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Ann Thorac Surg 2004;77:1424-1426
© 2004 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
Accepted for publication May 29, 2003.
* Address reprint requests to Dr Gasparri, Division of Cardiothoracic Surgery, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA.
e-mail: mgasparr{at}mcw.edu
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Introduction |
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A 75-year-old gentleman was treated for in situ laryngeal cancer with radiation therapy. Six-months later he developed laryngeal edema and stridor requiring tracheostomy. One-week later, he presented with bright red blood through and around the tracheostomy. He was evaluated by removal of the tracheostomy and flexible bronchoscopy to assess the airway. An erosion in the anterior wall of the trachea with pulsations and oozing was noted. The airway was secured by oral intubation and the patient transferred to our institution.
On arrival he was hemodynamically stable. Examination revealed the tracheostome to be foul smelling with obvious necrotic, infected tissue throughout its tract. Manual palpation of the tract revealed the innominate artery palpable at the base of the infected tracheostome.
The patient was taken urgently to the operating room. A partial upper sternotomy was T'd off at the third intercostal space. The ascending aorta and innominate artery were isolated. A right infraclavicular incision was used to isolate the axillary artery in the deltopectoral groove. After administration of 5000 U of heparin, a side-biting clamp was placed on the ascending aorta and an ascending aorta-to-axillary artery bypass performed using a 10-mm Dacron graft (DuPont Pharmaceuticals, Wilmington, DE) tunneled extrapleurally along the chest wall (Fig 1). The aortic and axillary artery anastomoses were constructed using running 4-0 and 5-0 Prolene (Ethicon, Somerville, NJ), respectively. Once perfusion was established, the innominate artery was divided proximal and distal to the area of fistulization and this segment, found at roughly the fourth tracheal ring, resected. Care was taken to preserve the right subclavian–right common carotid junction. At that point, the sternotomy was closed and the tracheostomy site explored. A portion of pectoralis muscle was placed between the innominate artery stump and the previous tracheostomy site and a new tracheostomy created at the second tracheal ring.
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Most authors currently advocate interruption of flow [1–4]. This recommendation is based on case reports and retrospective reviews. Two reviews in particular have been frequently cited. The first is by Gelman and coworkers [3], in which cases of 71 survivors of TIF from 1962 to 1994 were reviewed. Of the 71 initial survivors, only 40 survived "long-term" (>2 months). Maintenance of flow resulted in 15.8% "long-term" survival, whereas interruption of flow resulted in 71.2% "long-term" survival. Most deaths in the maintenance of flow group were due to suture repair or graft failure with subsequent rebleeding. Also noted was minimal neurologic sequelae in the interruption of flow group with only 2 cases of transient right arm weakness reported. Based on this, it was concluded that interruption of flow is the procedure of choice as it is well tolerated neurologically and is accompanied by a much lower mortality rate. Similarly, Yang and coworkers [4] reported data on 24 survivors of TIF from 1975 to 1984 and found comparable results. They drew similar conclusions to Gelman and associates [3].
Based on these data the majority of authors believe that ligation of the innominate artery is the treatment of choice due to decreased rebleeding rates and decreased mortality. Additionally, as there have been no reports of significant neurologic sequelae or vascular complications associated with innominate artery ligation, it is felt that restoration of flow is not crucial.
A more detailed review of each case in these articles as well as other case reports, however, reveals many points worth noting. In terms of the neurologic safety of procedures interrupting flow through the innominate, there have been 6 reported early survivors of innominate artery ligation who remained comatose postoperatively and ultimately expired. In all cases, it was felt that preoperative hypotension or cardiac arrest rather than innominate artery ligation accounted for the postoperative neurologic status. Additionally, in reported survivors of interruption of flow in which postoperative neurologic status was specifically noted to be normal, the average age was 24.5 years old (range 11 to 76 years old) with only 1 patient greater than 35 years of age. It may be suggested that in these young patients, in which there is most likely an absence of significant atherosclerotic disease, ligation of the innominate artery may be "safer." The potential danger of innominate artery ligation was well illustrated in a case report by Black and coworkers [5] in which a 70-year-old male was found to have a TIF. He underwent cerebral angiogram before operative repair and was found to have occlusion of the left internal carotid artery as well as significant stenoses of the right internal carotid and vertebral arteries. He underwent construction of an axillofemoral graft with division of the TIF and did well postoperatively.
Finally, in the cases in which innominate artery flow is maintained, it is done either through direct repair or construction of an "in situ" bypass conduit. The rebleeding episodes in these patients are predictable as it is well known that suture repair of an infected artery or graft placement in an infected field is doomed to failure and, by definition, the area of a TIF is infected. If, on the other hand, vascular continuity and antegrade flow are reestablished using "clean" inflow and outflow targets, as six case reports have described (two aorta-right carotid, two axillary-axillary, and two axillary-femoral), graft failure and rebleeding has not been reported.
Accordingly, we elected to perform an extraanatomic bypass to ensure antegrade flow followed by resection of the innominate artery. The bypass created, aorta-axillary artery (Fig 1), is a simple one to construct and has many advantages over the previously described extraanatomic bypasses performed (aorta-right carotid, axillary-axillary, axillary-femoral). The aorta is already exposed and a "clean" area proximal to the innominate artery can easily be isolated with a side-biting clamp, therefore avoiding a separate incision for inflow access (as opposed to axillary-femoral or axillary-axillary). The axillary artery is easy to expose in the deltopectoral groove with minimal dissection. Also, its location allows for a relatively short graft that is easy to tunnel in a straight fashion along the chest wall (as opposed to aorta-right carotid). This operation avoids a long-segment bypass that can lead to graft failure, and also avoids a groin incision that has its own attendant complications (as opposed to axillary-femoral). Finally, the construction of an aorta-to-axillary artery bypass avoids constructing a graft whose tunnel either crosses across the sternotomy incision or near the area of previous tracheostomy (as opposed to axillary-axillary).
Tracheoinnominate fistula, although more rare since the advent of low-pressure tracheostomy tubes, remains a highly lethal complication of tracheostomy. Successful management relies on early diagnosis and prompt management. Although reports have commented on the relative safety of innominate artery ligation, the aorta–axillary artery bypass allows an easy method to restore vascular continuity while protecting against the risk of rebleeding.
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This article has been cited by other articles:
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  H. Jamal-Eddine, A. K. Ayed, A. Al-Moosa, and N. Al-Sarraf Graft repair of tracheo-innominate artery fistula following percutaneous tracheostomy Interactive CardioVascular and Thoracic Surgery, August 1, 2008; 7(4): 654 - 655. [Abstract] [Full Text] [PDF]
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 J.-J. Hung, H.-S. Hsu, C.-S. Huang, and K.-Y. Yang Tracheoesophageal fistula and tracheo-subclavian artery fistula after tracheostomy Eur. J. Cardiothorac. Surg., October 1, 2007; 32(4): 676 - 678. [Abstract] [Full Text] [PDF]
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 E. M. Marone, G. Esposito, A. Kahlberg, Y. Tshomba, C. Brioschi, P. Zannini, and R. Chiesa Surgical treatment of tracheoinnominate fistula after stent-graft implantation J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1641 - 1643. [Full Text] [PDF]
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