- Email: [email protected]
Tracheal-innominate artery fistula after tracheal reconstruction
Tracheal-innominate artery fistula after tracheal reconstruction A case of successful repair The case history of a lon g-term survivo r o f a trach eal-innominate art ery fistula is presented. Th e com plication fo llowed trach eal recon stru ction for trach eal ste nosis. Th e operative approach em phasiz ing the need for reva scula rization of th e distal art erial tree precedin g ligation of th e inno m inate artery is discussed . M easur es to prev ent this com plica tio n are outlined .
Antonio G. Revilla, Jr., M.D ., James S. Donahoo, M.D ., and John L. Cameron, M.D ., Baltimore, Md.
Massive hemorrhage from a trachealinnominate artery fistula after tracheostomy is a rar e and usually fatal complication. The problem has also been encountered following tracheal reconstruction for stenosis.": Since 1965, when the first shortterm survivor of a trach eal-innominate artery fistula was reported.!" 1 add itional short-term and 4 long-term survivors have been documented in the literature.": :\. Co , !I . 1 11 Of the 6 known surv ivors, only 1 had had tracheal reconstruction for tracheal stenosis." This paper documents the case history of a second long-term survivor who developed a tracheal-innominate artery fi stula following a tracheal reconstruction. A course of surgical management of such patients is proposed, as well.
Case report K. w . (1HH -151-14-07 ) , a 26-yea r-old wom an, was admitted to The Johns Hopkins Ho spital on June 3, 1973, for correction of a tracheal stenosis. Ten weeks prior to adm ission, the patient had been admitted to another hospital with a barbiturate overdose. She required ventilatory support via an orotracheal tube for 3 days and subsequently through a tracheostomy tube for 3 Fro m the Dep artment of Surgery , The J ohns H opk ins University and Hosp ital, Baltim or e, Md. 2t205 . Received for publicati on Dec . 19, 1973.
Fig. 1. Arch aortogram revealing extravasation of contrast media from the innominate a rtery into a false aneurysm directl y adjacent to the trachea.
629
The Journal af
630
Revilla, Donahoo , Cameron
Tho ra cic and Card iovascular Surgery
Fig. 2. Intraoperative illustration showing construction of the ascending aorta-right common carotid artery bypass with saphenous vein. weeks. On extubation, she had severe stridor, and endoscopy reve aled a t racheal stenosis. The patient was sta rted on parenteral stero ids and underwent 3 tracheal dilatations witho ut improvement. A tantalum tra cheograrn revealed a tr ache al stricture starting approximatel y 6 em . above the carina. On June 7, 1973, a 6.5 em . segm ent of trachea was resected through a tran sverse cervical incision. In order to improve exposure during the anasto mosis, a median sternotomy was performed. The tracheal anastomosis was carried out with interrupted 2-0 Tevdek sutures. Immediately after operation, the patient breathed spontaneously. The orotracheal tube wa s left in place with the balloon defl ated for 10 hours. On extubation, the airway was clear. Postoperatively, the patient was ma intained in moderate ce rvical flexion . The patient did well until the tenth po st-
operative day, when she coughed up 30 c.c, of blood-streaked sputum. This episode was ascribed to granulation tissue at the site of the tracheal an astomosis. A tracheal tomogram revealed a normal-sized lumen at the anastomotic site. On the nineteenth postoperative day, the patient had a massive hemopt ysis of 600 c.c. of bright red blood. , The bleed ing sto pped spontaneously , vital sign s remained sta ble, and she exhibited no respiratory distress. An emergency a rch ao rtogram showed extravasation of contrast medi a from the innominate artery 2 em. above its takeoff (Fig. I) . She was immediately taken to the operating room, and the right side of the cervical inci sion and median stern o to my were reopened. Prior to any manipul ation of the fistula, the pericardium was opened and proxim al control of the innominate artery was obtained . A sa phenous vein bypass graft was then inserted between the
Volume 67 Number 4 April, 1974
ascending aorta and right common carotid artery (Fig. 2). Next, the innominate artery was clamped and transected both proximal and distal to the fistula, and its ends were oversewed with 5-0 Prolene sutures. The intervening segment of artery was dissected off the anterior wall of the trachea revealing a small fistulous connection with the trachea at the site of the anastomosis.. The tracheal defect was closed with interrupted 3-0 Prolene sutures reinforced by surrounding tissue (Fig. 3). At the termination of the procedure, the patient exhibited both a good right radial and right carotid pulse, in addition to an airtight closure of the trachea. A culture of the fistula at the time of operation revealed no growth. The patient's postoperative course was uneventful. A tantalum tracheogram obtained prior to discharge showed no significant narrowing at the site of the anastomosis (Fig. 4). The patient was discharged on July 12, 1973, and is well 4 months later.
Discussion
A tracheal-innominate artery fistula following primary tracheal reconstruction has been previously reported in 2 patients.v 8 In both instances, the problem followed transcervical tracheal reconstruction for tracheal stenosis. In I case the fistula was ascribed to distruption of the tracheal anastomosis by the balloon of a tracheostomy tube. The patient died shortly after ligation of the innominate artery, presumably of blood loss. In the second case a pinhole opening was encountered between the artery and the tracheal anastomosis. This was thought to be secondary to injury to the vessel at the time of operation with subsequent erosion into the trachea. The patient was a long-term survivor following ligation of the innominate artery. When a tracheal-innominate artery fistula develops, there are frequently one or more mild prodromal episodes of bleeding preceding a major life-threatening hemorrhage. Such bleeding is usually ascribed to granulation tissue from the tracheostomy stoma or tracheal anastomosis. Once a major episode of bleeding has occurred, the diagnosis is almost certain. An arch aortogram should be obtained if the patient's condition is stable. Once the diagnosis is established, immediate surgical intervention is mandatory.
631
Tracheal-innominate artery fistula
R. common .' cal:'oHd a .
Saphenous v: grail - - -- --
Resected innominate tl.. al(d aneurys
. 1 I
I
I I
I
I
I
Tt'ache<:\. ~ open ing ; closed and covered with H'\ymu5
Fig. 3. Intraoperative illustration showing the completed saphenous vein bypass, resected innominate artery specimen, and closure of the tracheal defect.
A median sternotomy with extension of the incision into the right neck offers the most direct approach to the problem. Through this incision, proximal and distal control of the innominate artery can be achieved and revascularization of the distal arterial tree from the ascending aorta can easily be carried out. If bleeding is not a problem at the time of exploration, the innominate artery is first isolated both proximal and distal to the fistula so that immediate control can be achieved at the first sign of resumed bleeding. The right subclavian and right common carotid arteries are then exposed. By means of partially occluding clamps, a bypass graft with a saphenous vein is performed from the ascending aorta to either one or both of these vessels, depending on whether their independent ligation becomes necessary for distal
632
Revilla, Donahoo, Cameron
The Journol of Tho ra cic and Ca rdiavascular Surgery
Fig. 4. Postoperative tantalum tracheogram revealing widely patent tracheal anastomosis.
control. We perfer to use autologous vein because of possible bacterial contamination associated with the tracheal communication. In the event that flow through the innominate artery has to be interrupted from the start because of bleeding, a temporary heparin-coated shunt bypass from the ascending aorta to the right common carotid artery can be instituted to support the cerebral circulation until a definitive bypass is performed. 7 Once bypassed , the innominate artery is then transected as far proximal and distal from the fistula as possible, and its ends are oversewn. The involved segment of artery is removed, and the tracheal defect is closed with interrupted sutures reinforced by surrounding tissue. Massive medistinal sepsis would certainly preclude any reconstructive procedures. In this case, ligation of the innominate artery may be necessary. Although tolerated by
some patients, innominate artery ligation has been known to cause serious hemodynamic and neurologic changes. " ,. r. Ligation of the right subclavian artery distal to the vertebral artery has been proposed as an adjunct to innominate artery ligation to lower the probability of neurologic sequelae by avoiding a steal phenomenon. t The etiology of this complication has been attributed to operative injury of the innominate artery or disruption of the tracheal anastomosis. In our case, the development of the tracheal -innominate artery fistula cannot be related to any specific event in the patient's course . The anastomosis had not disrupted and there was no evidence of sepsis. Apparently the proximity of the innominate artery to the tracheal suture line led to the injury and fistula. Obvious measures to prevent this unusual complication should include avoidance of positive-
Volume 67 Number 4
Tracheal-innominate artery fistula
633
April, 1974
pressure ventilation in the immediate postreconstruction period and the interposition of surrounding tissue between the tracheal anastomosis and the innominate artery. REFERENCES Biller, H. F., and Ebert, P. A.: Innominate Artery Hemorrhage Complicating Tracheostomy, Ann. Otol. Rhinol. Laryngol. 79: 301, 1970. 2 De Bakey, M. E., and Crawford, E. S.: Resection and Homograft Replacement of Innominate and Carotid Arteries With Use of Shunt to Maintain Circulation, Surg. Gynecol. Obstet. 105: 129, 1957. 3 Grillo, H. C.: Surgery of the Trachea, Curro Probl. Surg. 3: 59, 1970. 4 Killen, D. A., Foster, I. H., Gobbel, W. G., Jr., Stephenson, S. E., Jr., Collins, H. A., Billings, F. T., and Scott, H. W., Ir.: The Subclavian Steal Syndrome, I. THORAc. CARDIOVASC. SURG. 51: 539, 1966.
5 Mathog, R. H., Kennan, P. D., and Hudson, M. R.: Delayed Massive Hemorrhage Following Tracheostomy, Laryngoscope 81: 107,1971. 6 Mozersky, D. I., Barnes, R. W., Sumner, D. S., and Strandness, E., Ir.: Hemodynamics of Innominate Artery Occlusion, Ann. Surg. 178: 123, 1973. 7 Murray, G. F., Brawley, R. K., and Gott, V. L.: Reconstruction of the Innominate Artery by Means of a Temporary Heparin-Coated Shunt Bypass, I. THORAC. CARDIOVASC. SURG. 62: 34, 1971. 8 Myers, M. 0., Lawton, B. R., and Saulter, R. D.: An Operation for Tracheal-Innominate Artery Fistula, Arch. Surg. lOS: 269, 1972. 9 Reich, M. P., and Rosenkrantz, I. G.: Fistula Between Innominate Artery and Trachea, Arch. Surg. 96: 401, 1968. 10 Silen, M., and Spieher, D.: Fatal Hemorrhage From the Innominate Artery After Tracheostomy, Ann. Surg. 162: 1005, 1965.
Antonio G. Revilla, Jr., M.D ., James S. Donahoo, M.D ., and John L. Cameron, M.D ., Baltimore, Md.
Massive hemorrhage from a trachealinnominate artery fistula after tracheostomy is a rar e and usually fatal complication. The problem has also been encountered following tracheal reconstruction for stenosis.": Since 1965, when the first shortterm survivor of a trach eal-innominate artery fistula was reported.!" 1 add itional short-term and 4 long-term survivors have been documented in the literature.": :\. Co , !I . 1 11 Of the 6 known surv ivors, only 1 had had tracheal reconstruction for tracheal stenosis." This paper documents the case history of a second long-term survivor who developed a tracheal-innominate artery fi stula following a tracheal reconstruction. A course of surgical management of such patients is proposed, as well.
Case report K. w . (1HH -151-14-07 ) , a 26-yea r-old wom an, was admitted to The Johns Hopkins Ho spital on June 3, 1973, for correction of a tracheal stenosis. Ten weeks prior to adm ission, the patient had been admitted to another hospital with a barbiturate overdose. She required ventilatory support via an orotracheal tube for 3 days and subsequently through a tracheostomy tube for 3 Fro m the Dep artment of Surgery , The J ohns H opk ins University and Hosp ital, Baltim or e, Md. 2t205 . Received for publicati on Dec . 19, 1973.
Fig. 1. Arch aortogram revealing extravasation of contrast media from the innominate a rtery into a false aneurysm directl y adjacent to the trachea.
629
The Journal af
630
Revilla, Donahoo , Cameron
Tho ra cic and Card iovascular Surgery
Fig. 2. Intraoperative illustration showing construction of the ascending aorta-right common carotid artery bypass with saphenous vein. weeks. On extubation, she had severe stridor, and endoscopy reve aled a t racheal stenosis. The patient was sta rted on parenteral stero ids and underwent 3 tracheal dilatations witho ut improvement. A tantalum tra cheograrn revealed a tr ache al stricture starting approximatel y 6 em . above the carina. On June 7, 1973, a 6.5 em . segm ent of trachea was resected through a tran sverse cervical incision. In order to improve exposure during the anasto mosis, a median sternotomy was performed. The tracheal anastomosis was carried out with interrupted 2-0 Tevdek sutures. Immediately after operation, the patient breathed spontaneously. The orotracheal tube wa s left in place with the balloon defl ated for 10 hours. On extubation, the airway was clear. Postoperatively, the patient was ma intained in moderate ce rvical flexion . The patient did well until the tenth po st-
operative day, when she coughed up 30 c.c, of blood-streaked sputum. This episode was ascribed to granulation tissue at the site of the tracheal an astomosis. A tracheal tomogram revealed a normal-sized lumen at the anastomotic site. On the nineteenth postoperative day, the patient had a massive hemopt ysis of 600 c.c. of bright red blood. , The bleed ing sto pped spontaneously , vital sign s remained sta ble, and she exhibited no respiratory distress. An emergency a rch ao rtogram showed extravasation of contrast medi a from the innominate artery 2 em. above its takeoff (Fig. I) . She was immediately taken to the operating room, and the right side of the cervical inci sion and median stern o to my were reopened. Prior to any manipul ation of the fistula, the pericardium was opened and proxim al control of the innominate artery was obtained . A sa phenous vein bypass graft was then inserted between the
Volume 67 Number 4 April, 1974
ascending aorta and right common carotid artery (Fig. 2). Next, the innominate artery was clamped and transected both proximal and distal to the fistula, and its ends were oversewed with 5-0 Prolene sutures. The intervening segment of artery was dissected off the anterior wall of the trachea revealing a small fistulous connection with the trachea at the site of the anastomosis.. The tracheal defect was closed with interrupted 3-0 Prolene sutures reinforced by surrounding tissue (Fig. 3). At the termination of the procedure, the patient exhibited both a good right radial and right carotid pulse, in addition to an airtight closure of the trachea. A culture of the fistula at the time of operation revealed no growth. The patient's postoperative course was uneventful. A tantalum tracheogram obtained prior to discharge showed no significant narrowing at the site of the anastomosis (Fig. 4). The patient was discharged on July 12, 1973, and is well 4 months later.
Discussion
A tracheal-innominate artery fistula following primary tracheal reconstruction has been previously reported in 2 patients.v 8 In both instances, the problem followed transcervical tracheal reconstruction for tracheal stenosis. In I case the fistula was ascribed to distruption of the tracheal anastomosis by the balloon of a tracheostomy tube. The patient died shortly after ligation of the innominate artery, presumably of blood loss. In the second case a pinhole opening was encountered between the artery and the tracheal anastomosis. This was thought to be secondary to injury to the vessel at the time of operation with subsequent erosion into the trachea. The patient was a long-term survivor following ligation of the innominate artery. When a tracheal-innominate artery fistula develops, there are frequently one or more mild prodromal episodes of bleeding preceding a major life-threatening hemorrhage. Such bleeding is usually ascribed to granulation tissue from the tracheostomy stoma or tracheal anastomosis. Once a major episode of bleeding has occurred, the diagnosis is almost certain. An arch aortogram should be obtained if the patient's condition is stable. Once the diagnosis is established, immediate surgical intervention is mandatory.
631
Tracheal-innominate artery fistula
R. common .' cal:'oHd a .
Saphenous v: grail - - -- --
Resected innominate tl.. al(d aneurys
. 1 I
I
I I
I
I
I
Tt'ache<:\. ~ open ing ; closed and covered with H'\ymu5
Fig. 3. Intraoperative illustration showing the completed saphenous vein bypass, resected innominate artery specimen, and closure of the tracheal defect.
A median sternotomy with extension of the incision into the right neck offers the most direct approach to the problem. Through this incision, proximal and distal control of the innominate artery can be achieved and revascularization of the distal arterial tree from the ascending aorta can easily be carried out. If bleeding is not a problem at the time of exploration, the innominate artery is first isolated both proximal and distal to the fistula so that immediate control can be achieved at the first sign of resumed bleeding. The right subclavian and right common carotid arteries are then exposed. By means of partially occluding clamps, a bypass graft with a saphenous vein is performed from the ascending aorta to either one or both of these vessels, depending on whether their independent ligation becomes necessary for distal
632
Revilla, Donahoo, Cameron
The Journol of Tho ra cic and Ca rdiavascular Surgery
Fig. 4. Postoperative tantalum tracheogram revealing widely patent tracheal anastomosis.
control. We perfer to use autologous vein because of possible bacterial contamination associated with the tracheal communication. In the event that flow through the innominate artery has to be interrupted from the start because of bleeding, a temporary heparin-coated shunt bypass from the ascending aorta to the right common carotid artery can be instituted to support the cerebral circulation until a definitive bypass is performed. 7 Once bypassed , the innominate artery is then transected as far proximal and distal from the fistula as possible, and its ends are oversewn. The involved segment of artery is removed, and the tracheal defect is closed with interrupted sutures reinforced by surrounding tissue. Massive medistinal sepsis would certainly preclude any reconstructive procedures. In this case, ligation of the innominate artery may be necessary. Although tolerated by
some patients, innominate artery ligation has been known to cause serious hemodynamic and neurologic changes. " ,. r. Ligation of the right subclavian artery distal to the vertebral artery has been proposed as an adjunct to innominate artery ligation to lower the probability of neurologic sequelae by avoiding a steal phenomenon. t The etiology of this complication has been attributed to operative injury of the innominate artery or disruption of the tracheal anastomosis. In our case, the development of the tracheal -innominate artery fistula cannot be related to any specific event in the patient's course . The anastomosis had not disrupted and there was no evidence of sepsis. Apparently the proximity of the innominate artery to the tracheal suture line led to the injury and fistula. Obvious measures to prevent this unusual complication should include avoidance of positive-
Volume 67 Number 4
Tracheal-innominate artery fistula
633
April, 1974
pressure ventilation in the immediate postreconstruction period and the interposition of surrounding tissue between the tracheal anastomosis and the innominate artery. REFERENCES Biller, H. F., and Ebert, P. A.: Innominate Artery Hemorrhage Complicating Tracheostomy, Ann. Otol. Rhinol. Laryngol. 79: 301, 1970. 2 De Bakey, M. E., and Crawford, E. S.: Resection and Homograft Replacement of Innominate and Carotid Arteries With Use of Shunt to Maintain Circulation, Surg. Gynecol. Obstet. 105: 129, 1957. 3 Grillo, H. C.: Surgery of the Trachea, Curro Probl. Surg. 3: 59, 1970. 4 Killen, D. A., Foster, I. H., Gobbel, W. G., Jr., Stephenson, S. E., Jr., Collins, H. A., Billings, F. T., and Scott, H. W., Ir.: The Subclavian Steal Syndrome, I. THORAc. CARDIOVASC. SURG. 51: 539, 1966.
5 Mathog, R. H., Kennan, P. D., and Hudson, M. R.: Delayed Massive Hemorrhage Following Tracheostomy, Laryngoscope 81: 107,1971. 6 Mozersky, D. I., Barnes, R. W., Sumner, D. S., and Strandness, E., Ir.: Hemodynamics of Innominate Artery Occlusion, Ann. Surg. 178: 123, 1973. 7 Murray, G. F., Brawley, R. K., and Gott, V. L.: Reconstruction of the Innominate Artery by Means of a Temporary Heparin-Coated Shunt Bypass, I. THORAC. CARDIOVASC. SURG. 62: 34, 1971. 8 Myers, M. 0., Lawton, B. R., and Saulter, R. D.: An Operation for Tracheal-Innominate Artery Fistula, Arch. Surg. lOS: 269, 1972. 9 Reich, M. P., and Rosenkrantz, I. G.: Fistula Between Innominate Artery and Trachea, Arch. Surg. 96: 401, 1968. 10 Silen, M., and Spieher, D.: Fatal Hemorrhage From the Innominate Artery After Tracheostomy, Ann. Surg. 162: 1005, 1965.