From the Guidelines
Tracheo-innominate fistula management requires immediate action with hyperinflation of the tracheostomy tube cuff or digital pressure to control bleeding, followed by urgent surgical intervention, typically ligation of the innominate artery, as stated in the multidisciplinary guidelines for the management of paediatric tracheostomy emergencies 1.
Initial Management
- Controlling bleeding is the first step, which can be achieved by hyperinflating the tracheostomy tube cuff to tamponade the bleeding vessel.
- If the tracheostomy tube cuff is not present or hyperinflation is not possible, intubation of the stoma using a cuffed tracheal tube may be required, with the tube tip placed distal to the fistula, as suggested by the guidelines 1.
- Digital pressure can also be applied via a hyperinflated cuff or directly to the innominate artery site to control bleeding.
Surgical Intervention
- Urgent surgical intervention is necessary, which usually involves ligation of the innominate artery, as recommended by the guidelines 1.
- The surgical approach typically involves a sternotomy to expose the fistula, followed by ligation of the innominate artery and repair of the tracheal defect.
Stabilization and Prevention
- Before surgery, the patient should be stabilized with standard resuscitation measures, including fluid resuscitation and blood transfusions as needed, as stated in the guidelines 1.
- Broad-spectrum antibiotics may be considered to address potential infection, although the specific regimen is not specified in the guidelines 1.
- Prevention is crucial and involves proper tracheostomy tube placement, avoiding excessive cuff pressure, and regular tube position checks to prevent pressure necrosis and erosion into the innominate artery.
From the Research
Management of Tracheo-Innominate Fistula
The management of tracheo-innominate fistula involves several approaches, including:
- Surgical intervention with ligation and resection of the innominate artery at the fistula site, followed by a pectoralis major muscle flap 2
- Division of the innominate artery, restoration of the tracheal fistula with an autologous pericardial patch or direct closure, and aorto-innominate bypass grafting or extra-anatomical bypass grafting with a polytetrafluoroethylene (PTFE) graft 3
- Endovascular stenting as a viable treatment option for managing tracheoinnominate fistula 4, 5
- Innominate artery debridement and tracheal fistula repair, with maintenance of cerebral blood flow through an artificial vascular graft 6
Preventive Surgery
Preventive surgery may be considered for patients with tracheal stenosis who are at high risk for developing tracheo-innominate fistula, and includes:
- Bypass grafting to divide the innominate artery
- Partial resection of the anterior bony thorax (upper sternum, medial part of clavicles, and anterior part of upper ribs if necessary) 3
Key Considerations
- Immediate control of bleeding and transport to the operating room for surgical repair are crucial for successful management of tracheo-innominate fistula 2
- A high index of suspicion and prompt intervention are essential to prevent mortality 2
- The risk of bacterial contamination in the operative field may increase after tracheo-innominate fistula occurs, emphasizing the need for prompt surgical intervention 3