Tracheo-Innominate Artery Fistula after Stroke
A 46-year-old female had a tracheotomy under diagnosis of pneumonia during her course of conservative treatment () after being hospitalized in a neurosurgery center for intracerebral bleeding at the right basal ganglia region. After two months of the intracerebral hemorrhage, she was transferred to a rehabilitation center. In the third month after the tracheotomy, massive hemorrhage occurred through the tracheotomy tube when tracheal suction was carried out. The patient demonstrated cyanosis, respiratory failure, and shocks so that the cuff air in tracheotomy tube was maximally expanded. However, the bleeding did not stop. The tube was immediately removed while the suction was consistently carried out. A cuffed endotracheal intubation was tried through the oral cavity but the attempt was a failure due to visual obstruction. The cuffed endotracheal tube was inserted deep into the tracheal opening, and the cuff was expanded, followed by moving up the tube. The bleeding stopped at last. She was immediately transferred to an intensive care center, and blood test was carried out. The hemoglobin level decreased from 10.9 g/dl to 8.9 g/dl (about a drop of 2 g/dl), and cervical CT was carried out to identify the cause of bleeding. No special abnormality was identified, but the bronchoscopy did not show endotracheal area due to blood clot. Complete examination could not be done due to the risk of re-bleeding, hence conservative treatment was continued. One week after the bleeding, transfemoral angiography findings revealed that innominate artery made small luminal outpouching to trachea () at the carotid artery and subclavian artery bifurcation level, and thus diagnosis of TIAF was made. She was transferred to the thoracic surgery unit, and had an operation for TIAF, tracheoplasty with bypass graft. A rupture area of 1×0.5 cm was observed by a median sternotomy, and the innominate artery was rebuilt through replacement of the detached innominate artery by an artificial blood vessel that connected the right subclavian artery and the right aorta while the tracheoplasty was done using the fifth costal cartilage. A month later, tracheostenosis and inflammation were observed during a bronchoscopy that was carried out due to wheezing and tachypnea and subsequently, endotracheal balloon dilatation was conducted. However, no improvement in the symptoms was seen, hence replacement of Montgomery T-tube was carried out followed by continuation of rehabilitation after transferring her to the rehabilitation center. It has been eleven months since the surgery has been carried out, and the patient survives without further complications.