The patient was a 14-year-old female who had a prior history of tracheostomy, performed when in an intensive care unit because of head trauma, at the age of eight. She had been discharged from hospital after a one month stay and, around three months later, developed subglottic tracheal stenosis, which was treated with outpatient endoscopic dilatation sessions over a period of six years.\nDuring the fifth year of these dilatation sessions, she suffered repeated episodes of hemoptysis, without significant hemodynamic consequences, initially managed conservatively. However, bronchoscopy and CT revealed a TIF, which was identified as the source of the bleeding. This lesion was repaired by a surgical procedure to ligate the TIF, reconstruction of the brachiocephalic trunk with an expanded polytetrafluoroethylene (PTFE) prosthesis, preserving the carotid and vertebral arteries.\nAfter this initial surgical treatment, she progressed well for one year, during which the dilatation sessions were continued, but at the end of this period, hemoptysis recurred. This time, bronchoscopy and CT of the thoraco-cervical region did not reveal the source of the bleeding.\nUnder general anesthesia, selective arteriography of the brachiocephalic trunk revealed a TIF approximately six cm from the carina ( A). At this point, the fistula burst open once more, flooding the lower respiratory tract, with massive bleeding via the oral endotracheal tube, hemomediastinum with compression of the apical segment of the right lung and resultant deterioration of ventilatory function ( B).\nAs an emergency measure, a compliant occlusion balloon (Coda®, Cook Medical, Bloomington, United States) was placed in the mid-distal segment of the brachiocephalic trunk, achieving total obstruction of flow through the vessel ( 2B). Once the blood had been aspirated through the oral endotracheal tube, the patient’s saturation began to improve and hemodynamic stability was achieved.\nEndovascular treatment of the TIF was conducted with placement of a covered stent measuring 7 × 50 mm (Wallgraft®, Boston Scientific, Marlborough, United States) in the brachiocephalic trunk and right subclavian artery, proximal of the origin of the right vertebral artery, excluding the fistula and occluding the origin of the right common carotid artery, which totally controlled the bleeding ( ).\nThree days later, an elective surgical operation was conducted via a cervical access to debride devitalized tissues, remove the prostheses and perform carotid-carotid revascularization with preservation of the cervical vessels. One day after the last surgical procedure, the patient was already extubated, breathing spontaneously, hemodynamically stable, and free from signs of neurological deficits. She was put on antibiotics for three weeks and remained free from additional clinical complications over six months of outpatients follow-up.
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.