Tracheal Innominate Fistula

This is an erosion injury of the innominate artery by a tracheostomy tube. The usual injury is from a low tracheostomy where the lesser curve of the endotra-cheal tube rests up against the innominate artery and causes direct erosion into the posterior portion of the artery. This results in exsanguinating hemorrhage up through the tracheostomy. It should be noted that much more rarely a tracheal innominate fistula is secondary to a correctly placed tracheostomy tube in which the balloon actually erodes into the innominate artery. These patients frequently have a herald bleed in which there is a small amount of blood coming from the tracheostomy rather than the fulminant exsanguinating hemorrhage which these herald bleeds are a harbinger of.

Management of a tracheal innominate fistula requires immediate attention. The immediate methods of achieving some control in the Intensive Care Unit prior to surgery is shown in Figure 24.5 a-d. The patient may be intubated from above, i.e. orotracheally and the tracheostomy tube removed. The cuff of the oral tracheal tube is then inflated up against the bleeding innominate artery. This achieves airway control and temporary control of the bleeding. Finger compression of the fistula is performed while the endotracheal tube is positioned and inflated over the fistula. Another method is to place a rigid bronchoscope and push the tracheostomy tube cuff up against the bleeding innominate artery. The first method is the preferred method for emergency control in the Intensive Care Unit. The patient should be immediately transported to the operating room where a median sternotomy is performed and the innominate artery ligated proximally and distally. No attempt is made to place a graft or otherwise revascularize the innominate artery because the erosion nearly always involves some amount of infected material from the trachea and reactive inflammation around the innominate artery. This lesion has a high mortality, however people have been saved by early aggressive management.

Tracheoinnominate Artery Fistula

Fig 24.5a. Immediate vascular control for tracheoinnominate fistula. In most cases, the inner curve of the tracheostomy has eroded into the innominate artery.

Tracheo Innominate Fistula

Fig 24.5b. Intubation from above is performed.

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