A 46-year-old woman visited the emergency room with left hemiparesis and dysarthria. She was diagnosed with an intracerebral hemorrhage (ICH) at the right basal ganglia by brain computed tomography (CT) (). Three days later, a chest X-ray revealed a diffuse haziness in both lung fields (). Her pulmonary status was further complicated by an inability to cooperate with respiratory toilet and total opacification of both lungs on the chest X-ray. She was intubated due to aspiration pneumonia. Her condition was worsened despite intravenous administration of culture-specific antibiotics and repeated sputum drainage. A tracheostomy was performed two weeks later, and the patient was ventilated via a low pressure tube inserted through the second tracheal ring. Thereafter, she stabilized and began to improve.\nThree months after the tracheal intubation, massive bleeding was detected from the tracheal stoma on tracheal suction and the patient vital signs became unstable. Her blood pressure was below 80/60 and with 40% oxygen saturation. The tracheostomy tube was replaced with a flexible endotracheal tube and the endotracheal tube cuff was inflated until adequate ventilation and bleeding control was achieved. Portable fiber optic bronchoscopy could not identify the source of the hemorrhage at the anterior wall of the midtrachea. A thoracic CT scan demonstrated that the tip of the endotracheal tube was in contact with the tracheal wall in the back of a tracheoinnominate artery (). Suspecting TIAF, we brought the patient to the interventional radiology suite. Emergent aortic arch angiography was performed through the right common femoral artery. Catheterization of the aortic arch did not locate the fistula, but upon selective catheterization of the innominate artery, the fistula was clearly visible near the origin of the common carotid artery (). Embolization of the innominate artery using coils was not recommended by the interventionalist because of an occlusion of the right common carotid artery. We also were worry of unexpected results, such as ischemia caused by occlusion of the common carotid artery.\nThe operative procedure to control the fistula and maintain adequate blood flow to the brain consisted of first performing a right aorta-axillary artery bypass using a synthetic graft, followed by resection of the 3 mm fistula and oversewing the divided ends of the innominate artery. The defect in the trachea was approximated with 3-0 Vicryl sutures, and autologous tissue was interposed. Control of the fistula was confirmed by thoracic CT angiography with three-dimensional (3D) reconstruction ().\nPostoperatively, the patient exhibited no evidence of graft infection or erosion and recurrent bleeding. The patient's focal neurologic deficits remained unchanged. She was discharged after three months and continued to do well.
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.