A 44-year-old man with a tracheostomy was admitted for septic shock from a sacral pressure ulcer infection. He had a history of diabetes, end-stage kidney disease on hemodialysis, spinal cord injury at level T5-T6 due to a motor vehicle accident at the age of 16, and bilateral hemipelvectomy and lower-limb amputation because of recurrent osteomyelitis related to the pressure ulcers. His first tracheostomy was performed outside hospital in anticipation of the need for long-term mechanical ventilatory support as a result of acute respiratory failure secondary to gas gangrene from the pressure ulcer infection and pneumonia with CO2 narcosis. He underwent his third tracheostomy 72 days before admission. The tracheal cannula (Speech Cannula®, Koken®, Tokyo, Japan) had been used with the cuff inflated. There was a small amount of hemoptysis 4 days prior to obvious onset of the TIF. He had no anticoagulant or antiplatelet agent, and his platelet and coagulation function tests within the normal range.\nOn day 16 in the hospital, massive hemorrhage from the tracheostomy site ensued during suctioning, followed by cardiopulmonary arrest from asphyxiation. After cardiopulmonary resuscitation and replacement of the tracheostomy tube with an endotracheal tube were performed, he was transferred to the intensive care unit where he suffered a second cardiopulmonary arrest from hemoptysis-induced upper airway obstruction. Fiberoptic laryngoscopy showed the TIF as the source of bleeding based on the right anterior location of the hemorrhage and adjacent anatomical location of the trachea and innominate artery, as observed on previous computed tomography (Figure A). The cuff of the tube was hyperinflated, but even a slight movement of the tube resulted in recurrent massive hemorrhage. Thus, an endovascular stent graft was placed from his right common carotid artery under general anesthesia. Because the innominate artery was short (4 cm), placing endovascular stent within the length of innominate artery was not expected to be sufficient to seal the bleeding site. Therefore, the procedure to place a 7 cm endovascular stent graft (PXL161007, Gore® Excluder®, Gore) through the innominate and right proximal common carotid arteries sacrificing the right subclavian artery was selected (Figure A,B). There was no further hemorrhaging from the TIF. Four days later, he had an anterior mediastinal tracheostomy after laryngotracheal separation using a pectoralis major myocutaneous flap (Figure B). The postoperative course was uneventful with no neurologic sequela.
An 11-year-old girl with hypoxic-ischemic encephalopathy had gradually developed scoliosis, and she had experienced several episodes of mild wheezing associated with myotonia. Her SpO2 levels had decreased to 20–30% during episodes of severe myotonia. She was referred to a medical center after the abrupt onset of wheezing and respiratory distress. Chest X-ray revealed scoliosis (), and laryngoscopy showed neither supraglottic stenosis nor edema. Chest computed tomography (CT) revealed tracheal stenosis caused by compression by the innominate artery (). Bronchoscopy demonstrated narrowing of the trachea by external compression of its anterior wall as well as tracheomalacia () involving the middle trachea to the tracheal bifurcation. An uncuffed endotracheal tube was inserted distally to the stenosis, and this resulted in a prompt improvement in her respiratory condition. However, she was thought to require long-term tracheal intubation because of the tracheal stenosis and tracheomalacia. Furthermore, she was considered at increased risk of developing tracheal damage and subsequent formation of TIF from tracheal intubation. She was transported to our hospital for preventative ligation of the innominate artery and tracheostomy.\nBrain magnetic resonance CT showed a normal circle of Willis with no occlusion of the internal carotid or innominate arteries. 3D CT demonstrated that the innominate artery crossed the trachea from left to right just cranial to the manubrium (). We planned prophylactic ligation of the innominate artery to prevent the formation of TIF.\nThe patient was positioned supine under general anesthesia. A small curvilinear transverse skin incision was made just above the suprasternal notch. The innominate artery was exposed anterior to the trachea (). After clamping of the innominate artery, the SpO2, as measured at the right hand and oxygen saturation (rSO2) in both cerebral hemispheres, was initially reduced to 70% of baseline readings, but promptly increased to 90%. The innominate artery was transected, and both stumps were closed with continuous absorbable sutures. Thymus tissue was interposed between the proximal and distal stump. After tracheostomy at the 3rd tracheal ring, bronchoscopy revealed a widened tracheal lumen. She was transferred to the intensive care unit for postoperative recovery. The postoperative course was eventful with no neurological complications, and she was discharged on the 6th postoperative day.