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.
A 27-year-old man presented at the emergency department with massive hemorrhage from the tracheostomy tube. His was a case of multiple traumas due to a car accident that happened 8 month ago. He suffered a neck fracture that made him quadriplegic and was operated 8 month ago []. He had a nasogastric tube inserted and had a past history of discharge of food from the foramen of tracheostomy tube after oral feeding. Eight months after the tracheostomy intubation, massive bleeding was noted from the site of tracheostomy stoma and vital signs of the patient became unstable. His blood pressure was below 80/60 and the peripheral pulse was not palpable. As a result, an urgent surgery was performed on the patient under general anesthesia. The anesthetic agents were administered via the tracheostomy tube. We performed rigid bronchoscopy and observed tracheal stenosis from below the vocal cords. Because of the patient's critical health condition and severe tracheal stenosis, we could not have a clear view of the trachea. The tracheoesophageal fistula (TEF) was placed in membranous part of trachea, behind the tracheostomy stoma. During the operation, the bleeding had stopped, which we concluded as the pressure of tracheostomy cuff. The site of tracheostomy stoma was dissected. The operation procedure included division and ligature of the innominate artery and separation of the trachea from the divided artery. The defect of trachea was repaired and reinforced with strap muscle [].\nThen, the tracheostomy tube was reinserted. Due to TEF, a jejunostomy tube was inserted in the patient. After the operation was over, vital signs of the patient were stabilized. The course of neurologic examination was not changed after the operation, but right radial pulse was found to be weaker than left radial pulse. The patient was discharged from hospital after 13 days. Two months later, the patient was again admitted to the hospital for the repair of TEF. Endoscopy was done on the patient. A large foramen in anterior wall of esophagus below the upper esophageal sphincter was shown.\nIn the course of hospital stay, the patient developed deep vein thrombosis in the left leg that progressed into the inferior vena cava. Heparin was administered to the patient with a dose of 1000 U/h through infusion pump. Colored Doppler sonography was performed after 7 days, which revealed that the deep vein thrombosis had resolved. Later, the patient developed severe purulent discharge from the tracheostomy tube. Chest X-ray showed bronchiectasis and pneumonia in both the lower pulmonary lobes of the lung. Appropriate treatment was started depending on the discharge culture result. Despite full antibiotic coverage, the condition of the patient gradually deteriorated. He developed septic shock that was unresponsive to the medical treatment. Unfortunately, our patient expired after 46 days of the first operation.