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March 2015, Volume 65, Issue 3

Student's Corner

An Early Tracheo-Innominate Fistula: Lessons Learnt from a Clinical Encounter

Dania Aijaz Shah  ( 3rd Year Student, Medical College, Dow University of Health Sciences, Karachi, Pakistan. )
Adil Aijaz Shah  ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )
Amarah Shakoor  ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )
Saulat Hasnain Fatimi  ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )

Madam, a tracheo-innominate fistula is an infrequent yet life threatening complication which can approach rates of 0.1-1% after a tracheostomy. The incidence peaks1-2 weeks after the procedure.1 Despite immediate surgical intervention, the prognosis remains poor with mortality rates approaching 70% to 90%.2 We encountered an early tracheo-innominate fistula which became evident within 72 hours of a tracheostomy; much sooner than anticipated.
A 50-year old female presented after a traffic accident, in a comatose state, with a sub-dural haematoma diagnosed on CT-scan. After surgical evacuation of the haematoma she underwent a tracheostomy after developing ventilator-associated pneumonia. She began bleeding from the tracheostomy within 72 hours. CT-scan of the neck exhibited a pseudo-aneurysm in the innominate-artery and the presence of an early tracheo-innominate fistula which was confirmed with bronchoscopy. The lesion was approached via median-sternotomy. The artery was adherent to the distal trachea with surrounding abscess formation. After proximal and distal control, the arterial defect was repaired with a saphenous vein-patch (Figures-1 and 2).


Cultures revealed Methicillin-Resistant-Staphylococcus-aureus (MRSA) and Multi-Drug-Resistant-Pseudomonas. Vancomycin and Polymyxin were started. Ventilatory care was withdrawn on the 5th post-operative day after no signs of improvement and re-bleeding.
A higher incidence of tracheo-innominate fistulae is reported in patients with head injuries due to excessive hyper-extension of the neck.3 The pathogenic mechanisms are pressure necrosis from the tube-tip and an angulated neck of the tube rendering the anterior tracheal mucosa ischaemic and eroding the innominate-artery. Haemorrhage control takes priority to prevent hypoxaemia and respiratory compromise.4 Immediate over-inflation of the cuff serves tocompress the damaged artery, allowing the patient to ventilate.2 It also provides a time-window to fully investigate the site of damage.5
Bleeding after tracheostomy indicatesa tracheo-innominate fistulain 95% of cases.4 Despite heroic surgical measures the prognosis is often poor. To see one in a patient this early is rare and unprecedented.


References

1. Epstein SK. Late complications of tracheostomy. Respiratory care 2005;50:542-9.
2. Ogawa K, Nitta N, Sonoda A, Takahashi M, Suzuki T, Kitamura S, et al. Tracheo-brachiocephalic artery fistula after tracheostomy associated with thoracicdeformity: a case report. J Med Case Rep 2011; 5: 595.
3. Kapural L, Sprung J, Gluncic I, Kapural M, Andelinovic S, Primorac D, et al. Tracheo-innominate artery fistula after tracheostomy. Anesth Analg 1999; 88: 777-80.
4. Solanki SL1, Gupta D, Patil VP, Jain M. Tracheo-innominate artery fistula: report of two fatal cases and preventive measures. Anaesth Intensive Care 2013; 41: 807-8.
5. Praveen CV, Martin A. A rare case of fatal haemorrhage after tracheostomy. Ann R Coll Surg Engl 2007; 89: W6-8.

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