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 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.