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 25-year-old female was brought to our Emergency Room with acute pulsatile bleeding from her tracheostomy with an 8.1 mg/dl hemoglobin value upon admission. The patient suffered from long-term spastic tetraparesis due to cerebral palsy. Sixty months ago, the patient had undergone tracheostomy as a treatment of respiratory failure after aspiration pneumonia with sepsis. Inspection of the trachea using a flexible bronchoscope demonstrated active arterial bleeding from the trachea anterior wall with pooling of blood in the dependent airway. Blood was aspirated to clear the airways, and the cuff of the tracheostomy tube (Tracheoflex 8 mm, Teleflex Medical) was overinflated to control the bleeding in the short term. A diagnostic digital subtraction angiography (DSA) was carried out under emergency circumstances. The initial angiogram with the cuff inflated revealed no visible contrast medium extravasation. Therefore, the cuff of the tracheal tube was first deflated and then the tube was temporarily removed.\nGeneral anesthesia was induced with propofol and sufentanil, neuromuscular blockade was achieved by atracurium. Maintenance was provided with continuous infusion of propofol and remifentanil. A 9F sheath (Terumo) was inserted into the right common femoral artery. A diagnostic digital subtraction angiography (DSA) was carried out using a Tempo4 vertebral 4F catheter (Codman) under emergency circumstances. Straight posterior-anterior and 20° right and left anterior oblique angiographic projections of the brachiocephalic artery with 6 frames per second were acquired with manual bolus injection of each 8 ml Imeron 300 (Bracco Imaging).\nThe acquisition of an aortogram was considered but we decided to upfront continue with selective injections of the brachiocephalic trunk. The brachiocephalic trunk’s selective injection demonstrated a difficult to recognize small dot of contrast medium accumulation, which was considered the site of extravasation from the posterior wall of the brachiocephalic trunk to the anterior aspect of the adjacent trachea. We decided to implant a self-expanding stent-graft into the brachiocephalic trunk to seal the vessel wall’s erosion without covering the subclavian artery’s origin. Using the inbuild measurement tool of the DSA machine (Siemens Axiom Artis Zee) with a calibration of the distance between the target vessel and the table surface, the diameter and length of the brachiocephalic artery was determined as 6.9 mm and 36.7 mm, respectively. The available implant was a Fluency Plus Stent Graft 8 mm × 40 mm (BD Bard), mounted in an 80 cm long catheter with a 9F crossing profile. A stiff 0.035″ diameter and 300 cm length Radiofocus guidewire (Terumo) with an angled tip was navigated into the right external carotid artery using a 4F Tempo4 vertebral catheter (Codman) through a 9F sheath (Terumo), followed by the removal of the 4F catheter. The Fluency Stent Graft was inserted over the said guidewire into the brachiocephalic trunk without using a guide catheter. Deployment of the stent-graft immediately stopped the tracheal bleeding (Fig. ). Post-deployment adaptation of the stent-graft to the vessel wall with balloon angioplasty was not required, since the stent-graft instantaneously interrupted the extravasation. The implanted stent-graft was slightly longer than desired. The proximal end was reaching into the aortic arch but did not compromise the origin of the left common carotid artery. To prevent a thromboembolic occlusion of the stent, a loading dose of 1× 500 mg acetylsalicylic acid (ASA; Aspirin, Bayer Vital) IV and 1× 9 mg eptifibatide (Integrilin, GlaxoSmithKline) IV were given before implantation; 1× 180 mg ticagrelor (Brilique, AstraZeneca) PO was administered immediately after access via a feeding tube. The final DSA run demonstrated no active bleeding, exclusion of the fistula and flow in the right internal carotid, subclavian and vertebral arteries. Daily medication consisted of 2× 500 mg ASA IV and 2× 90 mg ticagrelor PO. Daily testing with Multiplate (Roche Diagnostics) and VerifyNow (Accriva) confirmed dual platelet function inhibition. A follow-up cranial CT was obtained after 30 days due to fluctuating vigilance and revealed no ischemic cerebral lesions. Follow-up bronchoscopy performed after 17 days for recurrent pneumonia showed no bleeding. Antibiotic treatment with Piperacillin/Tazobactam 4 g/0,5 g IV (HEXAL) was initiated on day 1 after the endovascular procedure. After discharge on day 8 after the procedure, the patient suffered from complicated pneumonia. During the second clinical admission, she died 31 days after the endovascular treatment in the intensive care unit from pulmonary failure.