Abstract
BackgroundA tracheo-innominate fistula is a rare but life-threatening complication of tracheostomy and has a mortality rate of 100% without therapy. The underlying cause is an acquired fistula between the brachiocephalic trunk and the trachea, induced by a tracheostomy cannula’s mechanical impact.Case presentationA 25-year-old female was admitted with pulsatile bleeding from a tracheostomy. The cause of the bleeding was a tracheo-innominate artery fistula, which was difficult to recognize. Said fistula was treated with implantation of a self-expanding stent-graft. The bleeding stopped immediately after the implantation of the stent-graft. Dual antiplatelet medication with aspirin IV and ticagrelor PO, bridged with a bolus of eptifibatide IV, was started right after the stent deployment.ConclusionsEndovascular self-expanding stent-graft implantation is a viable treatment option for tracheo-innominate artery fistulae, especially in hemorrhagic emergencies.
Highlights
A tracheo-innominate fistula is a rare but life-threatening complication of tracheostomy and has a mortality rate of 100% without therapy
In most cases (80%), the fistula is located between the brachiocephalic trunk (“innominate artery”) and the anterior aspect of the trachea
Tracheo-innominate fistula (TIF) mostly develop in a period of 3 days to 6 weeks after tracheostomy
Summary
Tracheo-innominate fistula (TIF) is a sporadic (0.1%– 1%) and potentially lethal complication after tracheostomy (Cooper and Grillo 1969; Qureshi 2018). We report a case of a patient with TIF that was successfully treated with endovascular stent graft reconstruction of the innominate artery. A diagnostic digital subtraction angiography (DSA) was carried out using a Tempo vertebral 4F catheter (Codman) under emergency circumstances. The brachiocephalic trunk’s selective injection demonstrated a difficult to recognize small dot of contrast medium accumulation, which was considered the site of extravasation from the posterior wall of the brachiocephalic trunk to the anterior aspect of the adjacent trachea. We decided to implant a self-expanding stent-graft into the brachiocephalic trunk to seal the vessel wall’s erosion without covering the subclavian artery’s origin. The final DSA run demonstrated no active bleeding, exclusion of the fistula and flow in the right internal carotid, subclavian and vertebral arteries. During the second clinical admission, she died 31 days after the endovascular treatment in the intensive care unit from pulmonary failure
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