The formation of a<unk>  is a medical emergency and requires immediate intervention. Blood volume control, management of the hemorrhage, and adequate oxygenation should be insured in these patients. In a majority of<unk>  cases (85%), hyperinflation of the tracheostomy cuff will control the bleeding, while the patient is prepared for surgery. However, if this fails the tracheostomy cuff must be removed, and the patient must be intubated from above. Next, pressure from the index finger can be applied on the bleeding site from within the tracheostomy to control the bleeding. In addition, the "Utley Maneuver", which involves digital compression of the artery against the posterior wall of the manubrium of the sternum following a right infraclavicular incision, may be used to urgently control the bleeding When the bleeding is controlled the patient should be immediately transferred on the operating room. Surgery A sternal saw and a rigid bronchoscopy is used during the operation. During the operation, a median sternotomy is performed in order to expose and ligate the involved artery above and below the<unk> . Division of the thymus and superior retraction of the innominate vein exposes the innominate artery. The innominate artery should be debrided to healthy tissue and closed with a monofilament suture. Next, the damaged segments of the trachea and the artery should be excised followed by reconstruction with a primary end to end anastomosis of the trachea. Innominate artery ligation leaves the carotid and subclavian circulations intact. Pulsatile back-bleeding from distal innominate artery stump should be checked to insure collateral circulation. In patients with poor pulsatile back-bleeding, an aorta-axillary artery bypass graft can be considered in patients with severe occlusion of the left common carotid artery, severe atherosclerosis, and brain ischemic or hemorrhagic insults. In addition, an autologous vein bypass between the aorta and the carotid artery or the opposite carotid artery and the subclavian artery may be performed to restore normal circulation. The interposition of viable tissue facilitates tracheal wall repair. Thus, vascularized tissues such as the thymus, strap muscles, the sternocleidomastoid, or the pectoralis major muscle should be interposed between tracheal defect and the vessel stumps to prevent bleeding, seal the mediastinum, fill dead space, cover major vital structures, provide a blood supply and venous drainage, and increase the concentration of antibiotics. Innominate artery ligation has a 10% risk of neurological deficit.
Tracheoinnominate fistula
Tracheoesophageal fistula
Laryngotracheal stenosis
Tracheal deviation
Subglottic stenosis
Tracheal tumor
Aortoesophageal fistula
Bronchopleural fistula