A strategy to prevent tracheo-innominate artery fistula in the course of laryngotracheal separation: 9-year experience in a children's hospital

Aim of the studyLaryngotracheal separation (LTS) is known to be the definitive solution for intractable aspiration pneumonia in neurologically impaired children. Postoperatively, a tracheostomy cannula is usually required. However, there are fatal cannula related complications such as a tracheo-innominate artery fistula (TIAF). We present our methods of preventing TIAF.MethodsA retrospective review in a single center from 2011 to 2019 identified 57 cases treated with LTS. We divided them into three groups: no pre-existing tracheostomy (n = 26), pre-existing tracheostomy with preservation of the pre-existing fistula (n = 20), and pre-existing tracheostomy without preservation of the pre-existing fistula (n = 11). The first group underwent traditional modified Lindeman's procedure. The second received transection of the trachea above the tracheostomy site, while the third had transection of the trachea at the tracheostomy site and creation of a distal end tracheostomy. Proper length and the angle of the cannula were selected to prevent damaging the innominate artery by the tip of the cannula. If the innominate artery compressed the trachea anteriorly, prophylactic arterial transection was considered.ResultsThree patients (5.3%) died from causes unrelated to the surgical treatment. Only one patient had a postoperative TIAF followed by LTS (1.8%). Other postoperative complications were: wound infection (8.8%), intratracheal granuloma (12.3%), intratracheal minor bleeding (10.5%), wound granuloma (43.9%), leakage (1.8%). No one required revision of LTS.ConclusionSuccess rates of LTS were high without major complications in all three groups and implies a safe operation and a definitive solution to intractable aspiration.     

Suprasternal approach for impending tracheo-innominate artery fistula

We report preventive innominate artery division or ligation through a suprasternal approach for impending tracheo-innominate artery fistula (TIF) with recurrent airway oozing in patients with severe neuromuscular disease. Our approach is less invasive and a favorable procedure as preventive surgery for impending TIF.     

Coronary artery spasm during non-cardiac surgical procedure

A case of coronary artery spasm during a non-cardiac surgical procedure is presented. Two paroxysmal episodes of ST segment elevation in lead 11 and aVF without changes in V5 developed during general anaesthesia. These changes were not preceded by increases in heart rate or arterial pressure. The second episode was associated with a ventricular bigeminal rhythm. This case demonstrates the importance of monitoring several leads in patients likely to develop peroperative spasm of the coronary arteries. Intravenous nitroglycerin was effective in treating the second episode of coronary artery spasm. However, this episode occurred in spite of nitroglycerin administered intravenously at a rate of 0.25 microgram/kg min.     

Tracheo-innominate artery erosion: Successful surgical management of a devastating complication.

Successful management of a patient with tracheo-innominate artery erosion requires the rapid institution of specific resuscitative and operative measures. Ten patients seen at the Charity Hospital of Louisiana in New Orleans and 127 documented cases from the world literature were analyzed regarding predisposing factors, diagnostic features, resuscitative measures and operative treatment. Diagnoses associated with abnormal neck positioning were seen in 48% of patients with tracheo-innominate erosions. In 69% of 96 instances, the site of erosion was located at the cannula end and implicates excessive anterior pressure. Caution is recommended in those patients with abnormal neck positions, low placed tracheostomy stomas and individuals with asthenic habitus. Resuscitative measures were highly successful when the tracheal ballon was inflated or when the method of retrosternal finger pressure was used. All personnel providing care for patients with tracheostomies should be aware of the initial measure of ballon inflation. Operative measures which permanently interrupted the innominate artery in the area of possible future erosion were the most successful. Of the 22 cases in which the innominate artery was sacrificed, only one had evidence of cerebral ischemia. Timely institution of proper measures can result in salvage of an unexpected number of these otherwise dramatic fatalities.     

Graft repair of tracheo-innominate artery fistula following percutaneous tracheostomy

Tracheo-innominate fistula (TIF) is a rare complication following percutaneous dilatational tracheostomy (PDT), occurring in < or =1% of cases. It usually develops three days to six weeks after the procedure and is fatal in the majority of cases, even after successful initial repair. We present a successfully treated case of TIF using a Goretex graft to replace the severely destroyed segment of the innominate artery.     

Tarsal coalitions. A new surgical procedure

Coalition is a congenital fusion of two or more tarsal bones. Symptoms, if present, usually begin in early adolescence. The typical symptom complexes are aching pain in the rearfoot exacerbated by activity, progression of the flatfoot deformity, decreased tarsal motion, and sometimes peroneal spasm. When patients are asymptomatic, no treatment is necessary. If symptoms begin, the individual should be treated conservatively. If that fails, surgical intervention should be undertaken. Calcaneonavicular coalitions respond well to excision with extensor digitorum brevis interposition. Talocalcaneal middle facet coalitions have responded well to resection with implant arthroplasty. When degenerative changes are present in the subtalar and midtarsal joints, triple arthrodesis is still the procedure of choice.     

Massive hemorrhage induced by tracheo-innominate artery fistula in two infants

Two cases of massive hemorrhagic shock induced by tracheo-innominate artery fistula are reported. The first case is a 4 year-old girl with encephalitis under prolonged mechanical ventilation. The second case is a 6 year-old tracheostomized girl with mental and motor retardation of congenital origin who has been taken care of at her home. This catastrophic complication is usually caused by long term placement of tracheostomy tube with the cuff inflated especially in malnourished pediatric patients. The cuff pressure is apt to be concentrated on one side of the tracheal wall especially in mechanically ventilated immobilized patients. Although this complication is rare because cuffed tube is currently avoided in pediatric patient, sophisticated care should be taken in managing tracheostomized patients.     

Surgical repair for tracheo-innominate artery fistula with a muscle flap

A 70-year-old woman was quickly diagnosed as having tracheo-innominate artery fistula by three-dimensional computed tomography. Immediate surgical exploration was performed to control the bleeding using a temporary shunt. After the damaged artery was excised, vascular reconstruction was performed to preserve the connection between the proximal and distal ends of the innominate artery with the interposition of a saphenous vein graft. A pedicled sternocleidomastoid muscle flap was successfully used for the tracheal reconstruction.     

Nailfold retraction due to burn wound contracture. A surgical procedure

Burn scar contracture on the dorsal aspect of fingers or toes often leads to retraction of the protecting nailfold, which may be extremely annoying to the patient. A surgical procedure for relocation of the nailfold is presented.     

Successful management of tracheo-innominate artery fistula with endovascular stent graft repair

Tracheo-innominate artery fistula is a highly lethal complication after tracheostomy. A 37-year-old man who had undergone a tracheostomy 14 years earlier because of dysphagia after brain surgery had a tracheo-innominate artery fistula with exsanguinating hemorrhage from his tracheostomy site. After temporary control of the bleeding, a stent graft was implanted in the innominate artery through the brachial artery. The patient recovered uneventfully and remained well 14 months after the procedure, with no sign of infection. Endovascular stent grafting may be the treatment of choice for patients with tracheo-innominate artery fistula.     

Occipital artery to extradural vertebral artery bypass procedure. Case report

A 17-year-old boy suffered blunt trauma to the posterior cervical spine and later developed vertebrobasilar transient ischemic attacks refractory to medical management. At angiography, a pseudoaneurysm of the distal left vertebral artery was found. By means of a posterior midline approach, an extradural occipital artery to vertebral artery anastomosis was performed and the affected vertebral artery was clipped distal to the pseudoaneurysm. The indications for this procedure, the operative approach, and the clinical outcome are described.     

Strategies to prevent surgical site infections

Surgical site infections (SSI) are a severe complication following surgical or orthopaedic procedures and are associated with significant increases in hospital length of stay (LOS), additional costs, morbidity and mortality. Hence, the prevention of SSI is essential and poses a major challenge in the healthcare system. Strategies and key points are presented and discussed. Infection control measures such as active surveillance of SSI, implementation of a checklist, compliance observations and instruction/training of healthcare workers as well as Staphylococcus aureus/MRSA screening, clipping instead of shaving, adherence to perioperative antibiotic prophylaxis, maintaining intraoperative normothermia and blood glucose control are essential for a comprehensive bundle in order to prevent SSI.     

Delayed sternal closure after vacuum-assisted closure therapy for tracheo-innominate artery fistula repair

We report a case of successful innominate artery resection with delayed sternal closure after vacuum-assisted closure (VAC) therapy for a tracheo-innominate artery fistula (TIF). A 42-year-old woman with cerebral palsy underwent tracheostomy for respiratory assistance. On postoperative day 14, she was transferred to our hospital after an episode of massive hemoptysis. TIF was diagnosed based on the findings of multidetector computed tomography. Thus, we resected the innominate artery and started VAC therapy to control the postoperative local infection. The patient recovered uneventfully, without any infectious sequelae. Our strategy, which includes VAC therapy, for TIF repair may eliminate postoperative infective problems that could induce sequential bleeding and sternal compromise. To our knowledge, this is the first report of using VAC therapy for TIF.     

Simple surgical technique to prevent direct secondary aortoenteric fistulas.

To prevent direct secondary aortoenteric fistulas, a devastating complication of abdominal aortic surgery, we describe here a rapid, very easy to perform and no cost operating technique. A part about 4 cm long of the vascular prosthesis was cut to obtain a partial tailored ring which was passed through the prosthesis. After the anastomosis was realized, the tailored ring was hitched up to totally cover proximal anastomosis and prevent direct contact between aorto-prosthetic anastomosis and the bowel.