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Trachea–Innominate Artery Fistula: Successful Management or 3 Consecutive Patients
Trachea-Innominate Successful
Patients
Joel 11. Cooper, M.D.
Patient 1 A 13-year-old boy was admitted to the hospital on October 28, 1975, with a head injury sustained when he was struck by an automobile while riding his bicycle. He was comatose on admission, with fixed, dilated pupils and decerebrate posturing. A large frontoparietal hematoma was present. He was immediately taken to the operating room, where a left temporal craniotomy was performed with bilateral frontal burr holes and a right temporal burr hole. An extradural hematoma was found on the left side, and a small subdural hematoma was found on the right side. A tracheostomy was performed at the end of the procedure. Postoperatively the patient showed no recogTrach.ea-innominate artery fistula is an un- nizable improvement, and he continued to have common but usually fatal complication of decerebrate posturing. He was treated with tracheostomy. A recent report by Jones and as- muscle relaxants and ventilatory support. On sociates [4] reviewed 137 cases recorded in the the sixth hospital day bright red bleeding was world literature, with 10 long-term survivors. observed around the tracheostomy tube and Successful management of trachea-innom- from the nasopharynx. After a blood loss of apinate artery fistula requires prompt recogni- proximately 500 ml, the bleeding ceased spontion and a series of specific maneuvers. We taneously. The tracheostomy tube was removed recently managed 3 consecutive patients who and the patient underwent bronchoscopy. No developed trachea-innominate fistula while re- source of bleeding was found. A tracheaceiving ventilatory support through a cuffed innominate artery fistula was suspected. tracheostomy tube. The complication was sucThe tracheostomy tube was removed to processfiilly managed, with long-term survival in vide ready access to the innominate artery, and each case. The purpose of this report is to iden- ventilation was continued through a cuffed orotify criteria for recognition of this complication tracheal tube. Three hours later, massive bleedand to outline in detail the management of these ing recurred from the tracheostomy site. This patients. was promptly controlled with digital pressure through the wound against the posterior aspect of the innominate artery (Fig 1). The patient was From the Division of Thoracic Surgery, 1-131 University Wing, Toronto General Hospital, Toronto, Ont, Canada taken to the operating room while digital control M56-1L7. of the bleeding was maintained. I wish to acknowledge with gratitude the assistance of Drs. The cervical tracheostomy incision was exRivo Ilves, Mladin Rusnow, and Stephen Plume, each of tended to the right, and a vertical midline inciwhom established emergency control of the innominate hemorrhage in 1 of these patients. I also wish to thank the sion was made from the tracheostomy site down staff of the Respiratory Care Unit at the Toronto General to the midsternum. A partial upper median Hospital for their support and assistance. sternotomy was made with horizontal extension Presented at the Thirteenth Annual Meeting of The Society into the right third interspace. This provided of Thoracic Surgeons, Jan 24-26, 1977, San Francisco, CA.
ABSTRACT Trachea-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Three successive patients who developed this complicationwhile receiving ventilatory assistance through a tracheostomy tube were successfully managed, with long-term survival. Bleeding was controlled by direct digital pressure on the innominate artery or by hyperinflation of the balloon cuff of the tracheostomy tube. In 2 patients, replacement of the tracheostomy tube with an orotracheal tube improved direct access to the innominate artery for digital compression. Late follow-up examination of the right carotid circulation revealed complete reversal of flow in the right internal and common carotid arteries in the 2 patients studied.
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Fig 1 . (Patient 1 .) The tracheostomy was placed too low, as seen in A . W h e n premonitory hemorrhage occurred, an orotracheal tube was initially positioned above the tracheostomy tube ( B ) . When bleeding recurred the tracheostomy tube was removed, the orotracheal tube advanced, and digital compression of the innominate artery applied, as seen in C .
good exposure of the ascending aorta, the innominate artery and vein, and the origins of the right common carotid and subclavian arteries. Vascular clamps were placed at the proximal and distal ends of the innominate artery. The trachea-innominate artery fistula was identified at the inferior border of the tracheostomy stoma. It was apparent that the original tracheostomy stoma had been situated approximately at the seventh tracheal ring. The stoma had subsequently enlarged, to leave a defect 3 rings in length and involving the entire anterior half of the tracheal circumference. Only 2 cm of intact trachea remained between the lower border of the stoma and the carina. The soft tissues around the fistula site were grossly infected and foul smelling. Culture of a piece of the innominate artery subsequently yielded anaerobic strep-
tococci, anaerobic diphtheroids, and bacteroides. The innominate artery was resected as completely as possible, with just enough preserved distally to maintain continuity between the right subclavian and right common carotid arteries. The arterial stumps were closed with running arterial suture material and were buried in adjacent soft tissue. The sternotomy was closed with heavy-gauge interrupted stainless steel wire. The neck incision was left widely open for drainage and was packed with sponges soaked in neomycin. The sponges were removed completely and replaced each hour during the next ten days. Initially the aortic suture line was exposed and was visible through the cervical wound. An orotracheal tube, fitted with a low-pressure cuff, was used for postoperative ventilation. The tracheal defect was located too distal to permit the cuff of the orotracheal tube to be placed below the defect, and the cuff was positioned at the level of the defect, through which it protruded anteriorly. After ten days the wound was clean and granulating. At that time the orotracheal tube was removed and the tracheostomy tube was reinserted. Postopera-
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Cooper: Trachea-Innominate Artery Fistula
tively there was no detectable change in the patient’s neurological status. There were no signs of vascular insufficiency in the right hand. Three weeks following resection of the innominate artery, the patient underwent bronchoscopy. There were exuberant granulations at the site of the anterior tracheal defect. In the hope of preventing tracheal narrowing during the healing phase, a No. 14 Montgomery Silastic T-tube was placed in the trachea with the horizontal limb protruding through the stoma. The upper limb extended well above the damaged area of trachea, and the lower limb was shortened so that it ended just above the carina. Twenty-four days following innominate artery resection the sternotomy incision was found to be infected. Because the sternotomy had been a partial one, the infection and nonunion caused no serious problem, and the wound eventually healed with drainage and antibiotic therapy. The patient made a very gradual neurological recovery. Two months following admission he was able to sit up and appeared to be aware of his surroundings. He began to say a few words during his third month in hospital, and at the end of that month he was discharged to the Crippled Children’s Centre for further rehabilitation. He continued to show steady improvement and eventually made a complete physical and neurological recovery with no residual deficit. He was able to make up all lost school work and to rejoin his regular class the following September. The Silastic T-tube was replaced after one month because of partial occlusion with sticky secretions. The new tube remained in place without incident for eight more months before being removed. Bronchoscopy at that time revealed normal tracheal caliber throughout. A tracheogram taken three months later showed no detectable tracheal abnormality. Nine months following innominate artery resection, a directional Doppler apparatus was used to record blood flow in the right arm and in the right internal and common carotid arteries. There was complete reversal of blood flow in the right common and right internal carotid arteries. Blood pressure in the right arm was 80 mm Hg with a somewhat damped arterial wave form. Blood pressure in the left arm was 100 mm Hg.
Patient 2 An 18-year-old girl was admitted on November 28, 1975, following an automobile accident in which she was thrown from the vehicle. She was found unconscious at the roadside and brought to the hospital, where she was found to have multiple rib fractures and paradoxical movement of the chest. She was intubated and given ventilatory support. She was comatose with decerebrate posturing and was believed to have suffered a brainstem injury. Carotid arteriograms were unremarkable. A tracheostomy by means of a cuffed metal Jackson tube, was performed on the fifth hospital day. Six days later, bright red bleeding appeared around the tracheostomy site. Thirty minutes after this discovery the bleeding became very brisk, and a diagnosis of tracheainnominate artery fistula was made. Hyperinflation of the tracheostomy cuff failed to control the hemorrhage completely, and the patient’s distal airway was flooded with blood. With the tracheostomy tube still in place, a rigid bronchoscope was passed through the mouth and down the trachea behind and beyond the tracheostomy tube (Fig 2 ) . This forced the tracheostomy tube and cuff forward against the innominate artery and stopped the hemorrhage. The airway was cleared of blood through the bronchoscope, which was then withdrawn without recurrence of bleeding. An orotracheal tube was placed with its tip remaining proximal to the tracheostomy tube. This provided an alternate airway if removal of the tracheostomy tube became necessary to allow direct digital control of the innominate artery. The patient received 4 units of whole blood and was taken to the operating room, where massive hemorrhage recurred before the operation was begun. The tracheostomy tube was removed, the orotracheal tube was advanced into the distal trachea, and the cuff was inflated. Hemorrhage was controlled by direct digital pressure on the posterior aspect of the innominate artery through the tracheostomy wound. The tracheobronchial tree was irrigated with successive 10 ml aliquots of saline to thin out the blood and allow its removal by suction. The operative procedure in this patient was the same as that for Patient 1. The tracheostomy stoma was found at approximately the fifth
442 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
C
Fig2. (Patient 2.) The tracheostomy tube was positioned too low ( A ) .Hemorrhage from the innominate artery resulted from tube erosion (B). The rigid bronchoscope was passed to clear blood from the airways. Forward pressure on the tracheostomy tube and cuff by the bronchoscope, (C) stopped the bleeding.
tracheal ring, with the innominate fistula at the lower edge of the tracheal defect. The defect in the innominate artery was close to its origin from the aorta. A partially occluding aortic clamp was applied to permit resection of all inflamed or damaged innominate artery, and the proximal suture was placed flush with the aortic arch. Figure 3 depicts the operative findings in this patient. Ventilation was maintained postoperatively with an orotracheal tube fitted with a largevolume, low-pressure cuff. The cuff was positioned distal to the tracheal stoma. Gauze sponges soaked in neomycin were used to pack the open cervical wound, and these were changed hourly during the first seven days. At that time the tracheostomy tube was reinserted through the original stoma and the orotracheal tube was removed. The sternotomy wound healed primarily. The patient was unresponsive, with decorticate posturing prior to and following the in-
nominate artery resection. No change occurred in her clinical status, pupil size, or EEG postoperatively, but as the patient never regained full consciousness, it was not possible to make a complete neurological assessment. The right hand retained excellent color and showed no evidence of vascular insufficiency. The patient was weaned from mechanical ventilation and the tracheostomy tube was removed seven weeks following admission. Three weeks later bronchoscopy was performed to examine the trachea. The tracheal caliber was normal. Granulation tissue was visible anteriorly at the stoma1 site. A blue loop of suture material was seen protruding from this granulation tissue into the lumen of the trachea. This was gently grasped and removed with the biopsy forceps without incident, delivering the entire aortic suture line intact. Presumably the suture had sloughed and migrated to the stoma site. Having failed to regain full consciousness, the patient was transferred to a chronic care hospital eight months following admission. She died one month later. Patient 3 A 35-year-old man was admitted to hospital on January 6,1976, for treatment of scoliosis due to poliomyelitis as a teenager. Several days after
443 Cooper: Trachea-Innominate Artery Fistula
Fig3. (Patient 2.) Operative photograph and line interpretation. T h e innominate artery has been divided distally. The tip of a n instrument has been passed through the divided end of the artery and out the fistula site. T h e balloon cuff of the orotracheal tube is visible through the tracheal defect (arrows).
admission, the patient underwent the first stage of a procedure designed to partially correct the scoliosis. This included use of halopelvic traction and posterior vertebral osteotomies at seven levels. Because of marked respiratory restriction from his deformity, the patient required postoperative ventilatory support, which was administered through an orotracheal tube for two days and subsequently through a tracheostomy tube. The tracheostomy was difficult to perform because of the traction apparatus, but the tracheostomy stoma was placed at the second or third tracheal ring.
Three weeks following tracheostomy the patient developed a massive arterial hemorrhage from the oropharynx. Blood also appeared around the tracheostomy tube, but no blood was present in the airway below it. Initially the hemorrhage was believed to represent massive hematemesis; later it was thought to represent bleeding from the nasopharynx. Nasopharyngeal packing failed to control the hemorrhage, and after 15 units of blood had been transfused, innominate artery hemorrhage was suspected. Hyperinflation of the tracheostomy cuff and forward leverage of the tracheostomy tube promptly stopped all bleeding. An orotracheal tube was passed and left above the tracheostomy tube as an alternate airway in case the tracheostomy tube had to be removed to allow direct digital pressure on the innominate artery (Fig 4). The patient was taken to the operating room with the tracheostomy tube still in place. The tracheostomy incision was extended to the right, and an upper, partial median sternotomy was performed with extension into the right third interspace (as in Patients 1 and 2). The tracheal stoma was found to have enlarged inferiorly to a length of three tracheal rings. The innominate artery was fused to the trachea just at the inferior edge of the elongated stoma. The operative procedure used was the same as for Patients 1 and 2. No neurological alteration resulted from the innominate artery resection, and the right hand maintained excellent color postoperatively. The cervical wound was left open and packed with gauze sponges soaked in neomycin, which were changed hourly for the next ten days. At that time the orotracheal tube was removed and the tracheostomy tube was reinserted. The patient subsequently had a complicated hospital course, including recurrent upper gastrointestinal bleeding, acute cholecystitis, recurrent pneumonia, respiratory failure, peptic stricture of the esophagus, and other problems. He was discharged almost a year later. Measurements of blood flow in the right brachial and carotid arteries were made at nine months by means of the directional Doppler apparatus. There was complete reversal of blood flow in the right internal and right common
444 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
A
B
bleeding episode, even removal of the tracheostomy tube and bronchoscopy may fail to disclose the true source of bleeding. If the source of the bleeding cannot be positively identified and innominate artery hemorrhage excluded, the patient should be taken promptly to the operating room for direct exploration of the neck and upper mediastinum to rule out a tracheainnominate artery fistula. This exploration can be done by enlarging the tracheostomy incision carotid arteries. Blood pressure was 75 mm Hg laterally. It does not require sternotomy. in the right arm and 109 mm Hg in the left arm. When trachea-innominate artery fistula is first suspected, an orotracheal tube should be Comment inserted proximal to the tracheostomy. This In each patient the innominate artery fistula ap- provides for an immediate alternate airway so peared to be the result of direct pressure from that the tracheostomy tube can be removed if the elbow of the tracheal cannula resting against necessary to allow digital access to the posterior the innominate artery, as described by Silen [81 aspect of the innominate artery. The technique in 1964. In the first 2 patients, the tracheostomy of digital control of bleeding from an innomistoma had been placed too low and the compli- nate artery fistula has been described in detail cation was presumably preventable. In the third by Utley and colleagues [9] and basically inpatient, the tracheostomy was correctly placed volves inserting the index finger between the and the complication resulted either from a trachea and the innominate artery and compresshigh-lying innominate artery or to downward ing the artery against the back side of the stermigration of the tracheal cannula from leverage num. Once the diagnosis of innominate artery fison the tube due to the patient’s deformity. A diagnosis of trachea-innominate artery fis- tula is confirmed, a partial upper sternotomy tula should be considered in any patient who with lateral extension into the third interspace has fresh arterial bleeding around or through the should be performed. A complete sternotomy is cannula several days or more after tracheos- not required and is potentially hazardous betomy. A transient premonitory hemorrhage fre- cause the operative field is usually contaminated quently occurs several minutes or hours before and an infected complete sternotomy can be a the major hemorrhage. After such a limited serious complication. With a partial sternotomy, Fig4. (Patient 3 . ) ( A )The tracheostomy tube was correctly placed. Erosion presumably occurred because of a high innominate artery. Trachea-innominate artery fistula was suspected only after loss of 25 units of blood. A t that point, hyperinflation of the cuff and a forward pull on the tracheostomy tube stopped the bleeding promptly ( B ) . The orotracheal tube was inserted to provide an alternate airway in case the tracheostomy tube had to be removed to allow digital compression of the innominate artery.
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Cooper: Trachea-Innominate Artery Fistula
infection and nonunion, such as occurred in Patient l, is a relatively minor problem. Resection of the left innominate vein is not necessary in these instances because adequate exposure can be obtained by retracting the vein superiorly. The decision to resect the innominate artery completely in all patients was based on reports indicating that attempts to repair or reconstruct the innominate artery under these circumstances were frequently followed by rebleeding at the suture line [2, 3, 6, 81. That sacrifice of the innominate artery rarely causes detectable neurological alteration has been well documented [l-91. As far as we could determine, innominate artery sacrifice caused no neurological defect in our 3 patients. We have had additional experience with a 68-year-old woman who underwent innominate artery resection without neurological consequence. Vascular reconstruction through the infected operative field is unwarranted. A carotidcarotid, or right femoral-axillary artery graft, could be established through a clean field if the need for revascularization somehow became apparent following the innominate artery resection. The decision to preserve the right carotidsubclavian bifurcation was based upon concern for the blood supply to the right upper extremity. No patient demonstrated any indication of vascular compromise to the right hand. In 2 patients a weak right radial pulse was palpable postoperatively. In spite of reversal of flow in the right internal carotid artery, symptoms of a subclavian steal have not subsequently appeared in the 2 patients who have completely recovered. The need for postoperative ventilatory support complicated the management of these patients. In each, an orotracheal tube fitted with a low-pressure cuff was used postoperatively. The cervical incision was left open for drainage of the neck and upper mediastinum. The neomycinsoaked sponges, packed into the wound, were changed hourly for at least a week. In 2 patients the proximal innominate suture line was visible through the neck wound and lay in an infected area. Meticulous wound care given by the nursing staff was obviously important in preventing infection and disruption of these suture lines.
After seven to ten days the wounds were clean and granulating, and replacement of the tracheostomy tube through the original stoma presented no hazards. In each patient the anterior tracheal defect was not repaired but was allowed to close by granulation. In Patient 1, who had a major anterior and lateral tracheal defect, a Silastic T-tube was inserted and left in place for nine months to ensure against tracheal stricture during the healing phase. If complete circumferential tracheal damage were present, tracheal stenosis might eventually result even with long-term stenting with a Silastic T-tube. Tracheal resection at a later date, however, seems preferable to tracheal resection at the time of innominate artery resection. This is especially true if continued postoperative ventilatory support is anticipated. The 3 patients presented illustrate the potential for long-term survival following tracheainnominate artery fistula. Such survival was made possible by the absence of other potentially fatal injuries or complications so often occurring in patients who require ventilatory assistance. Innominate artery fistula must be assumed in any patient with major fresh arterial bleeding through or around the tracheostomy site. Spontaneous cessation of the bleeding, or easy control with packing, must not be interpreted as an indication that such a fistula does not exist. In the event of massive hemorrhage from the innominate artery, survival is possible only if good fortune finds someone nearby who recognizes the problem and knows how to obtain emergency control of the hemorrhage. With digital control of the bleeding and establishment of an airway at the bedside, the complication is under control. The patient can then be transfused and transferred to the operating room in an orderly fashion for definitive treatment. References 1. Biller HF, Ebert PA: Innominate artery hemorrhage complicating tracheotomy. Ann Otol Rhino1 Laryngol79:301, 1970 2. Couraud L, Bruneteau A, Chevais R: Hemorragies tracheales cataclysmiques tardives apres tracheotomie. Ann Chir Thorac Cardiovasc 11:1091, 1972
446 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
3. Deslauriers J, Ginsberg RJ, Nelems JM, et al: Innominate artery rupture. Ann, Thorac Surg 20:671, 1975 4. Jones JW, Reynolds M, Hewitt RL, et al: Tracheoinnominate artery erosion. Ann Surg 184:194,1976 5. Mathog RH, Kenan PD, Hudson WR: Delayed massive hemorrhage following tracheostomy. Laryngoscope 81:707, 1971 6. Myers WO, Lawton BR, Sautter RD: An operation for tracheal-innominate artery fistula. Arch Surg 105:269, 1972 7. Reich MP, Rosenkrantz JG: Fistula between innominate artery and trachea. Arch Surg 96:401, 1968 8. Silen W, Spieker D: Fatal hemorrhage from the innominate artery after tracheostomy. Ann Surg 162:1005, 1965 9. Utley JR, Singer MM, Roe BB, et al: Definitive management of innominate artery hemorrhage complicating tracheostomy. JAMA 220:577, 1972
We also believe that attempts should be made to protect the tracheal or arterial suture line, if possible, by interposing soft tissue, muscle, or even pericardium.
c. GRILLO (Boston, MA): I want fo emphasize that with tracheostomy tubes in place, there are two basic types of fistulization. These differ in etiology, emergency treatment, definitive treatment, and prevention. Years ago Dr. Silen wrote about the more common type in which the inner ”elbow” of the tracheostomy tube erodes the artery lying immediately below the stoma. It is interesting to note that 2 of Dr. Cooper’s patients were young. This type of erosion occurs more easily in young persons. Because the trachea and innominate artery rise up on cervical extension, the tracheostomy is placed too low in the trachea. This is the principal origin of such stoma1 tracheainnominate artery fistulas. Other trachea-innominate fistulas result from Discussion high-pressure cuffs eroding directly through the DR. JAMES s. DONAHOO (Baltimore, MD): We too have walls (as in Patient 3 in the present study). The had experience with 3 patients who have had recent emergency management that we have used in stoma1 trachea-innominate artery fistulas. All 3 patients had erosion has been digital pressure plus insertion of an tracheal resection: 2 had primary tracheal anas- airway. When the erosion occurred some distance tomoses and 1 had insertion of a Nevi11 prosthetic below the stoma, alert residents have used an endodevice. AlI developed severe hemorrhage after this tracheal tube with a high-pressure cuff to tamponade and usually demonstrated a premonitory show of the hole until the patient could be operated on. minor bleeding. In the first group the artery should be resected. The Unlike Dr. Cooper, we performed arterial bypass stoma remains and heals on its own. If stenosis occurs on all 3 patients. One patient had a vein graft placed later, it is then repaired. On the other hand, if fistulas between the arch of the aorta and the carotid artery; 1 result from high-pressure cuffs-which are being had a carotid-carotid bypass, and 1underwent axil- used less and less-ne should usually resect the lofemoral bypass. Although 1 patient died of a my- tracheal segment concomitantly with resection of the cotic aneurysm of the aortic arch, 2 are living two innominate artery. years postoperatively without neurological sequelae. In our experience with at least 8 patients, drawn not Very frequently a trachea-innominate artery fistula entirely from the aforementioned group, in whom the can be subtle on arteriographic demonstration. In 1 innominate artery had been resected for acute hemorpatient who was operated on through a sternotomy rhage, no neurological problems have resulted. Their incision, a vein graft was utilized to bypass the in- ages ranged upward to 55 years. We therefore support fected area. Dr. Cooper’s approach and prefer not to introduce When there is a resected aneurysm and interpolated into a contaminated field what I think is the threatengraft, we like to place as much soft tissue as we can ing problem of vascular reconstitution. between the trachea and the suture line. We think this may protect the arterial suture line. We agree with Dr. Cooper that a high index of DR. JOE R . UTLEY (Lexington, KY): We have treated 3 suspicion should be maintained in any patient with a patients who survived this complication. I think our tracheal resection or tracheostomy, even if hemop- basic approach, with only minor differences, has tysis is apparently minor. Arteriograms should be been similar to that described by Dr. Cooper. taken and an operating room should be made ready It is important to recognize that there are still many immediately for an operative approach. We think that patients dying from trachea-innominate artery fisa vein bypass or some type of arterial bypass should tulas because of low tracheostomy. The physician be performed first, if this is possible without jeopar- available to them at the time of the bleeding often dizing the patient. Whereas Dr. Cooper has shown doesn’t know that the immediate treatment is digital that his patients have experienced no immediate neu- pressure on the fistula. We emphasize this to our rological complications, the late results of depriving junior residents, general surgeons, and otolarynthe brain of blood may not be readily apparent in gologists who manage a large number of patients with tracheostomies. short-term follow-up. DR. HERMES
447 Cooper: Trachea-Innominate Artery Fistula
The other common error is failure to recognize the bleeding as arterial because the patient is hypoxic and the blood is black. Frequently we find that it is described as venous bleeding, when actually it is coming from the artery but the patient is very hypoxic. Dr. Cooper has emphasized resecting the innominate artery and packing open the tracheostomy site. We have taken an alternative approach, that of not resecting any innominate artery but merely suturing it shut, closing the tracheostomy, placing a tracheal stoma at a higher position, or using an orotracheal tube for several days. This is a situation in which cricothyroidotomy may be helpful, but we have merely taken the opposite tack of trying to close the trachea and not resect the innominate artery. Patients can live without their innominate artery without any immediate neurological deficit, and it is possible in the long term that they might need some sort of cervical bypass approach. DR. RICHARD N . EDIE (New York, NY): We agree with Dr. Cooper’s aggressive diagnostic and therapeutic approach to this problem. We would like to comment on one aspect of the operative management. Once the presence of the fistula is demonstrated by arteriotomy, it is necessary to resect the innominate artery completely. The proximal end is oversewn first and allowed to retract inferiorly. However, the distal end of the innominate artery will not retract superiorly and laterally due to the two-point fixation of the junction of the right common carotid and right subclavian arteries. Thus we believe it is necessary to divide and ligate these two arteries individually so as to allow for their adequate retraction from the infected operative field. This maneuver will decrease the chance of a later vascular complication. D R . COOPER: I thank the discussants for their comments. I agree with Dr. Ferguson’s statements in his
presidential address (Ann Thorac Surg 24:6, 1977) to the effect that those who have failed to learn the lessons of history are doomed to repeat them. But somehow I am being forced to go through purgatory due to the errors of others who haven’t learned the history of innominate artery injury with low-lying tracheostomies. In reviewing the operative note on 1 case, I noticed that the resident had indeed counted the tracheal rings and duly recorded that the stoma was placed in the second and third rings. In this patient, the stoma was actually in the seventh and eighth rings; maybe the resident was counting from the wrong end. I would like to congratulate Dr. Donahoo on his successful revascularization. I do think, however, that under the circumstances perhaps it represents an unwarranted hazard, because we hear increasingly that people will tolerate resection of the innominate artery. Two of our patients have survived a year after resection with no apparent neurological problems. I would like to thank Dr. Grillo, not only for his comments but for the personal instruction he has given me over the years, including the management of this type of problem. Dr. Edie’s remark on the upward retraction of suture lines is important. We have left the carotid-subclavian axis in place but dissected it out enough so that we could bury it well behind the sternocleidomastoid muscle. Finally, as we have pointed out, Dr. Utley previously documented the maneuver of digital compression of the innominate artery. He thus popularized a maneuver previously recorded by the famous Von Spondom of Holland, better known to you as Peter, the young boy who put his finger in the dike. Dr. Utley’s previous manuscript pointed out how to apply this maneuver successfully to the innominate artery.
Patients
Joel 11. Cooper, M.D.
Patient 1 A 13-year-old boy was admitted to the hospital on October 28, 1975, with a head injury sustained when he was struck by an automobile while riding his bicycle. He was comatose on admission, with fixed, dilated pupils and decerebrate posturing. A large frontoparietal hematoma was present. He was immediately taken to the operating room, where a left temporal craniotomy was performed with bilateral frontal burr holes and a right temporal burr hole. An extradural hematoma was found on the left side, and a small subdural hematoma was found on the right side. A tracheostomy was performed at the end of the procedure. Postoperatively the patient showed no recogTrach.ea-innominate artery fistula is an un- nizable improvement, and he continued to have common but usually fatal complication of decerebrate posturing. He was treated with tracheostomy. A recent report by Jones and as- muscle relaxants and ventilatory support. On sociates [4] reviewed 137 cases recorded in the the sixth hospital day bright red bleeding was world literature, with 10 long-term survivors. observed around the tracheostomy tube and Successful management of trachea-innom- from the nasopharynx. After a blood loss of apinate artery fistula requires prompt recogni- proximately 500 ml, the bleeding ceased spontion and a series of specific maneuvers. We taneously. The tracheostomy tube was removed recently managed 3 consecutive patients who and the patient underwent bronchoscopy. No developed trachea-innominate fistula while re- source of bleeding was found. A tracheaceiving ventilatory support through a cuffed innominate artery fistula was suspected. tracheostomy tube. The complication was sucThe tracheostomy tube was removed to processfiilly managed, with long-term survival in vide ready access to the innominate artery, and each case. The purpose of this report is to iden- ventilation was continued through a cuffed orotify criteria for recognition of this complication tracheal tube. Three hours later, massive bleedand to outline in detail the management of these ing recurred from the tracheostomy site. This patients. was promptly controlled with digital pressure through the wound against the posterior aspect of the innominate artery (Fig 1). The patient was From the Division of Thoracic Surgery, 1-131 University Wing, Toronto General Hospital, Toronto, Ont, Canada taken to the operating room while digital control M56-1L7. of the bleeding was maintained. I wish to acknowledge with gratitude the assistance of Drs. The cervical tracheostomy incision was exRivo Ilves, Mladin Rusnow, and Stephen Plume, each of tended to the right, and a vertical midline inciwhom established emergency control of the innominate hemorrhage in 1 of these patients. I also wish to thank the sion was made from the tracheostomy site down staff of the Respiratory Care Unit at the Toronto General to the midsternum. A partial upper median Hospital for their support and assistance. sternotomy was made with horizontal extension Presented at the Thirteenth Annual Meeting of The Society into the right third interspace. This provided of Thoracic Surgeons, Jan 24-26, 1977, San Francisco, CA.
ABSTRACT Trachea-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Three successive patients who developed this complicationwhile receiving ventilatory assistance through a tracheostomy tube were successfully managed, with long-term survival. Bleeding was controlled by direct digital pressure on the innominate artery or by hyperinflation of the balloon cuff of the tracheostomy tube. In 2 patients, replacement of the tracheostomy tube with an orotracheal tube improved direct access to the innominate artery for digital compression. Late follow-up examination of the right carotid circulation revealed complete reversal of flow in the right internal and common carotid arteries in the 2 patients studied.
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440 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
Fig 1 . (Patient 1 .) The tracheostomy was placed too low, as seen in A . W h e n premonitory hemorrhage occurred, an orotracheal tube was initially positioned above the tracheostomy tube ( B ) . When bleeding recurred the tracheostomy tube was removed, the orotracheal tube advanced, and digital compression of the innominate artery applied, as seen in C .
good exposure of the ascending aorta, the innominate artery and vein, and the origins of the right common carotid and subclavian arteries. Vascular clamps were placed at the proximal and distal ends of the innominate artery. The trachea-innominate artery fistula was identified at the inferior border of the tracheostomy stoma. It was apparent that the original tracheostomy stoma had been situated approximately at the seventh tracheal ring. The stoma had subsequently enlarged, to leave a defect 3 rings in length and involving the entire anterior half of the tracheal circumference. Only 2 cm of intact trachea remained between the lower border of the stoma and the carina. The soft tissues around the fistula site were grossly infected and foul smelling. Culture of a piece of the innominate artery subsequently yielded anaerobic strep-
tococci, anaerobic diphtheroids, and bacteroides. The innominate artery was resected as completely as possible, with just enough preserved distally to maintain continuity between the right subclavian and right common carotid arteries. The arterial stumps were closed with running arterial suture material and were buried in adjacent soft tissue. The sternotomy was closed with heavy-gauge interrupted stainless steel wire. The neck incision was left widely open for drainage and was packed with sponges soaked in neomycin. The sponges were removed completely and replaced each hour during the next ten days. Initially the aortic suture line was exposed and was visible through the cervical wound. An orotracheal tube, fitted with a low-pressure cuff, was used for postoperative ventilation. The tracheal defect was located too distal to permit the cuff of the orotracheal tube to be placed below the defect, and the cuff was positioned at the level of the defect, through which it protruded anteriorly. After ten days the wound was clean and granulating. At that time the orotracheal tube was removed and the tracheostomy tube was reinserted. Postopera-
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tively there was no detectable change in the patient’s neurological status. There were no signs of vascular insufficiency in the right hand. Three weeks following resection of the innominate artery, the patient underwent bronchoscopy. There were exuberant granulations at the site of the anterior tracheal defect. In the hope of preventing tracheal narrowing during the healing phase, a No. 14 Montgomery Silastic T-tube was placed in the trachea with the horizontal limb protruding through the stoma. The upper limb extended well above the damaged area of trachea, and the lower limb was shortened so that it ended just above the carina. Twenty-four days following innominate artery resection the sternotomy incision was found to be infected. Because the sternotomy had been a partial one, the infection and nonunion caused no serious problem, and the wound eventually healed with drainage and antibiotic therapy. The patient made a very gradual neurological recovery. Two months following admission he was able to sit up and appeared to be aware of his surroundings. He began to say a few words during his third month in hospital, and at the end of that month he was discharged to the Crippled Children’s Centre for further rehabilitation. He continued to show steady improvement and eventually made a complete physical and neurological recovery with no residual deficit. He was able to make up all lost school work and to rejoin his regular class the following September. The Silastic T-tube was replaced after one month because of partial occlusion with sticky secretions. The new tube remained in place without incident for eight more months before being removed. Bronchoscopy at that time revealed normal tracheal caliber throughout. A tracheogram taken three months later showed no detectable tracheal abnormality. Nine months following innominate artery resection, a directional Doppler apparatus was used to record blood flow in the right arm and in the right internal and common carotid arteries. There was complete reversal of blood flow in the right common and right internal carotid arteries. Blood pressure in the right arm was 80 mm Hg with a somewhat damped arterial wave form. Blood pressure in the left arm was 100 mm Hg.
Patient 2 An 18-year-old girl was admitted on November 28, 1975, following an automobile accident in which she was thrown from the vehicle. She was found unconscious at the roadside and brought to the hospital, where she was found to have multiple rib fractures and paradoxical movement of the chest. She was intubated and given ventilatory support. She was comatose with decerebrate posturing and was believed to have suffered a brainstem injury. Carotid arteriograms were unremarkable. A tracheostomy by means of a cuffed metal Jackson tube, was performed on the fifth hospital day. Six days later, bright red bleeding appeared around the tracheostomy site. Thirty minutes after this discovery the bleeding became very brisk, and a diagnosis of tracheainnominate artery fistula was made. Hyperinflation of the tracheostomy cuff failed to control the hemorrhage completely, and the patient’s distal airway was flooded with blood. With the tracheostomy tube still in place, a rigid bronchoscope was passed through the mouth and down the trachea behind and beyond the tracheostomy tube (Fig 2 ) . This forced the tracheostomy tube and cuff forward against the innominate artery and stopped the hemorrhage. The airway was cleared of blood through the bronchoscope, which was then withdrawn without recurrence of bleeding. An orotracheal tube was placed with its tip remaining proximal to the tracheostomy tube. This provided an alternate airway if removal of the tracheostomy tube became necessary to allow direct digital control of the innominate artery. The patient received 4 units of whole blood and was taken to the operating room, where massive hemorrhage recurred before the operation was begun. The tracheostomy tube was removed, the orotracheal tube was advanced into the distal trachea, and the cuff was inflated. Hemorrhage was controlled by direct digital pressure on the posterior aspect of the innominate artery through the tracheostomy wound. The tracheobronchial tree was irrigated with successive 10 ml aliquots of saline to thin out the blood and allow its removal by suction. The operative procedure in this patient was the same as that for Patient 1. The tracheostomy stoma was found at approximately the fifth
442 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
C
Fig2. (Patient 2.) The tracheostomy tube was positioned too low ( A ) .Hemorrhage from the innominate artery resulted from tube erosion (B). The rigid bronchoscope was passed to clear blood from the airways. Forward pressure on the tracheostomy tube and cuff by the bronchoscope, (C) stopped the bleeding.
tracheal ring, with the innominate fistula at the lower edge of the tracheal defect. The defect in the innominate artery was close to its origin from the aorta. A partially occluding aortic clamp was applied to permit resection of all inflamed or damaged innominate artery, and the proximal suture was placed flush with the aortic arch. Figure 3 depicts the operative findings in this patient. Ventilation was maintained postoperatively with an orotracheal tube fitted with a largevolume, low-pressure cuff. The cuff was positioned distal to the tracheal stoma. Gauze sponges soaked in neomycin were used to pack the open cervical wound, and these were changed hourly during the first seven days. At that time the tracheostomy tube was reinserted through the original stoma and the orotracheal tube was removed. The sternotomy wound healed primarily. The patient was unresponsive, with decorticate posturing prior to and following the in-
nominate artery resection. No change occurred in her clinical status, pupil size, or EEG postoperatively, but as the patient never regained full consciousness, it was not possible to make a complete neurological assessment. The right hand retained excellent color and showed no evidence of vascular insufficiency. The patient was weaned from mechanical ventilation and the tracheostomy tube was removed seven weeks following admission. Three weeks later bronchoscopy was performed to examine the trachea. The tracheal caliber was normal. Granulation tissue was visible anteriorly at the stoma1 site. A blue loop of suture material was seen protruding from this granulation tissue into the lumen of the trachea. This was gently grasped and removed with the biopsy forceps without incident, delivering the entire aortic suture line intact. Presumably the suture had sloughed and migrated to the stoma site. Having failed to regain full consciousness, the patient was transferred to a chronic care hospital eight months following admission. She died one month later. Patient 3 A 35-year-old man was admitted to hospital on January 6,1976, for treatment of scoliosis due to poliomyelitis as a teenager. Several days after
443 Cooper: Trachea-Innominate Artery Fistula
Fig3. (Patient 2.) Operative photograph and line interpretation. T h e innominate artery has been divided distally. The tip of a n instrument has been passed through the divided end of the artery and out the fistula site. T h e balloon cuff of the orotracheal tube is visible through the tracheal defect (arrows).
admission, the patient underwent the first stage of a procedure designed to partially correct the scoliosis. This included use of halopelvic traction and posterior vertebral osteotomies at seven levels. Because of marked respiratory restriction from his deformity, the patient required postoperative ventilatory support, which was administered through an orotracheal tube for two days and subsequently through a tracheostomy tube. The tracheostomy was difficult to perform because of the traction apparatus, but the tracheostomy stoma was placed at the second or third tracheal ring.
Three weeks following tracheostomy the patient developed a massive arterial hemorrhage from the oropharynx. Blood also appeared around the tracheostomy tube, but no blood was present in the airway below it. Initially the hemorrhage was believed to represent massive hematemesis; later it was thought to represent bleeding from the nasopharynx. Nasopharyngeal packing failed to control the hemorrhage, and after 15 units of blood had been transfused, innominate artery hemorrhage was suspected. Hyperinflation of the tracheostomy cuff and forward leverage of the tracheostomy tube promptly stopped all bleeding. An orotracheal tube was passed and left above the tracheostomy tube as an alternate airway in case the tracheostomy tube had to be removed to allow direct digital pressure on the innominate artery (Fig 4). The patient was taken to the operating room with the tracheostomy tube still in place. The tracheostomy incision was extended to the right, and an upper, partial median sternotomy was performed with extension into the right third interspace (as in Patients 1 and 2). The tracheal stoma was found to have enlarged inferiorly to a length of three tracheal rings. The innominate artery was fused to the trachea just at the inferior edge of the elongated stoma. The operative procedure used was the same as for Patients 1 and 2. No neurological alteration resulted from the innominate artery resection, and the right hand maintained excellent color postoperatively. The cervical wound was left open and packed with gauze sponges soaked in neomycin, which were changed hourly for the next ten days. At that time the orotracheal tube was removed and the tracheostomy tube was reinserted. The patient subsequently had a complicated hospital course, including recurrent upper gastrointestinal bleeding, acute cholecystitis, recurrent pneumonia, respiratory failure, peptic stricture of the esophagus, and other problems. He was discharged almost a year later. Measurements of blood flow in the right brachial and carotid arteries were made at nine months by means of the directional Doppler apparatus. There was complete reversal of blood flow in the right internal and right common
444 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
A
B
bleeding episode, even removal of the tracheostomy tube and bronchoscopy may fail to disclose the true source of bleeding. If the source of the bleeding cannot be positively identified and innominate artery hemorrhage excluded, the patient should be taken promptly to the operating room for direct exploration of the neck and upper mediastinum to rule out a tracheainnominate artery fistula. This exploration can be done by enlarging the tracheostomy incision carotid arteries. Blood pressure was 75 mm Hg laterally. It does not require sternotomy. in the right arm and 109 mm Hg in the left arm. When trachea-innominate artery fistula is first suspected, an orotracheal tube should be Comment inserted proximal to the tracheostomy. This In each patient the innominate artery fistula ap- provides for an immediate alternate airway so peared to be the result of direct pressure from that the tracheostomy tube can be removed if the elbow of the tracheal cannula resting against necessary to allow digital access to the posterior the innominate artery, as described by Silen [81 aspect of the innominate artery. The technique in 1964. In the first 2 patients, the tracheostomy of digital control of bleeding from an innomistoma had been placed too low and the compli- nate artery fistula has been described in detail cation was presumably preventable. In the third by Utley and colleagues [9] and basically inpatient, the tracheostomy was correctly placed volves inserting the index finger between the and the complication resulted either from a trachea and the innominate artery and compresshigh-lying innominate artery or to downward ing the artery against the back side of the stermigration of the tracheal cannula from leverage num. Once the diagnosis of innominate artery fison the tube due to the patient’s deformity. A diagnosis of trachea-innominate artery fis- tula is confirmed, a partial upper sternotomy tula should be considered in any patient who with lateral extension into the third interspace has fresh arterial bleeding around or through the should be performed. A complete sternotomy is cannula several days or more after tracheos- not required and is potentially hazardous betomy. A transient premonitory hemorrhage fre- cause the operative field is usually contaminated quently occurs several minutes or hours before and an infected complete sternotomy can be a the major hemorrhage. After such a limited serious complication. With a partial sternotomy, Fig4. (Patient 3 . ) ( A )The tracheostomy tube was correctly placed. Erosion presumably occurred because of a high innominate artery. Trachea-innominate artery fistula was suspected only after loss of 25 units of blood. A t that point, hyperinflation of the cuff and a forward pull on the tracheostomy tube stopped the bleeding promptly ( B ) . The orotracheal tube was inserted to provide an alternate airway in case the tracheostomy tube had to be removed to allow digital compression of the innominate artery.
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infection and nonunion, such as occurred in Patient l, is a relatively minor problem. Resection of the left innominate vein is not necessary in these instances because adequate exposure can be obtained by retracting the vein superiorly. The decision to resect the innominate artery completely in all patients was based on reports indicating that attempts to repair or reconstruct the innominate artery under these circumstances were frequently followed by rebleeding at the suture line [2, 3, 6, 81. That sacrifice of the innominate artery rarely causes detectable neurological alteration has been well documented [l-91. As far as we could determine, innominate artery sacrifice caused no neurological defect in our 3 patients. We have had additional experience with a 68-year-old woman who underwent innominate artery resection without neurological consequence. Vascular reconstruction through the infected operative field is unwarranted. A carotidcarotid, or right femoral-axillary artery graft, could be established through a clean field if the need for revascularization somehow became apparent following the innominate artery resection. The decision to preserve the right carotidsubclavian bifurcation was based upon concern for the blood supply to the right upper extremity. No patient demonstrated any indication of vascular compromise to the right hand. In 2 patients a weak right radial pulse was palpable postoperatively. In spite of reversal of flow in the right internal carotid artery, symptoms of a subclavian steal have not subsequently appeared in the 2 patients who have completely recovered. The need for postoperative ventilatory support complicated the management of these patients. In each, an orotracheal tube fitted with a low-pressure cuff was used postoperatively. The cervical incision was left open for drainage of the neck and upper mediastinum. The neomycinsoaked sponges, packed into the wound, were changed hourly for at least a week. In 2 patients the proximal innominate suture line was visible through the neck wound and lay in an infected area. Meticulous wound care given by the nursing staff was obviously important in preventing infection and disruption of these suture lines.
After seven to ten days the wounds were clean and granulating, and replacement of the tracheostomy tube through the original stoma presented no hazards. In each patient the anterior tracheal defect was not repaired but was allowed to close by granulation. In Patient 1, who had a major anterior and lateral tracheal defect, a Silastic T-tube was inserted and left in place for nine months to ensure against tracheal stricture during the healing phase. If complete circumferential tracheal damage were present, tracheal stenosis might eventually result even with long-term stenting with a Silastic T-tube. Tracheal resection at a later date, however, seems preferable to tracheal resection at the time of innominate artery resection. This is especially true if continued postoperative ventilatory support is anticipated. The 3 patients presented illustrate the potential for long-term survival following tracheainnominate artery fistula. Such survival was made possible by the absence of other potentially fatal injuries or complications so often occurring in patients who require ventilatory assistance. Innominate artery fistula must be assumed in any patient with major fresh arterial bleeding through or around the tracheostomy site. Spontaneous cessation of the bleeding, or easy control with packing, must not be interpreted as an indication that such a fistula does not exist. In the event of massive hemorrhage from the innominate artery, survival is possible only if good fortune finds someone nearby who recognizes the problem and knows how to obtain emergency control of the hemorrhage. With digital control of the bleeding and establishment of an airway at the bedside, the complication is under control. The patient can then be transfused and transferred to the operating room in an orderly fashion for definitive treatment. References 1. Biller HF, Ebert PA: Innominate artery hemorrhage complicating tracheotomy. Ann Otol Rhino1 Laryngol79:301, 1970 2. Couraud L, Bruneteau A, Chevais R: Hemorragies tracheales cataclysmiques tardives apres tracheotomie. Ann Chir Thorac Cardiovasc 11:1091, 1972
446 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
3. Deslauriers J, Ginsberg RJ, Nelems JM, et al: Innominate artery rupture. Ann, Thorac Surg 20:671, 1975 4. Jones JW, Reynolds M, Hewitt RL, et al: Tracheoinnominate artery erosion. Ann Surg 184:194,1976 5. Mathog RH, Kenan PD, Hudson WR: Delayed massive hemorrhage following tracheostomy. Laryngoscope 81:707, 1971 6. Myers WO, Lawton BR, Sautter RD: An operation for tracheal-innominate artery fistula. Arch Surg 105:269, 1972 7. Reich MP, Rosenkrantz JG: Fistula between innominate artery and trachea. Arch Surg 96:401, 1968 8. Silen W, Spieker D: Fatal hemorrhage from the innominate artery after tracheostomy. Ann Surg 162:1005, 1965 9. Utley JR, Singer MM, Roe BB, et al: Definitive management of innominate artery hemorrhage complicating tracheostomy. JAMA 220:577, 1972
We also believe that attempts should be made to protect the tracheal or arterial suture line, if possible, by interposing soft tissue, muscle, or even pericardium.
c. GRILLO (Boston, MA): I want fo emphasize that with tracheostomy tubes in place, there are two basic types of fistulization. These differ in etiology, emergency treatment, definitive treatment, and prevention. Years ago Dr. Silen wrote about the more common type in which the inner ”elbow” of the tracheostomy tube erodes the artery lying immediately below the stoma. It is interesting to note that 2 of Dr. Cooper’s patients were young. This type of erosion occurs more easily in young persons. Because the trachea and innominate artery rise up on cervical extension, the tracheostomy is placed too low in the trachea. This is the principal origin of such stoma1 tracheainnominate artery fistulas. Other trachea-innominate fistulas result from Discussion high-pressure cuffs eroding directly through the DR. JAMES s. DONAHOO (Baltimore, MD): We too have walls (as in Patient 3 in the present study). The had experience with 3 patients who have had recent emergency management that we have used in stoma1 trachea-innominate artery fistulas. All 3 patients had erosion has been digital pressure plus insertion of an tracheal resection: 2 had primary tracheal anas- airway. When the erosion occurred some distance tomoses and 1 had insertion of a Nevi11 prosthetic below the stoma, alert residents have used an endodevice. AlI developed severe hemorrhage after this tracheal tube with a high-pressure cuff to tamponade and usually demonstrated a premonitory show of the hole until the patient could be operated on. minor bleeding. In the first group the artery should be resected. The Unlike Dr. Cooper, we performed arterial bypass stoma remains and heals on its own. If stenosis occurs on all 3 patients. One patient had a vein graft placed later, it is then repaired. On the other hand, if fistulas between the arch of the aorta and the carotid artery; 1 result from high-pressure cuffs-which are being had a carotid-carotid bypass, and 1underwent axil- used less and less-ne should usually resect the lofemoral bypass. Although 1 patient died of a my- tracheal segment concomitantly with resection of the cotic aneurysm of the aortic arch, 2 are living two innominate artery. years postoperatively without neurological sequelae. In our experience with at least 8 patients, drawn not Very frequently a trachea-innominate artery fistula entirely from the aforementioned group, in whom the can be subtle on arteriographic demonstration. In 1 innominate artery had been resected for acute hemorpatient who was operated on through a sternotomy rhage, no neurological problems have resulted. Their incision, a vein graft was utilized to bypass the in- ages ranged upward to 55 years. We therefore support fected area. Dr. Cooper’s approach and prefer not to introduce When there is a resected aneurysm and interpolated into a contaminated field what I think is the threatengraft, we like to place as much soft tissue as we can ing problem of vascular reconstitution. between the trachea and the suture line. We think this may protect the arterial suture line. We agree with Dr. Cooper that a high index of DR. JOE R . UTLEY (Lexington, KY): We have treated 3 suspicion should be maintained in any patient with a patients who survived this complication. I think our tracheal resection or tracheostomy, even if hemop- basic approach, with only minor differences, has tysis is apparently minor. Arteriograms should be been similar to that described by Dr. Cooper. taken and an operating room should be made ready It is important to recognize that there are still many immediately for an operative approach. We think that patients dying from trachea-innominate artery fisa vein bypass or some type of arterial bypass should tulas because of low tracheostomy. The physician be performed first, if this is possible without jeopar- available to them at the time of the bleeding often dizing the patient. Whereas Dr. Cooper has shown doesn’t know that the immediate treatment is digital that his patients have experienced no immediate neu- pressure on the fistula. We emphasize this to our rological complications, the late results of depriving junior residents, general surgeons, and otolarynthe brain of blood may not be readily apparent in gologists who manage a large number of patients with tracheostomies. short-term follow-up. DR. HERMES
447 Cooper: Trachea-Innominate Artery Fistula
The other common error is failure to recognize the bleeding as arterial because the patient is hypoxic and the blood is black. Frequently we find that it is described as venous bleeding, when actually it is coming from the artery but the patient is very hypoxic. Dr. Cooper has emphasized resecting the innominate artery and packing open the tracheostomy site. We have taken an alternative approach, that of not resecting any innominate artery but merely suturing it shut, closing the tracheostomy, placing a tracheal stoma at a higher position, or using an orotracheal tube for several days. This is a situation in which cricothyroidotomy may be helpful, but we have merely taken the opposite tack of trying to close the trachea and not resect the innominate artery. Patients can live without their innominate artery without any immediate neurological deficit, and it is possible in the long term that they might need some sort of cervical bypass approach. DR. RICHARD N . EDIE (New York, NY): We agree with Dr. Cooper’s aggressive diagnostic and therapeutic approach to this problem. We would like to comment on one aspect of the operative management. Once the presence of the fistula is demonstrated by arteriotomy, it is necessary to resect the innominate artery completely. The proximal end is oversewn first and allowed to retract inferiorly. However, the distal end of the innominate artery will not retract superiorly and laterally due to the two-point fixation of the junction of the right common carotid and right subclavian arteries. Thus we believe it is necessary to divide and ligate these two arteries individually so as to allow for their adequate retraction from the infected operative field. This maneuver will decrease the chance of a later vascular complication. D R . COOPER: I thank the discussants for their comments. I agree with Dr. Ferguson’s statements in his
presidential address (Ann Thorac Surg 24:6, 1977) to the effect that those who have failed to learn the lessons of history are doomed to repeat them. But somehow I am being forced to go through purgatory due to the errors of others who haven’t learned the history of innominate artery injury with low-lying tracheostomies. In reviewing the operative note on 1 case, I noticed that the resident had indeed counted the tracheal rings and duly recorded that the stoma was placed in the second and third rings. In this patient, the stoma was actually in the seventh and eighth rings; maybe the resident was counting from the wrong end. I would like to congratulate Dr. Donahoo on his successful revascularization. I do think, however, that under the circumstances perhaps it represents an unwarranted hazard, because we hear increasingly that people will tolerate resection of the innominate artery. Two of our patients have survived a year after resection with no apparent neurological problems. I would like to thank Dr. Grillo, not only for his comments but for the personal instruction he has given me over the years, including the management of this type of problem. Dr. Edie’s remark on the upward retraction of suture lines is important. We have left the carotid-subclavian axis in place but dissected it out enough so that we could bury it well behind the sternocleidomastoid muscle. Finally, as we have pointed out, Dr. Utley previously documented the maneuver of digital compression of the innominate artery. He thus popularized a maneuver previously recorded by the famous Von Spondom of Holland, better known to you as Peter, the young boy who put his finger in the dike. Dr. Utley’s previous manuscript pointed out how to apply this maneuver successfully to the innominate artery.