A Case of Tracheo-innominate Artery Fistula after Tracheostomy Successfully Treated with a Covered Stent

Abstract

A 78-year-old man underwent a tracheostomy after embolization for a dural arteriovenous fistula. Seventy days after tracheostomy, arterial bleeding appeared through the tracheal stoma. The bleeding stopped spontaneously. However, two days later, arterial bleeding reappeared, and he was diagnosed with a tracheo-innominate artery fistula (TIF). He then underwent urgent endovascular covered stent placement. After the procedure, there was no bleeding. TIF can be a fatal complication after tracheostomy and it is generally treated with open chest surgery. However, a successful endovascular treatment for TIF has recently been reported and may yield better results.

Keywords: covered stent; endovascular treatment; tracheo-innominate artery fistula; tracheostomy.

Fig. 1

CT angiography (CTA) at the first bleeding and the second bleeding. At the first bleeding, CTA did not show any extravasation (A). The tip of the tracheal cannula is touching the innominate artery (arrow: the contact point of the tip of the tracheal cannula and the innominate artery) (B). Two days later, a second bleeding occurred, and CTA still showed no obvious extravasation (C). The position of the tip of the tracheal cannula was adjusted so as not to contact the innominate artery (arrow: the tip of the tracheal cannula) (D).

Fig. 2

Endovascular procedure. A 12 Fr long sheath and guide wire were inserted from the right brachial artery, and a pigtail catheter was inserted from the right common femoral artery. Diagnostic imaging showed the entrance of the right brachiocephalic innominate artery and no obvious bleeding source (A). A covered stent made of polytetrafluoroethylene (VIABAHN; 13 mm × 50 mm) was placed so that it did not reach the origin of the common carotid artery and so that it covered the fistula definitively (arrow: distal end of covered stent; arrowhead: proximal end of covered stent) (B, C, D).