Technique for Managing Tracheo-Innominate Artery Fistula

Flexible bronchoscopy can be performed in cases of sentinel bleed to confirm the TIF. If the diagnosis is still in question, a rigid bronchoscopy with ventilation should be performed to maintain the airway and confirm the TIF. The airway is established with an endotracheal tube.

In cases where the diagnosis is clear on presentation, expeditious transport to the OR is needed. If the tracheostomy cuff is tamponading the TIF, a 0° rigid bronchoscope is inserted through the glottis. The tracheostomy tube is carefully removed while visualization is maintained through the bronchoscope. If this incites ongoing hemorrhage, the bronchoscope is advanced beyond the TIF and manual compression of the scope against the anterior trachea is used to control the bleeding. Inhalational anesthetic can be used through the bronchoscope. If hemorrhage is not present, an endotracheal tube is inserted below the fistula and the balloon is inflated to prevent bleeding into the distal airway.

A left radial arterial line is used for blood pressure monitoring as the innominate artery will be divided. Large-bore venous access is established and can be most expeditiously performed in the femoral vein or right subclavian vein. Internal jugular venous access will obscure the operative field, while left subclavian access may be rendered ineffective if the innominate vein is ligated.

The approach of median sternotomy versus upper hemisternotomy has been debated. Median sternotomy in the setting of TIF can result in postoperative mediastinitis (up to 40% in one series); however, it provides the most optimal exposure and is expedient. We prefer full sternotomy because it is unknown if hemisternotomy has a lower incidence of infection. The thymus is divided and innominate vein mobilized and divided if necessary with vascular stapler. Dissection of all the structures may be time-consuming in the setting of a large hematoma in the anterior mediastinum. Once identified, the innominate artery is identified and occluded proximally and distally (Fig. 4). The involved region is resected and the healthy intact innominate artery is oversewn in two layers with running 4-0 Prolene suture (first layer horizontal mattress and second layer over and over) at the proximal and distal ends (Fig. 5). At the proximal extent, it is often necessary to ligate the innominate artery at its origin. The distal ligation should be proximal to the bifurcation of the right subclavian and right common carotid arteries. Vascular staplers can be used to divide the artery expeditiously; however, long-term data on rebleeding at the staple line are unknown. The tracheal injury is debrided to healthy tissue and repaired with interrupted 4-0 polydioxanone suture and buttressed with a muscle flap using the sternocleidomastoid or strap muscles (Fig. 6). An alternative is to use thymus to buttress and separate the trachea and artery. The incidence of stroke is low after innominate artery ligation.^,  Following sternal closure, bronchoscopy should be performed to remove all blood from the distal airways.

The alternate approach of reconstructing the innominate artery is controversial due to a high risk of recurrent bleeding (60-86%).^,  However, this approach should be considered in the setting of severe left carotid artery stenosis/occlusion or patent right internal mammary artery bypass graft. Primary repair is not recommended as often tension is placed on the repair, increasing the risk of recurrent bleed. After resection of the innominate artery, an interposition vein graft (saphenous or jugular vein) is created by using running 5-0 Prolene suture (Fig. 7). Repair of the tracheal injury is performed as described above. A muscle flap is placed between the innominate artery and trachea.

Recent reports have described successful percutaneous stent graft insertion to control the acute hemorrhage. At a later time, debridement and reconstruction of the innominate artery can be performed depending on the status of the patient.