A 25-year-old female was brought to our Emergency Room with acute pulsatile bleeding from her tracheostomy with an 8.1 mg/dl hemoglobin value upon admission. The patient suffered from long-term spastic tetraparesis due to cerebral palsy. Sixty months ago, the patient had undergone tracheostomy as a treatment of respiratory failure after aspiration pneumonia with sepsis. Inspection of the trachea using a flexible bronchoscope demonstrated active arterial bleeding from the trachea anterior wall with pooling of blood in the dependent airway. Blood was aspirated to clear the airways, and the cuff of the tracheostomy tube (Tracheoflex 8 mm, Teleflex Medical) was overinflated to control the bleeding in the short term. A diagnostic digital subtraction angiography (DSA) was carried out under emergency circumstances. The initial angiogram with the cuff inflated revealed no visible contrast medium extravasation. Therefore, the cuff of the tracheal tube was first deflated and then the tube was temporarily removed.\nGeneral anesthesia was induced with propofol and sufentanil, neuromuscular blockade was achieved by atracurium. Maintenance was provided with continuous infusion of propofol and remifentanil. A 9F sheath (Terumo) was inserted into the right common femoral artery. A diagnostic digital subtraction angiography (DSA) was carried out using a Tempo4 vertebral 4F catheter (Codman) under emergency circumstances. Straight posterior-anterior and 20° right and left anterior oblique angiographic projections of the brachiocephalic artery with 6 frames per second were acquired with manual bolus injection of each 8 ml Imeron 300 (Bracco Imaging).\nThe acquisition of an aortogram was considered but we decided to upfront continue with selective injections of the brachiocephalic trunk. The brachiocephalic trunk’s selective injection demonstrated a difficult to recognize small dot of contrast medium accumulation, which was considered the site of extravasation from the posterior wall of the brachiocephalic trunk to the anterior aspect of the adjacent trachea. We decided to implant a self-expanding stent-graft into the brachiocephalic trunk to seal the vessel wall’s erosion without covering the subclavian artery’s origin. Using the inbuild measurement tool of the DSA machine (Siemens Axiom Artis Zee) with a calibration of the distance between the target vessel and the table surface, the diameter and length of the brachiocephalic artery was determined as 6.9 mm and 36.7 mm, respectively. The available implant was a Fluency Plus Stent Graft 8 mm × 40 mm (BD Bard), mounted in an 80 cm long catheter with a 9F crossing profile. A stiff 0.035″ diameter and 300 cm length Radiofocus guidewire (Terumo) with an angled tip was navigated into the right external carotid artery using a 4F Tempo4 vertebral catheter (Codman) through a 9F sheath (Terumo), followed by the removal of the 4F catheter. The Fluency Stent Graft was inserted over the said guidewire into the brachiocephalic trunk without using a guide catheter. Deployment of the stent-graft immediately stopped the tracheal bleeding (Fig. ). Post-deployment adaptation of the stent-graft to the vessel wall with balloon angioplasty was not required, since the stent-graft instantaneously interrupted the extravasation. The implanted stent-graft was slightly longer than desired. The proximal end was reaching into the aortic arch but did not compromise the origin of the left common carotid artery. To prevent a thromboembolic occlusion of the stent, a loading dose of 1× 500 mg acetylsalicylic acid (ASA; Aspirin, Bayer Vital) IV and 1× 9 mg eptifibatide (Integrilin, GlaxoSmithKline) IV were given before implantation; 1× 180 mg ticagrelor (Brilique, AstraZeneca) PO was administered immediately after access via a feeding tube. The final DSA run demonstrated no active bleeding, exclusion of the fistula and flow in the right internal carotid, subclavian and vertebral arteries. Daily medication consisted of 2× 500 mg ASA IV and 2× 90 mg ticagrelor PO. Daily testing with Multiplate (Roche Diagnostics) and VerifyNow (Accriva) confirmed dual platelet function inhibition. A follow-up cranial CT was obtained after 30 days due to fluctuating vigilance and revealed no ischemic cerebral lesions. Follow-up bronchoscopy performed after 17 days for recurrent pneumonia showed no bleeding. Antibiotic treatment with Piperacillin/Tazobactam 4 g/0,5 g IV (HEXAL) was initiated on day 1 after the endovascular procedure. After discharge on day 8 after the procedure, the patient suffered from complicated pneumonia. During the second clinical admission, she died 31 days after the endovascular treatment in the intensive care unit from pulmonary failure.
A 27-year-old man presented at the emergency department with massive hemorrhage from the tracheostomy tube. His was a case of multiple traumas due to a car accident that happened 8 month ago. He suffered a neck fracture that made him quadriplegic and was operated 8 month ago []. He had a nasogastric tube inserted and had a past history of discharge of food from the foramen of tracheostomy tube after oral feeding. Eight months after the tracheostomy intubation, massive bleeding was noted from the site of tracheostomy stoma and vital signs of the patient became unstable. His blood pressure was below 80/60 and the peripheral pulse was not palpable. As a result, an urgent surgery was performed on the patient under general anesthesia. The anesthetic agents were administered via the tracheostomy tube. We performed rigid bronchoscopy and observed tracheal stenosis from below the vocal cords. Because of the patient's critical health condition and severe tracheal stenosis, we could not have a clear view of the trachea. The tracheoesophageal fistula (TEF) was placed in membranous part of trachea, behind the tracheostomy stoma. During the operation, the bleeding had stopped, which we concluded as the pressure of tracheostomy cuff. The site of tracheostomy stoma was dissected. The operation procedure included division and ligature of the innominate artery and separation of the trachea from the divided artery. The defect of trachea was repaired and reinforced with strap muscle [].\nThen, the tracheostomy tube was reinserted. Due to TEF, a jejunostomy tube was inserted in the patient. After the operation was over, vital signs of the patient were stabilized. The course of neurologic examination was not changed after the operation, but right radial pulse was found to be weaker than left radial pulse. The patient was discharged from hospital after 13 days. Two months later, the patient was again admitted to the hospital for the repair of TEF. Endoscopy was done on the patient. A large foramen in anterior wall of esophagus below the upper esophageal sphincter was shown.\nIn the course of hospital stay, the patient developed deep vein thrombosis in the left leg that progressed into the inferior vena cava. Heparin was administered to the patient with a dose of 1000 U/h through infusion pump. Colored Doppler sonography was performed after 7 days, which revealed that the deep vein thrombosis had resolved. Later, the patient developed severe purulent discharge from the tracheostomy tube. Chest X-ray showed bronchiectasis and pneumonia in both the lower pulmonary lobes of the lung. Appropriate treatment was started depending on the discharge culture result. Despite full antibiotic coverage, the condition of the patient gradually deteriorated. He developed septic shock that was unresponsive to the medical treatment. Unfortunately, our patient expired after 46 days of the first operation.