Management of Tracheoinnominate Fistula
Tracheoinnominate fistula requires immediate cuff hyperinflation or digital pressure to control hemorrhage, followed by urgent surgical ligation and division of the innominate artery, which is the definitive treatment that provides the best chance of survival. 1
Immediate Emergency Management
Suspect tracheoinnominate fistula with any moderate bleeding from the tracheostomy site or pulsation of the tracheostomy tube, as approximately 50% of cases present with a sentinel bleed before massive hemorrhage. 2, 1
Immediate Hemorrhage Control
Hyperinflate the tracheostomy tube cuff if a cuffed tube is present, or immediately intubate the stoma with a cuffed endotracheal tube and advance the tip distal to the fistula site. 2, 1
Apply digital pressure either directly through the stoma to compress the innominate artery against the posterior sternum, or externally at the innominate artery site while preparing for surgery. 2, 1
Initiate standard resuscitation measures simultaneously, including massive transfusion protocol, while arranging immediate transport to the operating room. 2, 1
Critical Pitfall to Avoid
Do not deflate the cuff or remove digital pressure once hemorrhage control is achieved, as rebleeding is universally fatal without immediate surgical access. 2 The pressure applied via the hyperinflated cuff or digital compression is the only barrier preventing exsanguination during transport to the operating room. 2, 1
Definitive Surgical Management
Division and ligation of both ends of the innominate artery is the definitive treatment and provides immediate control of the bleeding source while eliminating the risk of rebleeding. 1 This approach has demonstrated superior outcomes compared to endovascular approaches in the available evidence. 1
Surgical Approach
Median sternotomy is the standard surgical approach for accessing and ligating the innominate artery. 3, 4, 5
Ligate both ends of the divided innominate artery to ensure complete hemostasis and prevent retrograde bleeding. 1, 3
Consider pectoralis major muscle flap coverage of the fistula site to separate the trachea from the vascular stump and reduce infection risk. 3
Post-Operative Considerations
Intensive monitoring is crucial after innominate artery ligation, as mediastinal infection and rebleeding are the primary causes of post-operative mortality. 1, 4 Most patients who survive the initial surgery but subsequently die do so from infectious complications rather than neurological sequelae from innominate artery ligation. 4
Alternative Approaches and Their Limitations
Endovascular stenting has been described as a temporizing measure in select cases, but carries significant risk of stent infection, further tracheal erosion, and recurrent hemorrhage. 6, 7 This approach should only be considered when surgical ligation is not immediately feasible or in patients with terminal conditions where palliation is the goal. 6, 7
The evidence demonstrates that endovascular stents may become infected or erode deeper into the trachea within weeks, leading to recurrent life-threatening hemorrhage. 7
Prognosis and Prevention
The overall survival rate remains extremely poor (approximately 7%) even with prompt surgical intervention, emphasizing the critical importance of prevention. 4 Key preventive measures include:
Proper tracheostomy tube positioning to avoid placement too low in the trachea where the innominate artery crosses anteriorly. 4, 5
Maintaining appropriate cuff pressures (20-30 cm H₂O) to prevent pressure necrosis of the tracheal wall. 2
Immediate investigation of any bleeding from a tracheostomy site, no matter how minor, as sentinel bleeds precede massive hemorrhage in 50% of cases. 2, 1