Negative results - Vascular general Graft repair of tracheo-innominate artery fistula following percutaneous tracheostomy

Tracheo-innominate fistula (TIF) is a rare complication following percutaneous dilatational tracheostomy (PDT), occurring in F1% of cases. It usually develops three days to six weeks after the procedure and is fatal in the majority of cases, even after successful initial repair. We present a successfully treated case of TIF using a Goretex graft to replace the severely destroyed segment of the innominate artery. 1. Case report A 21-year-old man had a motorcycle accident. On admis- sion, he had right-sided decerebrate rigidity, frequent sei- zures and Glasgow Coma Scale of 4. Following resus- citation and intubation, a CT brain scan was performed which showed depressed fracture of the right parietal region with an extradural haematoma which was evacuat- ed. There were no other significant injuries. Two weeks later, PDT wCiaglia Blue Rhino , Cook Company, Denmarkx was performed. Nine days later he had initial, self-limiting bleeding from the tracheostomy site, mouth and nose. Bronchoscopy (performed by ENT surgeons) was normal and CT of the neck with contrast was inconclusive. Two days later, bronchoscopy was repeated in the operating room, being prepared for an emergency procedure. After defla- tion of the cuff, massive bleeding occurred. A tracheostomy tube was replaced by an orotracheal tube with the cuff hyper inflated. Bleeding was controlled by digital compres- sion of the innominate artery (a finger was inserted in the pretracheal fascia to compress the artery) while an emer- gent median sternotomy was done. The innominate artery was dissected and the fistula identified (very close to the take-off of the innominate artery from aorta - Fig. 1a) and side-biting clamp applied proximal to the origin of the innominate artery. PDT site (located at the level of the 5th tracheal ring) was closed using 4-0 Vicryl. The tracheal fistula site (located at the level of the 10th tracheal ring) was closed with a purse-string suture and buttressed with a sternohyoid muscle flap (Fig. 1b). The innominate artery