • Low tracheostomy tube placement • Overinflation of tracheostomy cuff >20 mmHg • Malpositioned tracheostomy tube tip • Anatomical variations • Local infection of tracheostomy wound • Excessive manipulation of tracheostomy tube • Long-term ventilation • Radiation therapy • Steroids • Malnutrition • Diabetes

Pearson’s Thoracic and Esophageal Surgery Fig 20-7

Diagnosis

• Early diagnosis is key • Warning signs: - Sentinel bleed - Pulsating tracheostomy tube • Bronchoscopy • CT Angiogram • Angiogram • Low sensitivities, delay

in treatment

J Korean Neurosurg Soc. 2011 February; 49(2): 107–111

Journal of Vascular Surgery volume 33 Pages 1280-1282, June 2001

Principles of Management

• Secure airway • Control bleeding • Resuscitation

OR

Initial management

• Cuff overinflation • Oral endotracheal tube

placement distal to site • Digital compression of

artery via pretracheal space OR in trachea against sternum

• Compression via rigid bronchoscope

• Take to OR

e Department of Surgical Education, Orlando Regional Medical Center

Surgical management

• Median sternotomy • Extension into right third or fourth intercostal space • Innominate artery exposure by division of thymus

and superior retraction of innominate vein • Proximal and distal control • Preservation of anomalous left common carotid

artery

Figure 4 Ann Surg. 1976 August; 184(2): 194–204

Surgical management

• Interruption of flow - Simple ligation and resection • Maintenance of flow - Direct repair of defect - Interposition grafting

• Resection of involved innominate artery segment

Greenfield Chapter 80 Figure 80.33C

Figure 13-1, Chapter 13 Tracheal fistula to brachiocephalic artery

• Segment of damaged trachea excised with primary end-to-end anastomosis

• Strap muscle interposition

• Primary repair with buttress

• Relocation of tracheostomy Access Surgery Figure 37-1 A

• Aorto-to-axillary artery bypass graft

Ann Thorac Surg 2004;77:1424-1426

• Interposition graft between ascending aorta and division of innominate artery

Interact CardioVasc Thorac Surg(2008) 7 (4): 654-655.

Studies 1994 Gelman et al • 71 survivors of TIF from 1962 to 1994 • 40 survived long-term (>2 months) • Maintenance of flow 15.8% LT survival • Interruption of flow 71.2% LT survival • Recurrent bleeding and death: Maintenance of flow 60% and 86% vs. Interruption of flow 7% and 29% • Minimal neurologic sequelae 1988 Yang et al • 24 survivors from 1875 to 1984 • Similar results

Prevention • Reserve tracheostomy for patients requiring prolonged

ventilation • � Avoid: - Tight wound closure - Excessive neck hyperextension -� Tube manipulation (use long flexible tube

connection) • � Monitor cuff pressures to < 20 mmHg frequently • � Expose anterior trachea by isthmus division to count

rings from cricoid • Selection of site at 2nd or 3rd tracheal rings • �Bronchoscopy if questionable positioning

Summary

• Tracheoinnominate artery fistula is a rare but devastating complication of tracheostomy

• Outcomes highly dependent on rapid diagnosis and immediate management

• Resuscitation, airway protection, control of bleeding

• Simple ligation and resection recommended

References • The anatomical basis for post-tracheostomy innominate artery rupture. Laringoscope 98:1061, 1988 J Korean Neurosurg Soc. 2012 December; 52(6):

547–550. • Successful Treatment of Tracheoinnominate Artery Fistula Following Tracheostomy in a Patient with Cerebrovascular Disease • Tracheo-Innominate Artery Fistula After Tracheostomy Leonardo Kapural, MD*, Juraj Sprung, MD, PhD†, Ivo Gluncic, MD‡, Miranda Kapural,

MD*, Simon Andelinovic, MD§, Dragan Primorac, MD§, and Peter K. Schoenwald, MD† *Division of Anesthesiology and Critical Care Medicine and †Department of General Anesthesiology, The ClevelandClinic Foundation, Cleveland Anesth Analg 1999;88:777–80

• Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical reviewC. A. Grant1,*, G. Dempsey1, J. Harrison1 and T. Jones2 Br. J. Anaesth. (January 2006) 96(1): 127-131.

• Journal of Vascular Surgery Volume 33, Issue 6 , Pages 1280-1282, June 2001 • Successful management of tracheo-innominate artery fistula with endovascular stent graft repair Jun-o Deguchi, MD Takatoshi Furuya,

MD, Nobutaka Tanaka, MD Masakazu Nobori, MD Yasuo Seki, MD Yukihiro Nomura, MDIsao Umehara, MD Haruhisa Saito, MD, Tetsuro Miyata, MD J Korean Neurosurg Soc. 2011 February; 49(2): 107–111. • Is Computerized Tomography Angiographic Surveillance Valuable for Prevention of Tracheoinnominate Artery Fistula, a Life-Threatening

Complication after Tracheostomy? Jae Hoon Sung, M.D., Il Sup Kim, M.D., Seung Ho Yang, M.D., Jae Taek Hong, M.D., Byung Chul Son, M.D., andSang Won Lee, M.D.

• Preventive ligation of the innominate artery in patients with neuromuscular disorders Francesca Iodicea,*, Gianluca Brancacciob, Aldo Lauria and Roberto Di Donatob Eur J Cardiothorac Surg (2007) 31(4): 747-749.

• Access Surgery Chapter 37 Tracheal Injuries • Gelman J.J., Aro M., Weiss S.M. Tracheo-innominate artery fistula. J Am Coll Surg 1994;179:626-634 • Pearson’s Thoracic and Esophgeal Surgery 3rd Edition Chapter 20 • A novel approach to the management of tracheoinnominate artery fistula Mario G. Gasparri, MDa*, Alfred C. Nicolosi, MDa, G. Hossein Almassi,

Mda Ann Thorac Surg 2004;77:1424-1426 • Graft repair of tracheo-innominate artery fistula following percutaneous tracheostomy Hassan Jamal-Eddinea, Adel K. Ayeda,b, Ahmed Al-

Moosaa and Nael Al-Sarrafa,Interact CardioVasc Thorac Surg(2008) 7 (4): 654-655.

Farewell!