What is Tracheo Innominate Artery Fistula?
A tracheoinnominate fistula (TIF) is a serious problem that usually occurs after a tracheostomy, which is a procedure where a hole is made in the neck to allow one to breathe. TIF can cause heavy bleeding and has a high death rate. This complication can also happen after surgery to remove and repair parts of the windpipe, after damage to the neck from trauma, and due to hardware from nearby orthopedic surgery moving out of place. Although it’s quite rare, TIF can also develop after placement of endovascular stent grafts, which are small tubes inserted into blood vessels to improve blood flow.
What Causes Tracheo Innominate Artery Fistula?
A variety of conditions can increase your chances of developing a Tracheo-Innominate Fistula (TIF), a dangerous situation where a hole forms between the windpipe and a major blood vessel. Some of these conditions include pressure sores caused by a tracheostomy tube cuff (a balloon-like device at the end of a tracheostomy tube that’s expanded to keep the tube in place), long-term use of steroids or medications that weaken the immune system, positioning the tracheostomy (a medical procedure where a hole is made in your windpipe to assist with breathing) below the third tracheal ring (which is part of windpipe structure), inflammation or infection of the windpipe (known as tracheitis), and prolonged use of a breathing tube inserted through the mouth or nose.
Other factors that could make you more prone to developing a TIF are abnormal/high location of the innominate artery (a major blood vessel in your chest) and a spread of a skin infection at the site of the tracheostomy to the deeper tissues.
Risk Factors and Frequency for Tracheo Innominate Artery Fistula
TIF, or tracheo-innominate fistula, is a condition that is not common and happens in less than 1% of people, according to most studies. Most people who develop TIF – around 70% – do so within the first three weeks after getting a tracheostomy. However, some people have also developed TIF a year or more after having a tracheostomy.
Signs and Symptoms of Tracheo Innominate Artery Fistula
Tracheo-Innominate Fistula (TIF) usually shows up in patients who’ve had a tracheostomy in the past. In some cases, patients might notice minimal bleeding 24 to 48 hours before experiencing heavy bleeding. This initial minimal bleed is known as the sentinel or herald bleed and can happen in up to 30% of TIF patients. Patients will often observe bleeding, possibly in pulses, from around tracheostomy site.
Other symptoms can include spitting up blood, fever, and potential threats to the airway. Depending on how severe the bleeding is, patients may show signs of a shaky circulation, or even a bleeding shock. Most patients show these symptoms within 3 to 6 weeks after receiving a tracheostomy.
- Past tracheostomy procedure
- Minimal bleeding 24 to 48 hours before heavy bleeding (Sentinel/Herald bleed)
- Bleeding (often in pulses) around tracheostomy
- Spitting up blood
- Fever
- Unstable circulation
- Bleeding shock
- Signs showing up 3 to 6 weeks post tracheostomy
Testing for Tracheo Innominate Artery Fistula
When dealing with a condition like TIF, it’s extremely important to evaluate it as soon as possible – the success of treatment often depends on how quickly we’re able to identify the problem. There are a few ways doctors can do this, using tools like bronchoscopy, conventional angiography or computed tomography angiography. These are different types of scans that let us see inside your body.
However, none of these methods are perfect – they all have limited ability to spot TIF with certainty. That’s why, in addition to these tests, doctors also need to rely on their clinical judgment based on the symptoms and other related information. In other words, if they have reason to suspect TIF based on their professional experience and your health history, they will take it into account as well.
If doctors choose to do a bronchoscopy – a procedure that lets them look inside your trachea (the large tube in your neck that carries air in and out of your lungs) using a tiny camera – they might be able to directly see the site where bleeding is happening. This would be located on the front wall of the trachea. On the other hand, both conventional angiography and computed tomography angiography – techniques that use X-rays to view your blood vessels – will show a specific kind of discoloration (which doctors call a ‘blush’) from the innominate artery (a major blood vessel in the chest) going into the trachea.
Treatment Options for Tracheo Innominate Artery Fistula
When treating a sudden condition like this, it is crucial to diagnose and act quickly. One way to immediately control the bleeding is through a method called the Utley maneuver. This involves applying direct pressure to the artery located in the chest. You can also stop the bleeding by inflating the cuff of the tracheostomy tube, a tube that is inserted into the windpipe to allow airflow. At this point, more medical help will be needed because the patient will require emergency airway control while also managing the bleeding. One possible solution is to insert a cuffed endotracheal tube, a breathing tube, beyond the site of the bleeding. At this stage, it is also important to have blood readily available for the patient.
Many medical institutions nowadays have a fast-acting plan for massive bleeding. Depending on the hospital, a team of professionals from trauma/acute care surgery, cardiac surgery, thoracic surgery, or vascular surgery can then manage the condition. The next steps can either be open surgery techniques or through endovascular maneuvers, procedures performed inside the major blood vessels.
With open surgery, the medical team might use techniques like median sternotomy, where the sternum (breastbone) is split open, to control the bleeding. They may also use muscle flaps, like pectoralis major from the chest, to cover any holes in the trachea (the windpipe). Other materials that can be used to prevent infection include pericardium (the sac that surrounds the heart), thymus (a gland in the neck), or pleura (the lining that covers the lungs). However, there are potential risks to these procedures, like a stroke-like event after tying off the innominate artery, the major artery leaving the heart.
There are also some surgical bypass procedures that have been described, although they are generally not standard practice due to the potential risk of infection. These can involve the use of synthetic materials like PTFE (polytetrafluoroethylene), preserved arterial allografts (donated arterial tissue), and autologous vein grafts (vein grafts from the patient’s own body). They have been mentioned for their potential in handling these procedures. Possible post-operative complications can include mediastinitis (infection of the tissues in the middle of the chest), fistulization (the formation of an abnormal connection between two body parts), and sternal wound infection.
Endovascular techniques, procedures performed inside the major blood vessels, could be a better option for patients who have a high risk for open surgery. This could be because they have a previous history of open chest surgery or chest radiation. When a stent-graft, a tube made of fabric and metal mesh, is placed, the innominate artery needs to be selectively catheterized, or accessed using a fine tube, and sufficient seal zones are required.
There are also hybrid procedures used that involve both endovascular and open surgical techniques. For instance, a surgical bypass might be performed in combination with the placement of an endograft stent, a type of artificial blood vessel. The stent is usually placed via the femoral artery or direct cutdown on other vessels such as the carotid artery or the brachial or axillary artery. Upon completion of the procedure, an angiography, an X-ray examination of the blood vessels, is performed to ensure technical success. Possible complications from this procedure can include problems at the access site, stent migration, mal-deployment, or fracture. In cases of an inadequate seal, continuous bleeding from the TIF could occur.
In some cases, endovascular stenting can be used temporarily to stabilize a critically ill patient. This allows more time for resuscitation and intervention before a more definite open surgical procedure is performed at a later, safer time. In critically ill patients with ongoing bleeding, an occlusion balloon can be placed in the innominate artery, temporarily stopping the flow of blood and buying some time to organize resources for a more definitive repair option. Alternatively, coil embolization, where a metal coil is placed in an artery to prevent bleeding, can be used to control bleeding from the innominate artery while maintaining blood flow to the brain.
What else can Tracheo Innominate Artery Fistula be?
If there is bleeding around the area where a tracheostomy (an opening created at the front of the neck to allow a tube to be inserted into the windpipe to aid breathing) is performed, it can sometimes be confused with bleeding from an overgrowth of small blood vessels, commonly known as stomal granulation tissue. If bleeding occurs shortly after the tracheostomy procedure, it could be due to insufficient control of bleeding during the procedure or a bleeding disorder, where blood doesn’t clot normally.
What to expect with Tracheo Innominate Artery Fistula
After an operation, it’s important to closely watch patients in the intensive care unit because there can be a risk of further bleeding, even if the procedure seemed successful. Even when immediately identified and managed, the situation is quite serious. Often, these patients are already in a weakened state and in the intensive care unit due to multiple other health problems when the bleeding episode occurs.
During and after surgery, this condition can have a mortality rate over 50%. This means that more than half of the people in this situation may unfortunately not survive. It’s a serious condition, requiring vigilant monitoring and care.
Preventing Tracheo Innominate Artery Fistula
To prevent a condition called tracheo-innominate artery fistula, which is an abnormal connection between the windpipe and a major artery in the chest, there are several steps that should be taken:
First, the time a person is intubated, or has a tube placed in their windpipe to help them breathe, should be kept under three weeks. The longer the tube is in place, the greater the risk of developing the condition.
Second, when a tracheostomy – a procedure where a hole is made in the windpipe through the neck – is performed, it should be done using the right technique. This is important to ensure that the hole is made safely and without damage to the windpipe or surrounding blood vessels.
Third, when inserting a tracheostomy tube, it is better to use tubes that are blunt and flexible. These types of tubes are less likely to cause damage to the windpipe or the innominate artery.
Fourth, the hole for the tracheostomy should ideally be made between the second and third ring of the windpipe. This location is typically safer and reduces the risk of complications.
Lastly, try to limit repeated head and neck movements. These movements can cause the underside of the tube to rub against the innominate artery, which could potentially cause damage and lead to a tracheo-innominate artery fistula.
