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Exsanguinating tracheoinnominate artery fistula repaired with endovascular stent-graft
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Surgical Neurology 69 (2008) 306 – 309 www.surgicalneurology-online.com
Technique
Exsanguinating tracheoinnominate artery fistula repaired with endovascular stent-graft Jose´ E. Cohen, MDa,b,4, Alex Klimov, MDb, Gustavo Rajz, MDc, Iddo Paldor, MDa Sergei Spektor, MDa Departments of aNeurosurgery, and bRadiology, Hadassah Hebrew University Hospital, 91120 Jerusalem, Israel c Department of Neurosurgery, Tel Hashomer Medical Center, Tel Aviv, Israel Received 15 December 2006; accepted 27 December 2006
Abstract
Background: Tracheoinnominate artery fistula is a relatively rare but life-threatening complication of tracheostomy. Peristomal bleed or hemoptysis may be massive and usually fatal if treatment is not instituted immediately. Case Description: We report the case of a 40-year-old woman who sustained surgical evacuation of a brainstem cavernoma and developed a massive hemoptysis 13 days after a percutaneous tracheostomy. Because of the patient’s poor clinical condition, endovascular repair of the arterial injury was decided. The innominate artery was successfully repaired by means of urgent stent-graft placement. Conclusions: We believe that, if technically feasible, stent-graft placement can be a valuable therapeutic alternative for this dramatic condition. Physicians in charge of tracheostomized patients and neurointerventionalists should be familiar with this management strategy. D 2008 Elsevier Inc. All rights reserved.
Keywords:
Tracheoinnominate fistula; Hemoptysis; Complication; Tracheostomy; Stent-graft
1. Introduction Tracheoinnominate artery fistula (TIAF) is an uncommon but life-threatening complication of tracheostomy [1,7,10]. In the clinical setting, the occurrence of peristomal bleed or hemoptysis 3 days to 6 weeks after tracheostomy should be considered as the result of a TIAF until proven otherwise [1,7]. These bleedings may be massive and usually fatal if surgery is not performed immediately. Several temporizing maneuvers, such as overinflation of the tracheostomy cuff, endotracheal intubation with cuff overinflation, and digital compression via stoma, can contribute to control the bleeding and improve ventilation to proceed to emergency surgical intervention [1,7,8,10]. Although different surgical approaches have been proposed for the emergency manageAbbreviations: TIAF, Tracheo-innominate artery fistula; IA, Innominate artery. 4 Corresponding author. Departments of Neurosurgery and Radiology, POB 12000, 91120 Jerusalem, Israel. Tel.: +972 2 6777092; fax: +972 2 6416281. E-mail address: [email protected] (J.E. Cohen). 0090-3019/$ – see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2006.12.060
ment of TIAF, they are technically complex in an already debilitated patient and consequently present considerable morbidity and mortality rates [2,5,7]. In this article, we present a patient with poor clinical condition after exsanguinating hemoptysis that was successfully managed by endovascular stent-graft repair.
2. Case report A 40-year-old woman was admitted to the neurosurgical department with a history of sudden neurologic deterioration after a recurrent pontine hemorrhage secondary to a cavernous hemangioma. The patient was operated through a transpetrosal approach, and the cavernous hemangioma was completely removed. After surgery, the patient was alert and oriented, but because of severe deglutition impairment, she was kept intubated for 7 days. Two attempts to perform extubation failed. Inability to remove the endothracheal tube led to an uneventful surgical tracheostomy on day 8. The procedure was performed in the operating room by a senior
J.E. Cohen et al. / Surgical Neurology 69 (2008) 306 – 309
307
necrosis from high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, excessive neck movement, radiotherapy, and prolonged intubation have all been implicated in the pathophysiology of TIAF [1,6,7,8,10]. Successful management of TIAF depends on prompt diagnosis, control of bleeding, and rapid reestablishment of adequate ventilation. Peristomal bleed or hemoptysis 3 days to 6 weeks after tracheostomy should be considered as the result of a TIAF until proven otherwise [1,7]. Tracheoinnominate artery fistula bleedings are usually massive and may rapidly compromise patient ventilation and hemodynamic status. Rapid and effective control of bleeding can be
Fig. 1. Thoracic aortogram showing a small pseudoaneurysm located at the mid third of the IA.
anesthesiologist, and no complications were reported. Thirteen days after tracheostomy, a sudden massive hemorrhage developed via the tracheostomy tube. Adequate ventilation was not possible because of the amount of blood in the major airways. The patient rapidly developed hypoxemia and severe hypotension. The tracheostomy cuff was overinflated, and the bleeding was partially controlled. Intravenous fluids, blood (6 U), and inotropic agents were rapidly administered while the airway was continuously cleared with suction. Ventilation was considered acceptable, hemodynamic parameters were stabilized, and the patient was taken to the neuroangiography suite for an urgent diagnostic angiography. A thoracic aortogram followed by a selective catheterization of the innominate trunk showed a small innominate artery (IA) pseudoaneurysm that was outlined in multiple projections (Figs. 1 and 2). The IA diameter and length were measured (artery diameter 9.5 mm, length 22 mm)—the distance between the pseudoaneurysm and the ostium of the IA and its bifurcation. A premounted stent-graft (Jomed, Abbott Vascular Instruments, Rangendingenn, Germany; 17 mm in length, 6-12 mm in diameter) was placed in the IA, centered at the level of the pseudoaneurysm, and implanted after inflating the balloon to the predetermined diameter (10 mm). The pseudoaneurysm was completely excluded from circulation, and the parent vessels were preserved (Fig. 3). Four weeks later, the tracheostomy cannula was removed with no complications.
3. Discussion Since 1879, the rupture of the IA has been recognized as a relatively rare but potentially fatal complication of tracheostomy [9]. Reported incidence after surgical tracheostomy ranges between 0.1% and 1%, with a peak incidence 7 to 14 days after the procedure [1,7]. Pressure
Fig. 2. Selective subtracted (A) and unsubtracted (B) angiograms of the IA demonstrate the precise site of the arterial injury. Note the relation of the IA, the site of injury, and the tracheal tube.
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J.E. Cohen et al. / Surgical Neurology 69 (2008) 306 – 309
Fig. 3. A: Thoracic aortogram obtained after stent-graft implantation. B: Radioscopic image of the implanted stent.
achieved by overinflating the tracheostomy tube cuff. If this maneuver is not effective, digital compression of the IA via stoma is indicated. If bleeding continues, the endotracheal tube must be repositioned to let the overinflated cuff tamponade the fistula. Once bleeding is controlled, and ventilation and hemodynamic parameters are restored, the patient is generally transferred to the operating theater. As previously reported, diagnostic aortogram may be completely normal [4,12] and is not considered an essential requisite for the surgical planning. Surgical approaches for TIAF are beyond the scope of this discussion but are considered technically complex and are associated with considerable morbidity and mortality rates [2,5,6]. In our case, because of the persistent critical condition of the patient, open surgery was considered highly risky, and the endovascular approach was proposed. The aortogram showed a small IA pseudoaneurysm that was confirmed by selective catheterization of the innominate trunk and
performing repeated angiographic injections in multiple projections for different arterial segments. By using this technique, the exact site of the lesion could be precisely identified. If no aneurysm or vascular abnormalities are demonstrated on angiography, it is assumed that the artery fistula is caused by constant pressure of the inflated cuff or the elbow of the tracheal cannula against the IA, and the site of the IA that crosses the trachea on anteroposterior radioscopic view should be considered the site of the fistula. Since the first report by Parodi et al [11] on the use of stent-grafts for the treatment of abdominal aortic aneurysms, the effectiveness of endovascular stent-grafts has been recognized in many vascular diseases. Deguchi et al [4] reported the first case of endovascular repair of TIAF by means of a stent-graft implantation. Only a few subsequent case reports described endovascular treatment of this emergency, with some authors recommending the endovascular route as a therapy of choice in TIAF in selected cases [4,12]. Endovascular treatment can only be considered after full evaluation of the patient’s vascular anatomy (artery length, diameter, and ostial relations) and the site and characteristics of the injury. Endovascular interventions of the IA are among the most difficult and potentially dangerous procedures [3]. Risk is closely related to vessel anatomy: the proximity of the ostiums of the carotid and subclavian arteries, the relatively large diameter of the artery, and the short vessel length. If the arterial injury is close to a major trunk ostium, the stent-graft may compromise the ostium jeopardizing perfusion of the brain and/or the arm or becoming a potential embolic source. If a precise deployment is desired, balloon-expandable stents are preferred over more unpredictable self-expanding stent deployment. From a practical point of view, the availability of appropriately sized stents can also be a limiting factor for endovascular repair. The potential for graft infection is always a major theoretical concern, and some authors advocate treatment with prophylactic antibiotics after stent-graft implantation [4]. For this case, we selected the transfemoral route, which is the most familiar for most neurointerventionalists. This route presents several other advantages, such as excellent tolerance for the percutaneous placement of large-size introducer sheaths (even a 10F sheath), a straightforward approach to the IA in nontortuous aortic arches, an alternative contralateral femoral approach for pigtail injection if needed, and easy use of arterial closure devices. In conclusion, physicians in charge of tracheostomized patients should be aware of TIAF as a potentially devastating complication of tracheostomy, know the basic maneuvers to control bleeding, and recognize endovascular repair as a valuable alternative approach to surgery. References [1] Allan JS, Wright CD. Tracheoinnominate fistula: diagnosis and management. Chest Surg Clin N Am 2003;13:331 - 41.
J.E. Cohen et al. / Surgical Neurology 69 (2008) 306 – 309 [2] Brewster DC, Moncure AC, Darling RC, Ambrosino JJ, Abbott WM. Innominate artery lesions: problems encountered and lessons learned. J Vasc Surg 1985;2:99 - 112. [3] Criado FJ, Abul-Khoudoud O. Interventional techniques to facilitate supraaortic angioplasty and stenting. Vasc Endovasc Surg 2006; 40:140 - 7. [4] Deguchi J, Furuya T, Tanaka N, Nobori M, Seki Y, Nomura Y, Umehara I, Saito H, Miyata T. Successful management of tracheoinnominate artery fistula with endovascular stent graft repair. J Vasc Surg 2001;33:1280 - 2. [5] Dyer RK, Fisher SR. Tracheal-innominate and tracheal-esophageal fistula. In: Wolfe WG, editor. Complications in thoracic surgery: recognition & management. St Louis7 Mosbi Year Book; 1992. p. 288 - 306. [6] Gelman JJ, Aro M, Weiss SM. Tracheo-innominate artery fistula. J Am Coll Surg 1994;179:626 - 34.
309
[7] Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and clinical review. Br J Anaest 2006;96:127 - 31. [8] Keceligil HT, Erk MK, Kolbakir F, Yildirim A, Yilman M, Unal R. Tracheoinnominate artery fistula following tracheostomy. Cardiovasc Surg 1995;3:509 - 10. [9] Korte W. Ueber einige seltenere nachkrankheiten nach der tracheotomie wegen diphtheritis. Arch Klin Chir 1879;24:238. [10] Nelems JM. Tracheo-innominate artery fistula. Am J Surg 1981; 141:526 - 7. [11] Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991; 5491 - 9. [12] Vianello A, Ragazzi R, Mirri L, Arcaro G, Cutrone C, Fitta C. Tracheoinnominate fistula in a Duchenne muscular dystrophy patient: successful management with an endovascular stent. Neuromuscul Disord 2005;15:569 - 71.
Surgical Neurology 69 (2008) 306 – 309 www.surgicalneurology-online.com
Technique
Exsanguinating tracheoinnominate artery fistula repaired with endovascular stent-graft Jose´ E. Cohen, MDa,b,4, Alex Klimov, MDb, Gustavo Rajz, MDc, Iddo Paldor, MDa Sergei Spektor, MDa Departments of aNeurosurgery, and bRadiology, Hadassah Hebrew University Hospital, 91120 Jerusalem, Israel c Department of Neurosurgery, Tel Hashomer Medical Center, Tel Aviv, Israel Received 15 December 2006; accepted 27 December 2006
Abstract
Background: Tracheoinnominate artery fistula is a relatively rare but life-threatening complication of tracheostomy. Peristomal bleed or hemoptysis may be massive and usually fatal if treatment is not instituted immediately. Case Description: We report the case of a 40-year-old woman who sustained surgical evacuation of a brainstem cavernoma and developed a massive hemoptysis 13 days after a percutaneous tracheostomy. Because of the patient’s poor clinical condition, endovascular repair of the arterial injury was decided. The innominate artery was successfully repaired by means of urgent stent-graft placement. Conclusions: We believe that, if technically feasible, stent-graft placement can be a valuable therapeutic alternative for this dramatic condition. Physicians in charge of tracheostomized patients and neurointerventionalists should be familiar with this management strategy. D 2008 Elsevier Inc. All rights reserved.
Keywords:
Tracheoinnominate fistula; Hemoptysis; Complication; Tracheostomy; Stent-graft
1. Introduction Tracheoinnominate artery fistula (TIAF) is an uncommon but life-threatening complication of tracheostomy [1,7,10]. In the clinical setting, the occurrence of peristomal bleed or hemoptysis 3 days to 6 weeks after tracheostomy should be considered as the result of a TIAF until proven otherwise [1,7]. These bleedings may be massive and usually fatal if surgery is not performed immediately. Several temporizing maneuvers, such as overinflation of the tracheostomy cuff, endotracheal intubation with cuff overinflation, and digital compression via stoma, can contribute to control the bleeding and improve ventilation to proceed to emergency surgical intervention [1,7,8,10]. Although different surgical approaches have been proposed for the emergency manageAbbreviations: TIAF, Tracheo-innominate artery fistula; IA, Innominate artery. 4 Corresponding author. Departments of Neurosurgery and Radiology, POB 12000, 91120 Jerusalem, Israel. Tel.: +972 2 6777092; fax: +972 2 6416281. E-mail address: [email protected] (J.E. Cohen). 0090-3019/$ – see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2006.12.060
ment of TIAF, they are technically complex in an already debilitated patient and consequently present considerable morbidity and mortality rates [2,5,7]. In this article, we present a patient with poor clinical condition after exsanguinating hemoptysis that was successfully managed by endovascular stent-graft repair.
2. Case report A 40-year-old woman was admitted to the neurosurgical department with a history of sudden neurologic deterioration after a recurrent pontine hemorrhage secondary to a cavernous hemangioma. The patient was operated through a transpetrosal approach, and the cavernous hemangioma was completely removed. After surgery, the patient was alert and oriented, but because of severe deglutition impairment, she was kept intubated for 7 days. Two attempts to perform extubation failed. Inability to remove the endothracheal tube led to an uneventful surgical tracheostomy on day 8. The procedure was performed in the operating room by a senior
J.E. Cohen et al. / Surgical Neurology 69 (2008) 306 – 309
307
necrosis from high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, excessive neck movement, radiotherapy, and prolonged intubation have all been implicated in the pathophysiology of TIAF [1,6,7,8,10]. Successful management of TIAF depends on prompt diagnosis, control of bleeding, and rapid reestablishment of adequate ventilation. Peristomal bleed or hemoptysis 3 days to 6 weeks after tracheostomy should be considered as the result of a TIAF until proven otherwise [1,7]. Tracheoinnominate artery fistula bleedings are usually massive and may rapidly compromise patient ventilation and hemodynamic status. Rapid and effective control of bleeding can be
Fig. 1. Thoracic aortogram showing a small pseudoaneurysm located at the mid third of the IA.
anesthesiologist, and no complications were reported. Thirteen days after tracheostomy, a sudden massive hemorrhage developed via the tracheostomy tube. Adequate ventilation was not possible because of the amount of blood in the major airways. The patient rapidly developed hypoxemia and severe hypotension. The tracheostomy cuff was overinflated, and the bleeding was partially controlled. Intravenous fluids, blood (6 U), and inotropic agents were rapidly administered while the airway was continuously cleared with suction. Ventilation was considered acceptable, hemodynamic parameters were stabilized, and the patient was taken to the neuroangiography suite for an urgent diagnostic angiography. A thoracic aortogram followed by a selective catheterization of the innominate trunk showed a small innominate artery (IA) pseudoaneurysm that was outlined in multiple projections (Figs. 1 and 2). The IA diameter and length were measured (artery diameter 9.5 mm, length 22 mm)—the distance between the pseudoaneurysm and the ostium of the IA and its bifurcation. A premounted stent-graft (Jomed, Abbott Vascular Instruments, Rangendingenn, Germany; 17 mm in length, 6-12 mm in diameter) was placed in the IA, centered at the level of the pseudoaneurysm, and implanted after inflating the balloon to the predetermined diameter (10 mm). The pseudoaneurysm was completely excluded from circulation, and the parent vessels were preserved (Fig. 3). Four weeks later, the tracheostomy cannula was removed with no complications.
3. Discussion Since 1879, the rupture of the IA has been recognized as a relatively rare but potentially fatal complication of tracheostomy [9]. Reported incidence after surgical tracheostomy ranges between 0.1% and 1%, with a peak incidence 7 to 14 days after the procedure [1,7]. Pressure
Fig. 2. Selective subtracted (A) and unsubtracted (B) angiograms of the IA demonstrate the precise site of the arterial injury. Note the relation of the IA, the site of injury, and the tracheal tube.
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J.E. Cohen et al. / Surgical Neurology 69 (2008) 306 – 309
Fig. 3. A: Thoracic aortogram obtained after stent-graft implantation. B: Radioscopic image of the implanted stent.
achieved by overinflating the tracheostomy tube cuff. If this maneuver is not effective, digital compression of the IA via stoma is indicated. If bleeding continues, the endotracheal tube must be repositioned to let the overinflated cuff tamponade the fistula. Once bleeding is controlled, and ventilation and hemodynamic parameters are restored, the patient is generally transferred to the operating theater. As previously reported, diagnostic aortogram may be completely normal [4,12] and is not considered an essential requisite for the surgical planning. Surgical approaches for TIAF are beyond the scope of this discussion but are considered technically complex and are associated with considerable morbidity and mortality rates [2,5,6]. In our case, because of the persistent critical condition of the patient, open surgery was considered highly risky, and the endovascular approach was proposed. The aortogram showed a small IA pseudoaneurysm that was confirmed by selective catheterization of the innominate trunk and
performing repeated angiographic injections in multiple projections for different arterial segments. By using this technique, the exact site of the lesion could be precisely identified. If no aneurysm or vascular abnormalities are demonstrated on angiography, it is assumed that the artery fistula is caused by constant pressure of the inflated cuff or the elbow of the tracheal cannula against the IA, and the site of the IA that crosses the trachea on anteroposterior radioscopic view should be considered the site of the fistula. Since the first report by Parodi et al [11] on the use of stent-grafts for the treatment of abdominal aortic aneurysms, the effectiveness of endovascular stent-grafts has been recognized in many vascular diseases. Deguchi et al [4] reported the first case of endovascular repair of TIAF by means of a stent-graft implantation. Only a few subsequent case reports described endovascular treatment of this emergency, with some authors recommending the endovascular route as a therapy of choice in TIAF in selected cases [4,12]. Endovascular treatment can only be considered after full evaluation of the patient’s vascular anatomy (artery length, diameter, and ostial relations) and the site and characteristics of the injury. Endovascular interventions of the IA are among the most difficult and potentially dangerous procedures [3]. Risk is closely related to vessel anatomy: the proximity of the ostiums of the carotid and subclavian arteries, the relatively large diameter of the artery, and the short vessel length. If the arterial injury is close to a major trunk ostium, the stent-graft may compromise the ostium jeopardizing perfusion of the brain and/or the arm or becoming a potential embolic source. If a precise deployment is desired, balloon-expandable stents are preferred over more unpredictable self-expanding stent deployment. From a practical point of view, the availability of appropriately sized stents can also be a limiting factor for endovascular repair. The potential for graft infection is always a major theoretical concern, and some authors advocate treatment with prophylactic antibiotics after stent-graft implantation [4]. For this case, we selected the transfemoral route, which is the most familiar for most neurointerventionalists. This route presents several other advantages, such as excellent tolerance for the percutaneous placement of large-size introducer sheaths (even a 10F sheath), a straightforward approach to the IA in nontortuous aortic arches, an alternative contralateral femoral approach for pigtail injection if needed, and easy use of arterial closure devices. In conclusion, physicians in charge of tracheostomized patients should be aware of TIAF as a potentially devastating complication of tracheostomy, know the basic maneuvers to control bleeding, and recognize endovascular repair as a valuable alternative approach to surgery. References [1] Allan JS, Wright CD. Tracheoinnominate fistula: diagnosis and management. Chest Surg Clin N Am 2003;13:331 - 41.
J.E. Cohen et al. / Surgical Neurology 69 (2008) 306 – 309 [2] Brewster DC, Moncure AC, Darling RC, Ambrosino JJ, Abbott WM. Innominate artery lesions: problems encountered and lessons learned. J Vasc Surg 1985;2:99 - 112. [3] Criado FJ, Abul-Khoudoud O. Interventional techniques to facilitate supraaortic angioplasty and stenting. Vasc Endovasc Surg 2006; 40:140 - 7. [4] Deguchi J, Furuya T, Tanaka N, Nobori M, Seki Y, Nomura Y, Umehara I, Saito H, Miyata T. Successful management of tracheoinnominate artery fistula with endovascular stent graft repair. J Vasc Surg 2001;33:1280 - 2. [5] Dyer RK, Fisher SR. Tracheal-innominate and tracheal-esophageal fistula. In: Wolfe WG, editor. Complications in thoracic surgery: recognition & management. St Louis7 Mosbi Year Book; 1992. p. 288 - 306. [6] Gelman JJ, Aro M, Weiss SM. Tracheo-innominate artery fistula. J Am Coll Surg 1994;179:626 - 34.
309
[7] Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and clinical review. Br J Anaest 2006;96:127 - 31. [8] Keceligil HT, Erk MK, Kolbakir F, Yildirim A, Yilman M, Unal R. Tracheoinnominate artery fistula following tracheostomy. Cardiovasc Surg 1995;3:509 - 10. [9] Korte W. Ueber einige seltenere nachkrankheiten nach der tracheotomie wegen diphtheritis. Arch Klin Chir 1879;24:238. [10] Nelems JM. Tracheo-innominate artery fistula. Am J Surg 1981; 141:526 - 7. [11] Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991; 5491 - 9. [12] Vianello A, Ragazzi R, Mirri L, Arcaro G, Cutrone C, Fitta C. Tracheoinnominate fistula in a Duchenne muscular dystrophy patient: successful management with an endovascular stent. Neuromuscul Disord 2005;15:569 - 71.