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 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.