The patient was a 14-year-old female who had a prior history of tracheostomy, performed when in an intensive care unit because of head trauma, at the age of eight. She had been discharged from hospital after a one month stay and, around three months later, developed subglottic tracheal stenosis, which was treated with outpatient endoscopic dilatation sessions over a period of six years.\nDuring the fifth year of these dilatation sessions, she suffered repeated episodes of hemoptysis, without significant hemodynamic consequences, initially managed conservatively. However, bronchoscopy and CT revealed a TIF, which was identified as the source of the bleeding. This lesion was repaired by a surgical procedure to ligate the TIF, reconstruction of the brachiocephalic trunk with an expanded polytetrafluoroethylene (PTFE) prosthesis, preserving the carotid and vertebral arteries.\nAfter this initial surgical treatment, she progressed well for one year, during which the dilatation sessions were continued, but at the end of this period, hemoptysis recurred. This time, bronchoscopy and CT of the thoraco-cervical region did not reveal the source of the bleeding.\nUnder general anesthesia, selective arteriography of the brachiocephalic trunk revealed a TIF approximately six cm from the carina ( A). At this point, the fistula burst open once more, flooding the lower respiratory tract, with massive bleeding via the oral endotracheal tube, hemomediastinum with compression of the apical segment of the right lung and resultant deterioration of ventilatory function ( B).\nAs an emergency measure, a compliant occlusion balloon (Coda®, Cook Medical, Bloomington, United States) was placed in the mid-distal segment of the brachiocephalic trunk, achieving total obstruction of flow through the vessel ( 2B). Once the blood had been aspirated through the oral endotracheal tube, the patient’s saturation began to improve and hemodynamic stability was achieved.\nEndovascular treatment of the TIF was conducted with placement of a covered stent measuring 7 × 50 mm (Wallgraft®, Boston Scientific, Marlborough, United States) in the brachiocephalic trunk and right subclavian artery, proximal of the origin of the right vertebral artery, excluding the fistula and occluding the origin of the right common carotid artery, which totally controlled the bleeding ( ).\nThree days later, an elective surgical operation was conducted via a cervical access to debride devitalized tissues, remove the prostheses and perform carotid-carotid revascularization with preservation of the cervical vessels. One day after the last surgical procedure, the patient was already extubated, breathing spontaneously, hemodynamically stable, and free from signs of neurological deficits. She was put on antibiotics for three weeks and remained free from additional clinical complications over six months of outpatients follow-up.
A 19-year-old girl with CP at GMFCS V was referred to our department for treatment of a progressive spinal deformity. She had no history of respiratory failure until the age of 14 years. Within the past year of her first visit to our department, she was ambulanced to the ER twice due to acute oxygen desaturation. X-ray in assisted sitting position and computed tomography (CT) demonstrated severe scoliosis with a Cobb angle of 157 ° and tracheal stenosis at T2 due to compression between the innominate artery and the cervicothoracic hyperlordosis, suggesting that her acute oxygen desaturation had been caused by the impaired airway clearance at this level (Fig. a-c). After preoperative halo traction for three weeks, she underwent PSF from C7 to L5 with Ponte osteotomy at T1/2/3/4 and sublaminar taping from T1 to T6 to correct cervicothoracic hyperlordosis and thoracolumbar scoliosis simultaneously. Postoperative X-ray and CT revealed that her tracheal stenosis improved in parallel with the correction of cervicothoracic hyperlordosis. She had not developed respiratory failure until 1.5 years after surgery (Fig. d-f).