Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft

Abstract

Background: A tracheo-innominate fistula is a rare but life-threatening complication of tracheostomy and has a mortality rate of 100% without therapy. The underlying cause is an acquired fistula between the brachiocephalic trunk and the trachea, induced by a tracheostomy cannula's mechanical impact.

Case presentation: A 25-year-old female was admitted with pulsatile bleeding from a tracheostomy. The cause of the bleeding was a tracheo-innominate artery fistula, which was difficult to recognize. Said fistula was treated with implantation of a self-expanding stent-graft. The bleeding stopped immediately after the implantation of the stent-graft. Dual antiplatelet medication with aspirin IV and ticagrelor PO, bridged with a bolus of eptifibatide IV, was started right after the stent deployment.

Conclusions: Endovascular self-expanding stent-graft implantation is a viable treatment option for tracheo-innominate artery fistulae, especially in hemorrhagic emergencies.

Keywords: Stent-graft; Tracheoinnominate fistula; Tracheostomy.

Fig. 1

Diagnostic imaging in a 25-year-old female patient with a tracheoinnominate fistula. DSA of the brachiocephalic artery in posterior-anterior projection with an overinflated tracheal tube showed no bleeding source (a). Temporary removal of the tracheal tube and releasing the cuff revealed the contrast medium extravasation from the brachiocephalic artery’s posterior wall to the anterior wall of the adjacent trachea, with contrast medium in the trachea (arrow: bleeding spot; arrowhead: contrast medium in the trachea (b). The following completion flush DSA run of the aortic arch in a left anterior oblique projection showed the proper wall apposition of the stent-graft, the interruption of the previous extravasation, and the patency of the origins of the right subclavian and both common carotid arteries. The stent-graft was reaching slightly too far proximal into the aortic arch but did not compromise the origin of the left common carotid artery (c)