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

Management of Tracheostomy-Related Tracheoinnominate Fistula

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

Initial Emergency Management

• Immediate control of bleeding is crucial and can be achieved through hyperinflation of the tracheostomy tube cuff or insertion of a cuffed tracheal tube via the stoma with the tip placed distal to the fistula 2
• Digital pressure can be applied either directly or to the innominate artery site while preparing for definitive surgical treatment 2
• A sentinel bleed is reported in approximately 50% of cases, making any bleeding from a tracheostomy site a concerning finding that requires urgent attention 2

Definitive Management Options

• Surgical ligation (division and ligation of both ends of the innominate artery):

  • This is the traditional and most established approach for definitive treatment 1, 3
  • Provides immediate control of the bleeding source and eliminates the risk of rebleeding 3
  • Can be performed with a pectoralis major muscle flap to reinforce the repair and reduce infection risk 3

• Endovascular approaches:

  • More recent alternative involving placement of covered stents or embolization 4, 5
  • Less invasive than open surgical repair with potentially shorter recovery periods 5
  • May be considered as a temporizing measure or in patients who are poor surgical candidates 4
  • Carries potential risk of infection and stent-related complications 4

Clinical Considerations

• Tracheoinnominate fistula is a rare but potentially fatal complication of tracheostomy with high mortality if not treated promptly 3, 6
• Risk factors include low placement of the tracheostomy tube, excessive tube movement, high cuff pressure, and prior radiation therapy 7
• Successful management depends on:
  • High index of suspicion for any tracheostomy bleeding 3
  • Immediate control of bleeding 2
  • Rapid transport to the operating room for definitive treatment 3

Pitfalls and Caveats

• Delayed recognition of a sentinel bleed can lead to catastrophic hemorrhage and death 2
• Primary repair of the innominate artery carries a high risk of rebleeding due to the infected field and ongoing pressure from the tracheostomy tube 3
• Vascular grafts (vein or polytetrafluoroethylene) in this contaminated field have a high risk of infection and subsequent rupture 3
• Division and ligation of the innominate artery is generally well-tolerated due to collateral circulation through the circle of Willis and other vessels 3

Algorithm for Management

1. Recognize bleeding and suspect tracheoinnominate fistula
2. Immediate temporary control (cuff hyperinflation, digital pressure)
3. Urgent surgical exploration
4. Division of the innominate artery with ligation of both ends
5. Consider muscle flap interposition for additional protection
6. Intensive monitoring post-procedure