A 58-year-old woman presented to our hospital with profuse bleeding from a deflated cuff tracheal stoma. She had stage IVB anaplastic thyroid carcinoma with upper airway obstruction and had undergone tracheostomy 3 months prior to this admission. Pembrolizumab 100 mg (2 mg/kg) had been given every 3 weeks and she had received a radiation dose of 75 Gy in 25 fractions over the neck tumor. The cuff of a tracheostomy tube was over-inflated to temporarily stop bleeding in an emergency. In suspicion of a tracheo-innominate artery fistula, she received computed tomography angiography after initial stabilization (Figure 1 and Figure 2).
Besides adequate initial resuscitation, over-inflating the cuff of a tracheostomy tube may be an effective technique to temporarily control bleeding from tracheo-innominate artery fistulae [1,2,3,4,5]. This case demonstrated the reliability of computed tomography angiography as an imaging modality for confirmation.
Conceptualization, W.-R.T. and Y.-Y.C.; investigation, Y.-C.H. and W.-R.T.; writing—original draft preparation, Y.-C.H. and W.-R.T.; writing—review and editing, Y.-Y.C.; visualization, W.-R.T.; supervision, Y.-Y.C. All authors have read and agreed to the published version of the manuscript.
The study was conducted in accordance with the Declaration of Helsinki and was approved by National Cheng Kung University Hospital Institutional Review Board on 2023.12.20 (IRB No. B-EC-112-034; Date: 2023.12.20).
Written informed consent for the publication of details and images was obtained from the patient’s husband.
The authors declare no conflicts of interest.
Footnotes
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
Enlarge this image.Figure 1. Computed tomography angiography of a 58-year-old woman with excruciating tracheostoma bleeding temporarily controlled by over-inflating her tracheostomy. (A) Sagittal view, (B) coronal view, (C) axial view. The images revealed contrast extravasation at innominate artery middle part (pointed by bordered box arrows) that was directly tamponaded by over-inflated tracheostomy tube cuff (demonstrated by bulging tracheal wall and circled by arrowheads).
Enlarge this image.Figure 2. Fistula identification using angiography of the patient with a slightly deflated tracheostomy tube cuff. Flow of contrast into upper trachea through fistula (white star) at tracheostomy tube cuff (circled by arrowheads); right innominate artery (arrow). The patient was managed with endovascular stenting followed by ligation of innominate artery in a hybrid operation theater (Figure S1). Two weeks later, she was discharged to a chronic care center. The patient died peacefully at the chronic care center two weeks after discharge due to terminal disease.
Supplementary Materials
The following supporting information can be downloaded at:
References
1. Jones, J.W.; Reynolds, M.; Hewitt, R.L.; Drapanas, T. Tracheo-innominate artery erosion: Successful surgical management of a devastating complication. Ann. Surg.; 1976; 184, pp. 194-204. [DOI: https://dx.doi.org/10.1097/00000658-197608000-00011] [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/782389]
2. Ramadan, H.H.; El Solh, A.A. An update on otolaryngology in critical care. Am. J. Respir. Crit. Care Med.; 2004; 169, pp. 1273-1277. [DOI: https://dx.doi.org/10.1164/rccm.200402-222UP] [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/15087296]
3. Lin, C.Y.; Lee, K.C.; Yang, M.S.; Lieu, F.K. Tracheoinnominate artery fistula after percutaneous tracheostomy. J. Formos. Med. Assoc.; 2015; 114, pp. 88-89. [DOI: https://dx.doi.org/10.1016/j.jfma.2013.03.006] [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24076273]
4. Menen, R.S.; Pak, J.J.; Dowell, M.A.; Patel, A.R.; Ashiku, S.K.; Velotta, J.B. Treatment of Tracheoinnominate Fistula with Ligation of the Innominate Artery: A Case Report. Perm. J.; 2016; 20, pp. 15-166. [DOI: https://dx.doi.org/10.7812/TPP/15-166] [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27352412]
5. Khanafer, A.; Hellstern, V.; Meissner, H.; Harmening, C.; Schneider, K.; Henkes, H. Tracheoinnominate fistula: Acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft. CVIR Endovasc.; 2021; 4, 30. [DOI: https://dx.doi.org/10.1186/s42155-021-00216-8] [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/33740143]
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.
Details
; Tang, Wen-Ruei 2
; Ying-Yuan, Chen 2
1 Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan;
2 Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan;