TIF.pptx

TRACHEOINNOMINATE ARTERY FISTULA
PRESENTOR: Dr. Kanika Chaudhary

OVERVIEW
• INTRODUCTION
• HISTORICALASPECTS
• INCIDENCE
• PATHOGENESIS
• MANAGEMENT
• PREVENTION
• CONCLUSION

Tracheoinnominate Artery Fistula
Introduction
• Tracheoinnominate fistula (TIF) is an uncommon, life-threatening
complication that typically occurs when a tracheostomy tube erodes
into the posterior aspect of the innominate artery.
• It can also occur after tracheal resection and reconstructive
procedures, after penetrating neck trauma and tracheal stenting. It
can also rarely occur after placement of endovascular stent grafts.
• Without urgent operative intervention, the mortality rate is nearly
100%.

Historical Aspects
• 1879- Korte reported a fatal TIF in 5-year old child with diphtheria
after tracheostomy
• 1924- Schlaepter reviewed 115 cases of fatal hemorrhage after
tracheostomy and documented that the innominate artery was
involved in most cases
• 1964- Silen reported the first short-term survivor
• 1968- Reich reported the first long-term survivor of TIF

Incidence
• The incidence of TIF in tracheostomies has ranged from 0% to 1% and
averages 0.3%
• The overall incidence of postoperative hemorrhage after
tracheostomy is 3%
• 10% of post-tracheostomy hemorrhage is due to TIF
• The incidence is higher in patients with head injuries, presumably
owing to the relentless movement of these patients

Incidence
• TIF has been reported to occur as early as 2 days and as late as
many months following tracheostomy
• The peak incidence of TIF is between the first and second week
after tracheostomy
• 75% of TIF present within 3-4 weeks after tracheostomy
placement

Pathogenesis
 Anatomical Aspects:
• The tracheo-innominate artery (or trunk) is the first branch of the
aortic arch. It divides into the right common carotid and right subclavian
artery, 3–4 cm lateral to the trachea, behind the right sternoclavicular
joint.
• In its inferior proximal portion, its relations include:
 anterior: left tracheo-innominate vein and thymus;
 posterior: trachea (6–10th ring);
 posterior and left: left common carotid artery;
 right: right tracheo-innominate vein, superior vena cava and pleura.

• The tracheo-innominate artery supplies blood to the right arm and
the right side of the head and neck.
• Its absence on the left is explained by the direct branching of the left
common carotid and subclavian arteries from the aortic arch.
• A high lying innominate artery, particularly in the thin and young,
may act as a risk factor in fistula formation.
Pathogenesis

Pathogenesis
• The innominate artery present in normal fashion only 74% of
whites and 53% of blacks
• The most common variation- the left common carotid artery
originating from the base of the innominate artery, 20% whites
and 38% blacks

Pathogenesis
• The innominate artery is the most common artery
involved in massive hemorrhage after tracheostomy
• Althoughother vessels involved:
 common carotid artery
 inferior thyroid artery
 thyroid ima artery
 innominate vein
 aortic arch
• Other causes: stomal and tracheal granulation tissue, tracheitis

Pathogenesis
• The mechanism of injury in TIF after tracheostomy is
pressure necrosis from the elbow, cuff, or tip of the
tracheostomy tube
• The location of the fistula is at the cannula tip or cuff in
two thirds of the reported patients
• The close anatomical juxtaposition of the trachea and
innominate artery is the reason for TIF after
tracheostomy

Pathogenesis
• Dyer has described three general mechanisms by which a tracheostomy
appliance can induce pressure necrosis on the posterior aspect of the
innominate artery, resulting in TIF.
1. In most cases, fistulization occurs at the level of the endotracheal cuff,
which has often been inflated to inappropriately high pressures.
 Tracheal capillary pressure ranges between 20 and 30 mm Hg. In humans,
tracheal blood flow is impaired at 22 mm Hg and is totally obstructed at 37
mm Hg. Therefore, to avoid mucosal pressure necrosis, the use of low-
pressure tracheal cuffs inflated to <20 mm Hg is recommended.

Pathogenesis
 Although the incidence of tracheal damage has lessened with the
introduction of more compliant large-volume, low-pressure cuffs, this
mode of injury still accounts for a large percentage of TIF.
2. An ill-fitting or poorly positioned tracheostomy tube can also
damage the trachea when the tip of the cannula impinges against the
anterior tracheal wall.
 This problem is particularly apparent with rigid appliances that have a
fixed 90 bend. Recent tube designs have partially ameliorated this
problem by employing a gentler curve.

Pathogenesis
 Rigid plastic tracheostomy tubes can exert significant anterior pressure,
especially with superior angulation of the tracheostomy appliance.
 Excessive anterior pressure can also occur in individuals with peculiar
neck and tracheal anatomy.
 Also, head injury patients with repetitive opisthotonic posturing appear to
have an increased incidence of tracheal injury caused by this mechanism

3. About one third of patients with TIF have an erosion of the trachea
caused by abutment of the elbow of the cannula against the
innominate artery which is often caused by a tracheostomy
improperly placed below the fourth ring.
Pathogenesis

Pathogenesis
 Clinical factors contributing to TIF:
 Long-term ventilation
 Excessive movement of the tracheostomy
 High airway pressures requiring correspondingly high cuff
pressures to prevent air leakage
 Sepsis
 Frequent hypotension
 Radiation therapy
 Steroid therapy
 Malnutrition
 Infection
 Diabetes mellitus

Pathogenesis
• Technical characteristics contributing to TIF:
 Malfitting and poorly positioning tracheostomy tube
 9 0 degree tubes
 R i g i d tubes
 Improperly placed low tracheostomy below the fourthring
 High-lying innominate artery, especially inyoungpatients
 Peculiar neck anatomy resulting in excessive anterior
pressure

Pathogenesis
 TIF after upper airway reconstruction:
 A f t e r tracheal resection and reconstruction:
 due to necrosis and/or separation of suture line, excessive
tension, prior radiation, DM, steroids
 A f t e r mediastinal tracheostomy:
 due to excessive tension on the stomal suture linestomal
dehiscence,localized sepsis and ultimately erosion into the
innominate artery
 A l s o has been reported after placement of expandable metallic
stent for tracheal stenosis

Management Strategy
• The currently advocated management strategy in dealing with TIF:
 P r o m p t diagnosis
 Emergency management
 Definitive operativerepair

Diagnosis
• E a r l y diagnosis is the key to successfulmanagement
• Haemorrhage within 48 h is typically associated with local factors such
as traumatic puncture of anterior jugular or inferior thyroid veins, systemic
coagulopathy, erosions secondary to tracheal suction or
bronchopneumonia
• Haemorrhage occurring 3 days to 6 weeks after tracheostomy should be
thought of as a result of TIF until proven otherwise.
• Haemorrhage occurring after more than 6 weeks is rarely related to
TIF and more likely to be secondary to granulation tissue,
tracheobronchitis or malignancy.

Diagnosis
• About 50% of patients who are eventually diagnosed with TIF give a
history of relatively minor bleeding that has stopped spontaneously before
presentation (sentinel bleeding)
• Pulsation of the tracheostomy tube has also been described as being
indicative of TIF, but this finding is only present in a small number of
patients
• Direct bronchoscopic examination of the patient is usually the
definitive diagnostic test, and it should be performed at once by an
experienced surgeon in a fully equipped operating room.

Diagnosis
• Angiography:
 Not possible because of time constraints when considering the
diagnosis of TIF
 U s e f u l in patients with minor bleeding who have a negative
bronchoscopic examination or false negative
 B o t h views should be obtained: anterior and lateral
 The lateral film (demonstrating a posterior irregularity of the
artery) is the view that is most likely to be abnormal in TIF
 N o t possible in massive bleeding and has accuracy of only
about 20%

Emergency Management
• Management of possible sentinel bleeding:
 Rigid bronchoscopy with a 0º telescope to examine the stoma and
anterior wall with tracheostomy tube removed
 Performed in OR with equipment available for prompt surgical
intervention
 The rigid bronchoscope can be used to compress the innominate
artery against the sternum to control haemorrhage

• Survival possible only if bleeding can be
controlled at the bedside prior to definitive
control in the OR
 First maneuver should be
overinflation of the cuff of the
tracheostomy
 Successful in 85% of cases
 If bleeding persists:
 The tube should be slowly withdrawn with
pressure directed against the anterior
tracheal wall

 If overinflation of the cuff does not control
the hemorrhage:
 An oral endotracheal tube should be placed
 The tracheostomy tube is removed
 Stomal hemorrhage is controlled by
Digital compression of the innominate artery
against the manubrium(Utley’s Maneuver)

 Entering the pretracheal fascial plane through the
tracheostomy wound
 Bluntly dissect innominate artery off the trachea with
index finger
 Compressed against the sternum
 Successful in about 90% of the cases
• Utley’s Maneuver involves:

• Preoperative management:
 Clearance of the distalairway
 Vo l u m e resuscitation
 B l o o d transfusion
 Occlusion of the innominate artery must be maintained
during transport to the operating room and until control of the
artery is achieved

Operative management
• Full median sternotomy has been traditionally the most common
approach
• One report noted 40% incidence of sternal wound complications due to
contamination by tracheal secretion following TIF repair
• An upper partial sternotomy that is carried laterally into the right
third interspace is preferred

• The optimum surgical correction for TIF, however, remains
controversial
• Two basic strategies:
 Approaches thatmaintain flow through the innominate artery
 Direct repair of the defect
 Interposition grafting
 Approaches that interrupt flow through the innominate artery
 Simple ligation
 Resection of the innominate artery with bypass, while attempting
to preserve the right carotid–right subclavian junction

• Most authors currently advocate
interruption of flow
 Gelman, et al: Reviewed 71 survivors of
TIF from 1962 to 1994
 Of the 71 initial survivors, only 40
survived "long-term" (>2 months)
 Maintenance of flow resulted in 15.8%
"long-term" survival, whereas
interruption of flow resulted in 71.2%
"long-term" survival
 Yang, et al:
 Reviewed 24 survivors of TIF from
1975 to 1984
 Comparable results

• Majority of authors believe that ligation of the innominate artery is the
treatment of choice
 Decreased rebleedingrates
 Decreased mortality
• Bypass or simple ligation?
 N o reports of significant neurologic sequelae or vascular complications
associated with innominate artery ligation
 Restoration of flow may not becrucial
 However, reported survivors with intact neurologic function have
had an average age of 24.5
 Ligation may only be safe in patients without atherosclerosis

• Endovascular techniques are maybe preferable in a patient who is at
prohibitively high risk for open surgery. It may also be preferable in
patients with a prior history of a median sternotomy, thoracotomy, and
chest radiation.
• For endovascular stent-graft placement, selective catheterization of the
innominate artery and adequate seal zones are required.

• Some authors have described hybrid procedures that employ both
endovascular and open surgical techniques whereby a surgical bypass
is performed (such as a carotid-subclavian bypass) along with
placement of an endograft stent as the bypass provides longer landing
zones.
• The stent can place via the femoral artery or direct cutdown on other
vessels such as the carotid artery or the brachial or axillary artery
• Completion angiography is performed at the conclusion of the
procedure to confirm technical success.

• In a critically ill patient with ongoing bleeding, placement of an
occlusion balloon (such as a Fogarty catheter) under fluoroscopic
guidance in the innominate artery can be a life-saving maneuver,
and this can be achieved via transfemoral or transbrachial routes.
• This can buy some time to contemplate on or mobilize resources for
a more definitive repair option.
• Under fluoroscopic guidance, some authors have described the use
of coil embolization for the control of the bleeding from the
innominate artery with the selective performance of a bypass to
preserve cerebral circulation as well.

Prevention
• Prevention is the best treatment
• Tracheostomy should be reserved for patients requiring ventilation
longer than two weeks
• Should be performed in controlled setting with a secure airway by
an experienced surgeon
• Excessive hyperextension of the neck should be avoided
• The anterior trachea should always be fully exposed by division of
the thyroid isthmus so that tracheal rings may be counted properly
• Accurate placement of the stoma in the second and third ring
• Tracheal rings should always be counted from the cricoid

Prevention
 Pliable noncreative tracheostomy tubs preferable
 Cuff pressures should be monitored frequently and should not
exceed 20 mm Hg
 Tight closure of the tracheostomy skin incision should be avoided to
reduce the risk of wound sepsis
 Prompt treatment of peristomal sepsis
 Ventilator induced tracheostomy movement should be minimized with
long flexible connecting tubing
 If there any doubt about the proper position of tube flexible
bronchoscopy should be performed

• Sung JH et al described the role of contrast enhanced chest computed
tomography (CECT) in diagnosing correct placement of TT and relation
of innominate artery to the TT.
• They described relation between TT and innominate artery by 3 terms:
1. Proximal position of TT based on cervical vertebra level and
termed “tracheostomy tube departure level”.
2. Distal position of TT and course of innominate artery and
termed "tracheostomy tube-innominate artery configuration"
3. Gap between the tube and innominate artery, named
"tracheostomy tube to innominate artery gap".
Prevention

• They concluded that if there is low “tracheostomy
tube departure level”, match or crossing type of
configuration with reverse-L shaped innominate
artery, small trachea and thin gap between trachea
and innominate artery, early ligation of innominate
or removal of TT should be considered
Prevention

Conclusion
 Tracheoinnominate fistula is a devastating complication of
tracheostomy
 Although the advent of low-pressure cuffs has made this a rare
complication, mortality associated with TIF remains high
 The outcome following TIF is largely dependent upon its timely
diagnosis and prompt management with most authors advocating
simple ligation or resection due to high reported rates of rebleeding
associated with vascular reconstruction

REFERENCES
1. C.D. Wright, Management of tracheoinnominate artery fistula. Chest Surg Clin N Am 6
(1996), pp. 865–873.
2. Dyer RK, Fisher SR: Tracheal-innominate and tracheal-esophageal fistula. Complication
in Thoracic Surgery. St. Louis, Mosby-Year Book, 1992, p 294
3. Mehalic TF, Farhat SM: Tracheoarterial fistula: A complication of tracheostomy in patients
with brain stem injury. J Trauma 12:140, 1972
4. Gelman JJ, Aro M, Weiss SM: Tracheo-innominate artery fistula. J Am Coll Surg 179:626,
1994
5. Jones JW, Reynolds M, Hewitt RL: Tracheo-innominate artery erosion: Successful surgical
management of a devastating complication. Ann Surg 184:194,1976
6. Oshinsky AE, Rubin JS, Gwozdz CS: The anatomical basis for post-tracheostomy
innominate artery rupture. Laringoscope 98:1061, 1988
7. McDonald JJ, Anson BJ: Variation in the origin of arteries derived from the aortic arch.
Anat Rec 62:139, 1935
8. Cooper JD, Grillo HC: The evolution of tracheal injury due to ventilatory assistance
through cuffed tubes: A pathologic study. Ann Surg 169:334, 1969
1

REFERENCES
9. Grillo HC, Mathisen DJ: Cervical exenteration. Ann Thorac Surg 49:401, 1990
10. Maynar M, Lopez L, Gorriz E: Massive brachiocephalic artery bleeding due to a Gianturco tracheal
stent. J Vasc Interv Radiol 4:289, 1993
11. Utley JR, Singer MM, Roe BB: Definitive management of innominate artery hemorrhage complicating
tracheostomy. JAMA 220:577, 1972
12. MG Gasparri, AC Nicolosi, GH Amassi A Novel Approach to the Management of Tracheoinnominate
Artery Fistula: Ann Thorac Surg 2004; 77:1424
13. Gelman JJ, Aro M, Weiss SM. Tracheo-innominate artery fistula. J Am Coll Surg 1994;179:626–34.
14. Yang FY, Criado E, Schwartz JA, Keagy BA, Wilcox BR. Trachea-innominate artery fistula:
retrospective comparison of treatment methods. South Med J 1988;81:701–6.
15. Saleem T, Anjum F, Baril DT. Tracheo Innominate Artery Fistula. [Updated 2020 Dec 4]. In: StatPearls
Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
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preventive measures. Anaesthesia and Intensive Care. 2013 Nov;41(6):807-808.

17. Kapural, Leonardo MD; Sprung, Juraj MD, PhD; Gluncic, Ivo MD; Kapural, Miranda MD;
Andelinovic, Simon MD; Primorac, Dragan MD; Schoenwald, Peter K. MD Tracheo-
Innominate Artery Fistula After Tracheostomy, Anesthesia & Analgesia: April 1999 - Volume
88 - Issue 4 - p 777-780 doi: 10.1213/00000539-199904000-00018
18. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a
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REFERENCES

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