How is a tracheostomy-related tracheoinnominate fistula best managed?

Management of Tracheostomy-Related Tracheoinnominate Fistula

The best management for a tracheostomy-related tracheoinnominate fistula is division of the innominate artery and ligation of both fistula ends (option A). 1, 2

Initial Emergency Management

• When a tracheoinnominate fistula is suspected, immediate measures should be taken to control bleeding while preparing for definitive surgical intervention:
  • Hyperinflation of the tracheostomy tube cuff or insertion of a cuffed tracheal tube via the stoma with the tip placed distal to the fistula can temporarily control bleeding 1
  • Digital pressure applied directly to the bleeding site or to the innominate artery against the sternum can help manage immediate hemorrhage 1, 3
  • Standard resuscitation measures should be initiated simultaneously 1

Definitive Surgical Management

• Division of the innominate artery with ligation of both fistula ends is the most effective definitive treatment with the highest survival rate 2, 4
• This approach:
  • Eliminates the source of bleeding permanently 5
  • Prevents rebleeding, which is a common cause of mortality 5
  • Avoids the risk of graft infection that can occur with reconstruction methods 5, 2

Why Other Options Are Less Optimal

• Division with vein graft or polytetrafluoroethylene graft (options B and C):

  • Higher risk of infection in the contaminated field of a tracheal fistula 5, 4
  • Mediastinal infection following reconstruction is a major cause of rebleeding and death 5
  • In a retrospective study of 14 patients, those who underwent reconstruction had higher mortality rates due to mediastinal infection 5

• Primary repair of the innominate artery (option D):

  • Not feasible in most cases due to tissue damage and inflammation at the fistula site 2, 4
  • High risk of dehiscence and rebleeding 4

Surgical Approach

• Median sternotomy is required for proper exposure and control of the proximal and distal innominate artery 2, 4
• The procedure should include:
  • Control of both ends of the innominate artery 4
  • Complete division of the artery at the fistula site 2
  • Secure ligation of both ends 2, 4
  • Debridement of infected or necrotic tissue 5
  • Separation of the tracheal defect from the vascular repair, ideally with viable tissue interposition 4

Post-Surgical Considerations

• Cerebral perfusion is typically maintained through collateral circulation via the circle of Willis 3
• Long-term follow-up studies have shown complete reversal of flow in the right internal and common carotid arteries, confirming adequate collateral circulation 3
• Careful monitoring for neurological complications is necessary, though these are rare with proper surgical technique 2, 3

Prognosis and Outcomes

• Despite optimal management, tracheoinnominate fistula carries a high mortality rate (reported survival rates as low as 7.1%) 5
• Early diagnosis and immediate surgical intervention significantly improve survival chances 2
• Prevention through proper tracheostomy technique and care remains the most effective strategy 5, 2