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 17-year-old girl with CP at GMFCS V was referred to our department for surgical treatment of her spinal deformity. Within the past year of her first visit to our department, she needed emergency hospitalization twice for acute respiratory failure and has been recommended for tracheostomy due to tracheal stenosis. Although her preoperative anterior-posterior radiograph in the supine position showed thoracolumbar scoliosis with a Cobb angle of 130 °, which seemed to have little impact on her thoracic cavity, preoperative lateral X-ray and CT clearly demonstrated a flattened tracheal lumen at the T3/4 level due to exaggerated cervicothoracic hyperlordosis (Fig. a-c). After preoperative halo traction for three weeks, she underwent PSF from C7 to L5 with Ponte osteotomy at T2/3/4/5/6 and sublaminar taping from T2 to T5 like case 1 (Fig. d, e). Postoperative CT revealed expansion of the tracheal lumen (Fig. f). Although she required gastrostomy postoperatively due to severe aspiration pneumoniae, she developed no respiratory failure related to impaired airway clearance during the one-year follow-up period without having a tracheostomy.