A Case of Tracheoinnominate Artery Fistula after Tracheostomy

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We report a case of acquired tracheoinnominate artery fistula (TIF) at 6 months after tracheostomy in a 78-year-old woman. She had massive hemorrhage from the stoma when the tracheostomy tube cuff was deflated. The hemorrhage was temporarily controlled by hyperinflating the cuff. Contrast-enhanced computed tomography (CT) angiography revealed TIF. The patient died the next day because of massive rebleeding. TIF, a highly fatal complication of tracheostomy (incidence rate, 0.1%-4%), mostly occurs within 48 h to 4 weeks after tracheostomy. TIF usually results from erosion of the tracheal and innominate arterial walls by the tracheostomy tube cuff or tube tip. The risk factors for this condition include high intracuff pressure, mucosal trauma caused by malpositioned cannula tip, low tracheostomy, and deformity and shifting of the trachea and major blood vessels. Although the complication cannot be completely prevented, it may be avoided by creating the stoma at the second to third tracheal cartilage or appropriate management of intracuff pressure. Minor tracheal bleeding, also called "sentinel bleeding," is an early sign of TIF ; if noted, the cause of bleeding should be immediately confirmed by bronchoscopy or CT, and suitable interventions should be initiated. Thus, TIF is a life-threatening condition and is a risk that should be considered in tracheostomy management.