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 19-year-old girl with CP at GMFCS V was referred to our department for treatment of a progressive spinal deformity. She had no history of respiratory failure until the age of 14 years. Within the past year of her first visit to our department, she was ambulanced to the ER twice due to acute oxygen desaturation. X-ray in assisted sitting position and computed tomography (CT) demonstrated severe scoliosis with a Cobb angle of 157 ° and tracheal stenosis at T2 due to compression between the innominate artery and the cervicothoracic hyperlordosis, suggesting that her acute oxygen desaturation had been caused by the impaired airway clearance at this level (Fig. a-c). After preoperative halo traction for three weeks, she underwent PSF from C7 to L5 with Ponte osteotomy at T1/2/3/4 and sublaminar taping from T1 to T6 to correct cervicothoracic hyperlordosis and thoracolumbar scoliosis simultaneously. Postoperative X-ray and CT revealed that her tracheal stenosis improved in parallel with the correction of cervicothoracic hyperlordosis. She had not developed respiratory failure until 1.5 years after surgery (Fig. d-f).