Tracheoarterial Fistula Research Articles

AB094. SOH23ABS_067. Revisiting the role of submental intubation in maxillofacial trauma cases

Background: Airway management in maxillofacial trauma cases can prove particularly challenging as often the conventional methods of intubation are unsuitable. Standard orotracheal intubation may be a hinderance to the surgeon who may need to perform intra-operative maxillomandibular fixation. Nasotracheal intubation, a commonly used alternative is often not appropriate either particularly if there is a nasal fracture or base of skull fracture present. Clear communication between the anaesthetist and surgeon is paramount for successful intubation as both parties are forced to share the same working space. In these types of trauma cases Submental Intubation provides an excellent choice for airway securement. The Submental Intubation technique as an alternative method of airway management was first described in 1986 by Hernandez Altemir. It is a safe and effective method of intubation with a low risk of morbidity. It provides access to maxillofacial fractures without interference from an anaesthetic tube enabling maxillomandibular fixation and access to naso-orbito-ethmoid fractures. It avoids the need for tracheostomy which has many reported complications including post-op bleeding, surgical emphysema, tracheostomy site infections, nerve injury, tracheal stenosis, poor scar aesthetics, tracheoarterial fistula and death. Submental intubation has no associated major complications when compared to tracheostomy.

Tracheoarterial fistula in a patient with amyotrophic lateral sclerosis successfully managed by overinflation of the tracheostomy tube cuff alone: a case report

BackgroundTracheoarterial fistula is the most devastating complication after tracheostomy, and its mortality, without definitive treatment, approaches 100%. In general, the combination of bedside emergency management, that is, overinflation of the tracheostomy tube cuff, and definitive treatment such as surgical or endovascular intervention is necessary to prevent the poor outcome. Patients with neuromuscular diseases such as amyotrophic lateral sclerosis are susceptible to tracheoarterial fistula because of long-term mechanical ventilation and muscle weakness.Case presentationWe describe a case of tracheoarterial fistula in a Japanese 39-year-old patient with amyotrophic lateral sclerosis with long-term ventilator management. The patient was clinically diagnosed with a tracheoarterial fistula because of massive bleeding following sentinel hemorrhage. The massive hemorrhage was controlled by overinflation of the tracheostomy tube cuff alone, without definitive treatment.ConclusionsThis case suggests overinflation of the tracheostomy tube cuff alone plays an important role, semi-permanently, in the management of tracheoarterial fistula, especially in cases where surgical or endovascular intervention is not indicated. Clinicians taking care of patients with tracheostomy undergoing long-term mechanical ventilation should be aware that tracheoarterial fistula might occur following tracheostomy.

Артеріотрахеальна нориця як ускладнення пролонгованої трахеостомії

У статті наведений клінічний випадок рідкісного та тяжкого ускладнення пролонгованої трахеостомії у вигляді формування нориці між просвітом трахеї та брахіоцефальною артерією та розвитку масивної кровотечі з неї. Лікування пацієнта було ургентним й успішним. Пацієнту проведене оперативне втручання з наступним алопротезуванням плечоголовного стовбура (використаний судинний протез Vascutec 8 мм) та формуванням анастомозу методикою безперервного шва. На 17-ту післяопераційну добу пацієнта виписали додому в задовільному стані.

A Computed Tomographic Assessment of Tracheostomy Tube Placement in Patients with Chronic Neurological Disorders: The Prevention of Tracheoarterial Fistula.

Objective Tracheoarterial fistula (TAF) is a rare but devastating complication of tracheostomy caused by pressure necrosis from the elbow, tip, or over-inflated cuff of the tracheostomy tube. The incidence of TAF is reportedly higher in patients with neurological disorders than in those without such disorders. To evaluate the incidence of and factors contributing to the misalignment of tracheostomy tubes in bedridden patients with chronic neurological disorders. Methods We retrospectively assessed three-dimensionally reconstructed serial computed tomography (CT) images to see if the tip of the tube made contact with the tracheal wall and if the main arteries were running adjacent to the tube's elbow, tip or cuff. Results The tip of the tube was in contact with the tracheal wall in 14 of the 30 patients assessed. Among them, the tip was adjacent to the innominate artery in eight, the aortic arch in three and an aberrant right subclavian artery in one. In one patient with the tube tip adjacent to the aortic arch and the other four patients, the cuff of the tube was adjacent to the innominate artery across the tracheal wall. Patients with the tube tip in contact with the anterior tracheal wall had a significantly greater cervical lordosis angle than those without contact (p<0.05). Conclusion More than half of tracheostomized patients with chronic neurological disorders had a latent risk of TAF. The variability in the location of the innominate artery, anomalies of the aortic arch, and skeletal deformities may therefore be contributing factors.

Iatrogenic tracheoarterial fistula: Case report and literature review

Tracheo-innominate fistula is a rare but recognised life-threatening complication most commonly associated with prolonged endotracheal intubation. We report the case of a 16-year-old boy who developed a tracheo-innominate fistula secondary to the prolonged intubation after a pool accident. After 16 days of hospitalisation, the patient died as a consequence of a massive haemorrhage into the tracheobronchial tree and asphyxia. This is a rare complication, and to our knowledge, no case of tracheo-innominate fistula or any other case series concerning this rare complication has been reported in Serbia recently. This case report addresses the epidemiology of a trachea-innominate fistulisation as a complication of prolonged tracheal intubation, with a special overview of its forensic importance as an iatrogenic injury.

Postintubation Tracheoesophageal Fistula - Diagnosis, Treatment and Prognosis.

This article focuses on a sample of 11 patients with postintubation tracheoesophageal fistula, operated in our department between 2005 and 2015. The anterior approach with tracheal resection was performed in 10 of these patients, while an atypical surgical technique was preferred in a case involving a large-sized fistula. Three of these patients were subject to surgery while still on the ventilator, in order to help weaning them from mechanical ventilation. Two patients were operated following a relapse of the fistula, after attempts of closing it in other surgical units. Results: Two patients (of those who were still on mechanical ventilation) died from intubation-related complications that persisted after tracheal resection (anastomotic dehiscence with mediastinitis and tracheoarterial fistula in the brachiocephalic arterial trunk). The nine remaining patients improved, with their airways restored and having regained normal deglutition. Conclusions: The surgical approach of this pathology is successful in surgical units that are specialised in tracheal and oesophageal surgery. Adequately timing the surgery is crucial for a good outcome.

Comparative study between percutaneous dilatation tracheostomy and surgical tracheostomy

Introduction Tracheostomy is one of the most common procedures performed in the ICU. Tracheostomy decreases the dead space and the effort of breathing, and facilitates suction and chest drainage. The easy placement of the tracheostomy tube makes it the only acceptable method for home ventilation. Tracheostomy can be performed either through percutaneous dilatation using the Seldinger technique in the ICU or surgically by an ENT surgeon in the operating room (OR). The approach for tracheostomy, whether percutaneous or surgical, remains a point of debate. Aim This an observational (prospective cohort) study to compare percutaneous dilatation tracheostomy (PDT) with surgical tracheostomy (ST) with regard to both perioperative and late postoperative complications. Patients and methods A total of 200 patients admitted to King Abdulaziz Specialist Hospital between February 2010 and December 2013 were allocated to two groups: group A included 100 patients who had undergone PDT, and group B included 100 patients who had undergone ST. Both perioperative and late postoperative complications were recorded and compared between the two groups. Changes in blood gases, atelectasis, emphysema, pneumothorax, failure to cannulate the trachea or false passage, tracheal ring fractures, wrong site, and tracheal wall injury were considered perioperative complications, whereas bleeding, infection, stenosis, and tracheoarterial and tracheoesophageal fistula were considered late postoperative complications. Results PDT resulted in a significantly higher perioperative complication rate as regards blood gas changes, false passage, and tracheal wall injury, but there was no significant difference with regard to atelectasis, tracheal ring fractures, wrong site, emphysema, and pneumothorax. However, PDT resulted in a significantly lower postoperative complication rate as regards bleeding and infection, but no statistically significant difference was found in the incidence of stenosis. Tracheoarterial and tracheoesophageal fistula were not reported in either PDT or ST. Conclusion PDT is a safe and reliable method for tracheostomy in all ICU cases and is associated with lower incidence of postoperative complications in terms of bleeding and stomal infection.

Trachejos patologija: skubioji chirurgine pagalba pulmonologijoje

Krūtinės (torakalinės) chirurgijos ir pulmonologijos nuolatinė sąveika yra būtina, siekiant užtikrinti visapusišką kvalifikuotą medicinos pagalbą kvėpavimo organų ligomis sergantiems pacientams. Tokio dviejų medicinos disciplinų veiksmingo bendradarbiavimo pavyzdys gali būti skubi pulmonologinė (bronchologinė) ir chirurginė pagalba gydant dažniausiai pasitaikančias trachėjos spindį siaurinančias ligas bei jų komplikacijas. Daugeliu atvejų pulmonologai (bronchologai) pirmieji sutinka tokių ligų ištiktus pacientus, nustato ligos diagnozę ir pradeda gydyti. Skubi (urgentinė) krūtinės chirurgijos intervencija būtina, kai nepakanka (ar iš viso negalima taikyti) pulmonologinių metodų. Šiuo straipsniu siekiama supažindinti su urgentinių chirurginių intervencijų indikacijomis ir galimybėmis ir taip pagerinti pulmonologų, krūtinės chirurgų bei kitų specialybių gydytojų tarpusavio supratimą, diagnostikos ir gydymo veiksmų pereinamumą ir tęstinumą.

Tracheotomy bleeding from an unusual tracheo-arterial fistula: involvement of an aberrant right subclavian artery

The development of a tracheo-arterial fistula is a rare but severe complication of tracheotomy. The reported patient presented with such a fistula involving an aberrant right subclavian artery, termed an arteria lusoria, an aortic arch abnormality which is usually asymptomatic. A 30-year-old man was admitted to our institution for bleeding through his tracheotomy. He had been treated for advanced Duchenne muscular dystrophy, involving invasive assisted ventilation, since the age of 10 years. Surgical exploration and computed tomography scanning revealed a tracheo-arterial fistula involving an aberrant right subclavian artery, associated with severe scoliosis. Emergency, transient haemostasis was achieved by over-inflation of the tracheostomy tube cuff. Aneurysm ablation was successfully achieved as the result of an endovascular interventional radiology procedure. Arteria lusoria is one of the most common aortic arch abnormalities. The occurrence of an aneurysm of this artery in a tracheotomised patient has not previously been described. In Duchenne muscular dystrophy patients, spinal deformities may result in thoracic compression, which may alter the anatomical relations of mediastinal vessels. Such deformities are slowly progressive. Thus, vigilance is required in the long term management of Duchenne muscular dystrophy patients with a tracheostomy.

Hemorrhage due to tracheoarterial fistula with severe motor and intellectual disability

Tracheoarterial fistula (TAF) is an unusual but highly lethal complication of tracheostomy, and successful surgical intervention for TAF has been reported. Few investigations are available for TAF in severe motor and intellectual disability (SMID). The aim of the present paper was to analyzed TAF in SMID to clarify which clinical variables might predict the occurrence of TAF, and adequate management for lifesaving. Medical records at Metropolitan Fuchu Medical Center were retrospectively investigated for SMID between 1970 and 2000, and 10 TAF patients verified on operation or autopsy were identified. Details were reviewed including clinical status, emergency treatment at the occurrence of TAF, and operation and/or autopsy recordings. Four of 10 patients underwent successful operation and survived, while the other six died from hemorrhagic shock. Eight patients had tracheoinnominate artery fistula, the others had tracheocarotid artery fistula. Characteristic features as SMID such as etiology of brain disease, muscle tonus and convulsion were no apparent relevance to occurrence of TAF. All patients suffered from endotracheal granuloma extending to the arterial walls. Seven of 10 patients had re-bleeding after stabilization of the first massive hemorrhage, especially fiber bronchoscopy to confirm the diagnosis of TAF precipitated to fatal re-bleeding. One patient underwent interruption of the artery at relapse of TAF, the other three underwent suturing and had good outcome. There were no apparent predictors of TAF in SMID. Tracheal granuloma was recognized and consequent on formation of TAF, so control of granuloma may prevent TAF. Fiber bronchoscopy for suspected TAF is not recommended because it precipitates fatal bleeding.

A rare case of fatal haemorrhage after tracheostomy

Tracheo-arterial fistula after tracheostomy causing massive haemorrhage is fortunately rare, but can be serious and often fatal. Brachiocephalic trunk is commonly at risk of erosion because of its close relation with the trachea. Factors responsible for fistula are pressure from tube rubbing on the trachea and adjacent vessel, infection, malignant neoplastic invasion of a vessel near the trachea and low tracheostomy. We present a rare case of massive arterial bleeding which happened on the second day and recurred on fifth day, because of slippage of the ligature from the thyroid artery, causing aspiration and death. A low tracheostomy below the third ring should be avoided. If there is bleeding, as a first-aid measure the cuff should be over inflated without removing the tracheostomy tube.

Tracheoesophageal fistula and tracheo-subclavian artery fistula after tracheostomy

Tracheoesophageal fistula and tracheo-arterial fistula are both uncommon but life-threatening complications after a tracheostomy. The most common source of a major hemorrhage is from the tracheo-innominate artery fistula. Most tracheo-arterial fistulas occur within the first 3 weeks after tracheostomy. We describe a very rare case of a patient who developed both a tracheoesophageal fistula and massive hemorrhage from a tracheo-left subclavian artery fistula 4 months after a tracheostomy procedure.

Survival of a child without sequelae after tracheoarterial fistula

Tracheoarterial fistula (TAF) involves erosion through the tracheal wall into the innominate artery resulting in bleeding. It is a rare but lethal complication of tracheostomy. Mortality is 100% without operative interference. Even with appropriate management, a survival rate of only 14.3% has been reported. We report a case of TAF in a child, where rapid institution of resuscitative and operative measures resulted in survival. Initial temporary control of bleeding was achieved by hyperinflation of cuff. Computed tomography (CT) angiography confirmed the diagnosis. The damaged segment of the eroded artery was resected and ligated. This case highlights the role of early diagnosis and prompt aggressive therapy for management of this potentially lethal complication.

Tracheo-arterial fistula in tracheostomy patients with Duchenne muscular dystrophy

A tracheo-arterial fistula is a serious and life threatening potential complication of a tracheostomy. Since 1984, we experienced nine fatal cases of tracheo-arterial fistula among 60 Duchenne muscular dystrophy (DMD) patients who underwent a tracheostomy. Representative cases included a patient with lordosis (Case 8), in whom the fistula was located in the brachiocephalic artery close to the trachea, and another with severe scoliosis (Case 9), which caused the aorta to compress the trachea. Such anatomical changes can be the cause of a fistula between the trachea and brachiocephalic artery. The anatomical locations between the trachea and brachiocephalic artery are modified by thoracic deformities in DMD patients, and should be confirmed using computed tomography (CT) prior to a tracheostomy procedure. Further, during such a procedure, the tracheal stoma must be placed in a location clearly away from the arteries, and should be followed by regular post-operative examinations using CT and careful management to avoid a tracheo-arterial fistula.

The Incidence of Tracheoarterial Fistula in Patients With Chronic Tracheostomy Tubes: A Retrospective Study of 544 Patients in a Long-term Care Facility

<h3>Objective:</h3> The incidence of tracheoarterial fistula (TAF) in patients with short-term tracheostomy tubes has been reported between 0.6% and 0.7%. The purpose of this study was to determine the incidence of TAF in patients with long-term tracheostomy tubes used for the management of chronic respiratory failure. <h3>Setting:</h3> Long-term ventilator facility. <h3>Design:</h3> Retrospective. <h3>Methods:</h3> Medical records of 544 patients admitted to our institution between January 1981 and December 2002 were reviewed. All patients underwent tracheostomy prior to admission to our facility. Patient age, length of stay (LOS), duration of tracheostomy, and serum albumin levels were compared between patients with and without TAF; p values were obtained using the Student unpaired <i>t</i> test for equal variances. <h3>Results:</h3> TAF was diagnosed in five patients. The incidence of TAF in our population was 0.7%. The average age of these patients was significantly less than the study population (31.20 years vs 68.27 years). When one patient outlier was eliminated, LOS was not significant. <h3>Conclusion:</h3> TAF is an uncommon complication of tracheostomy tubes. The incidence of TAF in patients with long-term tracheostomy tubes is similar to that reported in short-term tracheostomy tubes.

Major aorto-pulmonary collateral arteries (MAPCAs)—Bronchial fistula presenting as tracheotomy bleed

Tracheal hemorrhage is a common occurrence in pediatric patients with long-term tracheotomies. The majority of these events are related to self-limited etiologies, such as granulation tissue or suction trauma. Tracheo-arterial fistula, however, represents a frequently fatal form of tracheal hemorrhage that may initially be difficult to distinguish from other causes. Previous reports have described the pathophysiology, presentation and management of tracheo-arterial fistula involving the innominate artery. We describe a case of a 21-month-old male with a history of significant congenital cardiac malformations and chronic tracheotomy tube dependence who presented with intermittent, brisk bleeding from the tracheotomy tube. He was ultimately diagnosed with and treated for an arterio-bronchial fistula from a major aorto-pulmonary collateral artery. We review the etiology and management of this disorder.

Tracheo-Innominate Artery Fistula After Tracheostomy

Tracheo-Innominate Artery Fistula After Tracheostomy

Tracheoarterial fistula: an unusual complication of tracheostomy.

The tracheoarterial fistula is an unusual but devastating complication of tracheostomy. It occurs with a frequency of approximately 0.7%, and it is uniformly fatal if not recognized and surgically corrected. Mucosal damage from the tracheal cannula, pressure necrosis from high cuff pressure, or mucosal trauma from an improperly positioned cannula tip results in erosion through the tracheal wall into the vascular structures that lie in the pretracheal space. Bleeding from this complication almost always occurs late (> 48 hours postprocedure). It is often preceded by sentinel hemoptysis. A paucity of signs and symptoms that precede or are associated with this complication require a high index of clinical suspicion to make the diagnosis. In addition to bleeding, other potential clues include a low-lying tracheostomy tube, pulsation of the tracheostomy tube, and the presence of infection, hypotension, malnutrition, and corticosteroid use. Unfortunately, there are no consistently useful diagnostic tools for tracheoarterial fistula. Fiberoptic bronchoscopy and angiography have been performed with mixed results. Should no other cause be found to explain the hemorrhage from or around the tracheostomy, or from disease distal to the primary carina, the patient must be taken to the operating room for a more definitive examination and possible vascular repair. Management is divided into acute stabilization and support, with protection of the airway and restoration of circulating blood volume, followed by definitive repair should the patient survive. Measures to prevent tracheal damage by the tracheostomy tube, such as proper surgical technique and proper inflation of the tracheostomy tube cuff, may go a long way to avoid this potentially lethal complication. Early consideration of this entity may be what saves the life of its victim.

Ulcération du tronc brachio-céphalique par une canule de trachéotomie

We report the case of a 27-year-old severe head trauma patient who developed an erosion of the brachiocephalic artery, 19 days after the insertion of a tracheal cannula. Emergency treatment included overinflation of the tracheostomy cuff and surgery via sternotomy, with occlusion of the tracheostomy and the tracheo-arterial fistula and reimplantation of the brachiocephalic artery via a vascular prosthesis. This life-threatening complication is due to close anatomic relationships between the trachea and the brachiocephalic artery. In our case, the tip of the cannula eroded the anterior trachea wall resulting in a tracheo-arterial fistula with massive haemorrhage. Warning symptoms such as pulsations of the cannula and aspiration of blood must be recognised without delay and followed by an adequate pre-established management.

Tracheostomies in Burn Patients

The use of tracheostomies in burned patients with inhalation injuries is now reserved for specific indications rather than as prophylactic airway management. A 5-year burn center experience with tracheostomies used in this fashion is presented. Ninety-nine tracheostomies were performed in 3246 patients who had indications of prolonged respiratory failure or acute loss of airway. Although colonization of the sputum was universal, neither rates of pulmonary sepsis nor mortality were significantly increased in patients who underwent tracheostomies. Twenty-eight patients developed late upper airway sequelae, including tracheal stenosis (TS), tracheoesophageal fistula (TEF), and tracheoarterial fistula (TAF). Duration of intubation correlated only with development of TAF, whereas patients in whom TEF developed were significantly older and more likely to have evidence of tracheal necrosis at the time of tracheostomy. The pathogenesis of upper airway sequelae in these patients as divergent responses to the combined insults of inhalation injury, infection, and intubation is considered.