What is the best management for a tracheostomy-related tracheoinnominate fistula?

Management of Tracheostomy-Related Tracheoinnominate Fistula

Division of the innominate artery and ligation of both fistula ends is the best management for a tracheostomy-related tracheoinnominate fistula, as this approach has the lowest rebleeding rate and best long-term survival. 1

Initial Emergency Management

• Tracheoinnominate fistula is a rare but potentially fatal complication of tracheostomy that requires immediate intervention 2
• If bleeding is suspected from a tracheoinnominate fistula, immediate measures should include:
  • Hyperinflation of the tracheostomy tube cuff, if present 3
  • Alternatively, insertion of a cuffed tracheal tube via the stoma with the tip placed distal to the fistula 3
  • Digital pressure can be applied either directly or to the innominate artery site while preparing for definitive treatment 3
• Standard resuscitation measures should occur simultaneously with emergency management 3

Diagnostic Considerations

• A sentinel bleed is reported in approximately 50% of cases, making any bleeding from a tracheostomy site a concerning finding 3
• Moderate bleeding from the stomal site or pulsation of the tracheostomy tube should raise suspicion for a tracheoinnominate fistula 3
• Bronchoscopy and angiography may be performed but are often nondiagnostic 1

Definitive Surgical Management

• Division of the innominate artery and ligation of both fistula ends is the preferred definitive treatment because:

  • It has a very low rebleeding rate (7%) 1
  • It provides good long-term survival (64%) 1
  • There is no convincing evidence that interruption of the innominate artery causes significant neurologic or vascular compromise 1

• Attempting to maintain continuity of the innominate artery (such as with vein grafts or PTFE grafts) is contraindicated due to:

  • High rebleeding rate (60%) 1
  • Poor long-term survival (10%) 1

Alternative Approaches

• Recent advances in endovascular technology have led to reports of successful treatment with:

  • Endovascular embolization of the innominate artery 4
  • Endovascular stent placement 5

• However, these newer techniques:

  • May require multiple coils to inhibit blood flow into the fistula 4
  • Have less long-term outcome data compared to surgical ligation 4, 5
  • Should be considered only when surgical options are not feasible or are contraindicated 4

Surgical Technique Considerations

• Successful management often involves:
  • Ligation and resection of the innominate artery at the fistula site 6
  • Placement of a pectoralis major muscle flap to separate the trachea from the vascular structures 6
  • Immediate control of bleeding with rapid transport to the operating room 6

Important Caveats

• Mortality rates are high if definitive treatment is delayed 2
• Peak incidence of tracheoinnominate fistula occurs 3 days to 6 weeks post-tracheostomy procedure 2
• The reported incidence is 0.1%-1.0% after tracheostomy 2
• Once bleeding occurs from a tracheoinnominate fistula, it is usually fatal without immediate intervention 2