Tracheo-innominate artery fistula.

Abstract

We read with great interest the case report (1) on tracheo-innominate artery fistula (TIF) after tracheostomy. TIF is a rare but life-threatening complication occurring in 0.6% to 0.7% of patients undergoing tracheostomy (2). The mortality rate of untreated TIF is almost 100%, and the best management is avoidance of the development of this fatal complication. The most common site of TIF is at the stoma from a low-lying tracheostomy tube; less commonly high cuff pressures may produce mucosal necrosis and tracheal erosion in the vicinity of the innominate artery. The mechanism of injury is reported to be pressure necrosis from either the elbow, the cuff, or the tip of the tracheostomy tube (TT), with the latter two contributing in two thirds of the reported cases. Although Kapural et al. (1) have described various preventive measures to minimize the probability of TIF formation, we would like to suggest a few more measures that have been found useful and are as follows: In patients with a tracheostomy, prolonged or excessive hyperextension of the neck should be avoided. After 1 wk of tracheostomy, the TT should be replaced with a readjustable TT, and the length of the TT in the tracheal lumen should be adjusted by 1 to 2 cm on alternate days so that the position of distal end of the TT and the cuff varies and thereby avoids constant pressure at one point and thus allows the tracheal mucosa to recover. A soft, smooth 100% silicone cuffed TT is nonreactive and minimizes tissue irritation and mucosal trauma. A weekly fiberoptic tracheo-bronchoscopy may facilitate in early detection of tracheal pressure necrosis or nidus for TIF. Light weight tubing is recommended and dragging on the TT should be minimized. Sushil P. Ambesh MD Vijay Kumar MB, BS Kumkum Srivastava MD