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.
A 17-year-old girl with CP at GMFCS V was referred to our department for surgical treatment of her spinal deformity. Within the past year of her first visit to our department, she needed emergency hospitalization twice for acute respiratory failure and has been recommended for tracheostomy due to tracheal stenosis. Although her preoperative anterior-posterior radiograph in the supine position showed thoracolumbar scoliosis with a Cobb angle of 130 °, which seemed to have little impact on her thoracic cavity, preoperative lateral X-ray and CT clearly demonstrated a flattened tracheal lumen at the T3/4 level due to exaggerated cervicothoracic hyperlordosis (Fig. a-c). After preoperative halo traction for three weeks, she underwent PSF from C7 to L5 with Ponte osteotomy at T2/3/4/5/6 and sublaminar taping from T2 to T5 like case 1 (Fig. d, e). Postoperative CT revealed expansion of the tracheal lumen (Fig. f). Although she required gastrostomy postoperatively due to severe aspiration pneumoniae, she developed no respiratory failure related to impaired airway clearance during the one-year follow-up period without having a tracheostomy.