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Innominate Artery Compression Syndrome Resulting From A Vascular Stent: Management Of A Teenager With Tracheoinnominate Fistula
Kolapo Dairo, B.A., Monirah Albathi, M.D., Jonathan Grischkan, M.D., Sergio A. Carrillo, M.D..
Nationwide Children's Hospital, Columbus, OH, USA.
Objective(s): Tracheoinnominate artery fistula (TIF) is a life-threatening complication of tracheostomy placement characterized by the development of an anomalous connection from the trachea to the innominate artery. Mortality of TIF without surgical intervention approaches 100%. We describe the multidisciplinary management of a patient who developed a TIF following tracheostomy placement, initially treated with an endograft.
Methods: A 17-year-old male underwent tracheostomy tube placement after suffering a gunshot wound to the head requiring craniectomy. 6 days post-op, he developed massive bleeding from the tracheostomy tube, raising the concern for TIF. Given his clinical status, he underwent catheter-based stenting of the innominate artery, successfully averting hemorrhage. After weeks of intense therapy, he was discharged home.
Results: On follow-up, rigid bronchoscopy noted near-complete tracheal obstruction at the fistula site caused by anterior extrinsic compression from the endograft. Based on the tracheal obstruction and risk for additional erosion/fistula, he underwent vascular bypass grafting of the head vessels with excision of the stented innominate artery and primary tracheoplasty, including debridement and excision of the fistulous track. Mechanical circulatory support was not utilized. He enjoyed an uncomplicated course postoperatively. Repeat bronchoscopy demonstrated a patent airway. The patient continues to do well 1 year after surgery without neurologic or airway concerns.
Conclusions: Expeditious discovery and treatment of TIF in a patient with risk factors is crucial in minimizing mortality and must be managed in a multidisciplinary fashion. Follow-up is important to understand the natural history of catheter-based interventions. Ultimate repair can be accomplished safely without extracorporeal circulation.
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