A RARE CASE OF TRACHEOINOMINATE FISTULA

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Within 2-4 weeks after placement, a tip or cuff of a tracheostomy tube may erode into the anterior wall of the trachea, resulting in a morbid and often fatal outcome. We present a rare case of tracheoinnominate fistula (TIF) after a tracheostomy. CASE PRESENTATION: A 51-year-old woman with non-ischemic cardiomyopathy after a complicated ascending aortic aneurysm status post orthotopic heart transplant presented with gradual onset of dyspnea and facial swelling. CTA of the chest revealed an aneurysm of the innominate artery measuring 3.7 x 3.4 cm and a significant subglottic tracheal stenosis. A large multinodular goiter was noted on ultrasound. Due to her diffuse facial swelling, exophthalmos, and engorged veins, her culprit diagnosis was thought to be SVC syndrome. After a subsequent CT venography, she underwent stenting of the right innominate vein. However, her symptoms persist, and as a result of her worsening stridor, the patient was intubated. She then underwent a tracheostomy and partial thyroidectomy. Twelve days post tracheostomy, patient had a self-resolving episode of non-massive hemoptysis. Given her innominate artery aneurysm, a sentinel bleed for a tracheoinnominate fistula was suspected. Her uncuffed tracheostomy tube was quickly exchanged for a cuffed one, and the balloon was hyperinflated. After a temporary tamponade, she was emergently taken to the operating room for an innominate artery ligation and a carotid-to-carotid bypass. DISCUSSION: Development of tracheoinnominate fistula is a rare complication of tracheostomy occurring in only 1% with nearly a 90% mortality. When faced with a massive hemoptysis or even a sentinel bleed, one must have a high index of suspicion for TIF in a patient with a recent tracheotomy placement. Common risk factors include low tracheostomy, high innominate artery, cuff overinflation, infection, and immunosuppressed state. Our patient unfortunately had a perfect storm—a history of a complicated ascending aortic aneurysm involving the innominate artery, on chronic immunosuppressants, and subglottic tracheal stenosis requiring a low tracheostomy. To minimize exsanguination, suspect TIF and quickly tamponade the anterior wall of the tracheal with one’s finger or overinflating the balloon. CONCLUSIONS: Tracheoinnominate fistula, although more rare since the advent of low-pressure tracheostomy tubes, remains a highly lethal complication of tracheostomy. Successful management relies on early diagnosis and prompt management. Reference #1: 1. Allan JS, Wright CD: Tracheoinnominate fistula: Diagnosis and management. Chest Surg Clin North Am 13:331-341, 2003 GrilloCG: Tacheal fistulato barchiocephalic artery,inGrilloCG (ed): Surgery of the Trachea and Bronchi. Hamilton, Ontario, BC Decker, Ch. 13, 2003, pp 1-9 Reference #2: 2. GrilloCG: Tacheal fistulato barchiocephalic artery,inGrilloCG (ed): Surgery of the Trachea and Bronchi. Hamilton, Ontario, BC Decker, Ch. 13, 2003, pp 1-9 Reference #3: 3. Technique for Managing Tracheo-Innominate Artery Fistula, Gorav Ailawadi, MD DISCLOSURES: No relevant relationships by Bindu Akkanti, source=Web Response No relevant relationships by Kha Dinh, source=Web Response No relevant relationships by Samim Jafri, source=Web Response