Tracheo-innominate Artery Fistula Following Percutaneous Tracheostomy
Sudhan Nagarajan, Elbert E. Wiliams, Amit Pawale, Ramachandra Reddy.
Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA.
OBJECTIVE: A 58 year old lady, with known cirrhosis from chronic hepatitis C virus infection and prior history of hepatocellular carcinoma treated with transarterial chemoembolization presented with hematemesis and hypotension. She underwent esophageal variceal banding and her hospital course was further complicated by acute kidney injury, hepatorenal syndrome and ventilator dependent respiratory failure. We elected to perform a bedside percutaneous tracheostomy to help her wean from mechanical ventilation and to manage her lung secretions better. A size 8 Shiley tracheostomy tube was inserted using Seldinger technique without any complications. Fiberoptic bronchoscopy after the procedure showed clear airway and no bleeding. Three weeks later, gradually being weaned off from the mechanical ventilator, she developed torrential bleeding around the trachesotomy site. The bleeding was controlled with finger and she was reintubated with an endotracheal tube and the balloon placed distally. The patient was taken emergently to the operating room. Median sternotomy was performed and after opening the pericardium, the innominate artery was dissected out and clamped proximally and distally. The artery was separated from the trachea carefully and the fistulous arterial segment was removed. End to end primary anastomosis of the innominate artery was carried out. The large tracheal defect was repaired using a bovine pericardial patch. Postoperatively, no further bleeding was seen, but the patient deteriorated overall and was ultimately received palliative care per wishes of her family.
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