Delayed Hemorrhage from an Anomalous Carotid Artery Following Tracheostomy

ELA YEO BUT MASSIVE hemorrhage from a tracheostomy incision is commonly fatal'-' and is fortunately a rare complication of the procedure. In the past, consideration has been given to causes such as excessive cuff pressure, tube tip erosion of great vessels, invasive infection, and low placement of the tracheos­tomy incision.'" Too little emphasis has been given to the frequently aberrant anatomy of the aortic arch ves­sels that may be damaged primarily during tracheos­tomy or eroded later by the endotracheal tube.'-'o The following case is presented to highlight this important factor. Common arch anomalies are illustrated to serve as guideposts for the surgeon. Case Report A 27-year-old black woman was admitted with multiple stab wounds to the left posterior triangle of the neck and immediate onset of C4 quadriplegia. On initial evaluation the patient had a respiratory rate of 18 per minute, a pulse of 120 heats per minute, and a blood pressure of 90j70 mmHg. At this time she could maintain her airway and her ventilation was adequate. Following stabilization, the patient underwent emergency arch aortography to detect possible arterial injury. The angio­gram (Fig.