Innominate Artery Rupture: A Major Complication of Tracheal Surgery

doi:10.1016/S0003-4975(10)65760-8

The Annals of Thoracic Surgery

Volume 20, Issue 6, December 1975, Pages 671-677

https://doi.org/10.1016/S0003-4975(10)65760-8 Get rights and content

Abstract

Innominate artery rupture is a life-threatening complication of tracheal reconstructive surgery. Early postoperative rupture of the innominate artery occurred in 8 of 100 consecutive patients undergoing tracheal resection and reconstruction (93, end-to-end anastomosis; 7, Marlex prosthesis). A premonitory transient hemoptysis occurred in 4 of the 8 patients. This sign may permit early diagnosis and effective treatment. When massive hemorrhage occurs, prompt arterial compression, control of the airway, and subsequent ligation of the artery may be lifesaving. Direct repair of the arterial defect is not recommended. If the innominate artery lies in direct contact with the suture line following primary anastomosis, soft tissue interposition is recommended.

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Cited by (42)

Operative management of catastrophic bleeding in the head and neck
2017, Operative Techniques in Otolaryngology - Head and Neck Surgery
Citation Excerpt :
There is no evidence to suggest this procedure leads to significant neurological or vascular insult.35-37 Although arterial reconstruction has been successful historically, ligation of the innominate artery alone has had significantly better morbidity and mortality.36,37 Rupture of the carotid artery and its branches are referred to as a carotid blowout and the clinical signs and symptoms preceding have been termed carotid blowout syndrome (CBS).
The otolaryngologist commonly performs several procedures in close proximity to the carotid and innominate arterial systems. In this article, we will discuss the management of catastrophic bleeding following adult tonsillectomy and tracheostomy, as well as the management of carotid blowout syndrome in head and neck cancer patients. Although the bleeding risk from tonsillectomy is considered very low, the acceptance of transoral robotic surgery as a treatment modality of oropharyngeal head and neck carcinomas makes the spectre of catastrophic oropharyngeal bleeding more real. Aggressive resection in this area can leave minimal parapharyngeal fat over the carotid artery and damage from manipulation of smaller vessels can lead to pseudoaneurysms. Tracheostomy also carries a very low but real risk of trachea-innominate artery fistula, which has devastating consequences. Finally, we will discuss how to identify head and neck cancer patients who are at risk for carotid blowout syndrome as well as appropriate interventions to manage this condition.
Advances in tracheal surgery: Are we close to finding the ideal tracheal substitute?
2010, Revue des Maladies Respiratoires
La chirurgie trachéale a progressivement évolué avec l’essor de l’anesthésie, la compréhension des différentes pathologies rencontrées et les efforts de nombreux chirurgiens dans le monde entier. À l’ère de la transplantation d’organes, le remplacement de la trachée reste un problème non résolu et l’un des plus grands défis en chirurgie thoracique. L’utilisation d’un greffon aortique rigidifié par une endoprothèse comme substitut trachéal a conduit, chez l’animal, à une régénération tissulaire inattendue sous la forme d’une « néo-trachée » fonctionnelle comprenant un épithélium respiratoire et du cartilage. Ces résultats ont mené aux premières applications cliniques, en France, chez des malades ayant des tumeurs malignes étendues de la trachée jusqu’alors incurables. Les travaux de recherche fondamentale et clinique doivent être amplifiés en ce domaine, pour, d’une part, offrir un traitement chirurgical standardisé aux lésions trachéales complexes et, d’autre part, mieux analyser les mécanismes de régénération trachéale.
Tracheal surgery has evolved progressively with advances in anaesthesia, the understanding of tracheal pathology and the efforts made by surgeons all over the world. In the era of organ transplantation, tracheal replacement remains an unsolved problem and one of the most important challenges in thoracic surgery. In animals, the use of a stent supported aortic graft as a tracheal substitute led to unexpected tissue regeneration in the form of a functional “neo-trachea” with respiratory epithelium and cartilage. These results led to the first clinical applications in France in patients with extensive, incurable, malignant tracheal tumors. Experimental and clinical research programs have to be increased in order, firstly to provide a standardized surgical technique for complex tracheal lesions and secondly to understand better the mechanisms of tracheal regeneration.
Is emergency revasularization of tracheo-innominate artery fistulae mandatory?
2010, Journal des Maladies Vasculaires
Chez les patients trachéotomisés, les fistules entre la trachée et le tronc artériel innominé (TAI) sont des complications rares (incidence : 0,1 – 1 %) mais fatales en l’absence de traitement. Le traitement de référence est chirurgical, la plupart des auteurs préconisant la ligature du tronc innominé, cette technique procurant de meilleurs résultats en termes de morbimortalité qu’une chirurgie de revascularisation. Ce travail rapporte un cas traité avec succès par une technique de revascularisation du TAI, isolé de la trachée par un greffon d’interposition pédiculé sterno-cléidomastoïdien, avec deux années de recul. La chirurgie de revascularisation doit être réservée à des cas particuliers. La fréquence des infections à point de départ trachéal au contact de sutures vasculaires justifie la réalisation systématique d’un greffon d’interposition vivant venant isoler la trachée du TAI.
Tracheo-innominate artery fistulas are a rare but life-threatening complications (incidence between 0.1 and 1 %) occurring in tracheostomy patients. Surgery is the treatment of choice. Most authors recommend ligation of the innominate artery, which provides better results in terms of morbidity/mortality than revascularization surgery. We report here a case of innominate artery revascularization isolated from the trachea by a sternocleidomastoid pediculate interposition graft. The procedure was successful as demonstrated by the 2 years follow-up. Revascularization surgery should be reserved of specific cases. The risk of tracheal-mediated infections developing in contact with the vascular sutures warrants systematic use of an interposition graft isolating the trachea from the innominate artery.
Biodegradable polymer coating promotes the epithelization of tissue-engineered airway prostheses
2010, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
In contrast with the previous studies using a collagen-monolayered prosthesis, good results were achieved in terms of epithelization. Together with major advances in surgical techniques that now enable rather complex forms of bronchoplasty20,21 and reconstruction of tracheal defects more than 6 cm long,22 the risk of potentially fatal complications, such as local infection, stenosis, or rupture of the adjacent vessels,23-25 still precludes the clinical use of artificial prostheses in this situation. However, because reconstruction of the trachea involving lengthy resections exceeding 4 cm is associated with a high morbidity rate,26 there is a clinical demand for an appropriate prosthesis that can avoid any stretching stress at the anastomosis site.
We have developed a prosthesis that includes a collagen layer for tracheobronchial reconstruction and applied it in a canine model. In previous studies luminal epithelization remained partial or rather slow because of the early disintegration of the collagen layer. We have improved this type of prosthesis by coating the luminal surface with a biodegradable polymer, which serves to protect the collagen layer. The effect of the polymer coating on the epithelization of the luminal surface of the prosthesis was examined.
The main frame consisted of a polypropylene mesh tube, measuring 15 mm in inner diameter and 30 mm in length, with reinforcing rings. Collagen extracted from porcine skin was conjugated to this frame. The luminal surface was coated with a polymer, poly (L-lactic-acid-co-ε-caprolactone). In 5 beagle dogs the left main bronchus was replaced with this prosthesis, periodic bronchoscopic observations were conducted, and microscopic evaluations were performed.
All dogs survived until they were killed, except for 1 animal in which pneumonia developed, and this animal died at 13 months after replacement. None of the dogs showed adverse complications caused by the prosthesis. Bronchoscopic observations revealed that the polymer remained on the luminal surface for 2 weeks. The luminal surface in 4 dogs was completely covered with ciliated columnar epithelium or nonciliated squamous epithelium, and 90% epithelization was achieved in 1 dog.
The biodegradable polymer coating protected the collagen layer and promoted better epithelization. This improved epithelization on the luminal surface could therefore potentially increase the success rates in airway replacement with artificial prostheses.
Replacement of the Left Main Bronchus With a Tissue-Engineered Prosthesis in a Canine Model
2008, Annals of Thoracic Surgery
Citation Excerpt :
Reconstruction of the airway with an artificial prosthesis has been studied for decades. However, the degree of success has been limited because of problems such as local infection, stenosis, or rupture of the adjacent vessels [19–21]. The risk of such fatal complications currently precludes the clinical use of artificial prostheses in this situation.
Stenosis of the left main bronchus caused by inflammatory diseases and neoplasms is a serious clinical problem because it can cause obstructive pneumonia and may require pneumonectomy. As an alternative to various treatments currently available, including balloon dilatation, stenting, and bronchoplasty, we propose the use of a prosthesis developed based on the concept of in situ tissue engineering for replacement of the left main bronchus.
The main frame of the tissue-engineered prosthesis is a polypropylene mesh tube, 12 to 15 mm in inner diameter and 30 mm in length, with reinforcing rings. Collagen extracted from porcine skin is conjugated to this frame. A consecutive series of 8 beagle dogs underwent replacement of the left main bronchus with this tissue-engineered prosthesis.
All dogs survived the postoperative period with no morbidity except 1, which required intravenous administration of antibiotic for a week for pneumonia and recovered. Three dogs were euthanized for examination at 3 and 4 months after bronchus replacement, and the other five were monitored for more than 1 year. In two dogs, histologic examination revealed that the luminal surface was completely covered with ciliated columnar epithelium or nonciliated squamous epithelium. Exposure of the polypropylene mesh to various degrees was observed in 6 dogs, but the prosthesis remained stable and no adverse effects such as infection, sputum retention, or dehiscence were observed.
These long-term results suggest that our tissue-engineered prosthesis is applicable for replacement of the left main bronchus.
Tracheo-arterial fistula in tracheostomy patients with Duchenne muscular dystrophy
2006, Brain and Development
A tracheo-arterial fistula is a serious and life threatening potential complication of a tracheostomy. Since 1984, we experienced nine fatal cases of tracheo-arterial fistula among 60 Duchenne muscular dystrophy (DMD) patients who underwent a tracheostomy. Representative cases included a patient with lordosis (Case 8), in whom the fistula was located in the brachiocephalic artery close to the trachea, and another with severe scoliosis (Case 9), which caused the aorta to compress the trachea. Such anatomical changes can be the cause of a fistula between the trachea and brachiocephalic artery. The anatomical locations between the trachea and brachiocephalic artery are modified by thoracic deformities in DMD patients, and should be confirmed using computed tomography (CT) prior to a tracheostomy procedure. Further, during such a procedure, the tracheal stoma must be placed in a location clearly away from the arteries, and should be followed by regular post-operative examinations using CT and careful management to avoid a tracheo-arterial fistula.

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: Presented at the Eleventh Annual Meeting of The Society of Thoracic Surgeons, Montreal, Que., Canada, Jan. 20–22, 1975.

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Innominate Artery Rupture: A Major Complication of Tracheal Surgery

Abstract

J Thorac Cardiovasc Surg

Tracheal innominate artery fistula after repair of tracheal stenosis

J Thorac Cardiovasc Surg

Innominate artery hemorrhage complicating tracheostomy

Ann Otol Rhinol Laryngol

Tracheoarterial fistula: A complication of tracheostomy in patients with brain stem injury

J Trauma

Surgery of the trachea

Curr Probl Surg

Delayed massive hemorrhage following tracheostomy

Laryngoscope

Hemodynamics of innominate artery occlusion

Ann Surg