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.
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.