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J Thorac Cardiovasc Surg 2007;133:1641-1643
© 2007 The American Association for Thoracic Surgery

Brief Communication

Surgical treatment of tracheoinnominate fistula after stent-graft implantation

Enrico Maria Marone, MDa,*, Gloria Esposito, MDa, Andrea Kahlberg, MDa, Yamume Tshomba, MDa, Chiara Brioschi, MDa, Piero Zannini, MDb, Roberto Chiesa, MDa

a Chair of Vascular Surgery, Department of Thoracic and Cardiovascular Surgery, Scientific Institute H. San Raffaele, Vita-Salute University School of Medicine, Milan, Italy
b Chair of Thoracic Surgery, Department of Thoracic and Cardiovascular Surgery, Scientific Institute H. San Raffaele, Vita-Salute University School of Medicine, Milan, Italy.

Received for publication December 6, 2006; accepted for publication December 12, 2006.

* Address for reprints: Enrico Maria Marone, MD, Chair of Vascular Surgery, Scientific Institute H. San Raffaele, Vita-Salute University School of Medicine, Via Olgettina 60, 20132, Milan, Italy. (Email: marone.enrico{at}hsr.it).


Figure 1
Drs Brioschi, Esposito, Marone, Tshomba, Prof Chiesa, and Dr Kahlberg (left to right)


Protrusion of stent-grafts into adjacent structures is an uncommon but life-threatening complication of endovascular procedures and may result in fistulization. Tracheoinnominate fistulization is a devastating and often fatal condition, requiring prompt diagnosis and appropriate surgical treatment.1Go This report describes a case of a tracheoinnominate fistula as a delayed complication of a posttraumatic pseudoaneurysm endovascular repair.

Clinical Summary

A 21-year-old Asian man with a 5-cm posttraumatic pseudoaneurysm of the innominate artery was treated at the referring hospital by implantation of three covered stents from the origin of the innominate artery to the proximal tract of the right common carotid artery. Postoperative computed tomographic scans showed complete pseudoaneurysm exclusion and right subclavian artery occlusion at the origin, reperfused by the right vertebral artery. The postoperative course was complicated by a tracheal ring laceration (requiring endoscopic toilet and tracheostomy), pulmonary infection, and sepsis. The patient was given antibiotic therapy and discharged in stable conditions.

Two months later, a scheduled fiberbronchoscopy, followed by magnetic resonance imaging of the chest, showed erosion of stent-grafts into the tracheal lumen for a 3-cm long segment, with multiple ulcerations of the right lateral wall. The patient was transferred to our institution for further treatment. On the first day, he had several episodes of hemoptysis. Preoperative imaging confirmed protrusion of the stent-grafts into the tracheal lumen (Figure 1). The patient underwent right cervicosternotomy and surgical exploration of the cervicothoracic region. A fistula was found between the innominate artery, where the stent-grafts had been placed, and the trachea. The grafts seemed also to be excessively oversized relative to the artery diameter. We proceeded to excision of the innominate artery and stent-grafts, extra-anatomic cerebral revascularization (through a left-to-right common carotid artery crossover bypass with a 6-mm expanded polytetrafluoroethylene ringed graft), and tracheal reconstruction with an autologous patch of thymus, pericardium, and arterial wall.


Figure 1
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  		Figure 1. A, Computed tomographic scan showing innominate artery stent-grafts (white arrow) protruding into the tracheal lumen close to T-tube (black arrow). B, Preoperative digital subtraction angiography of aortic arch and supra-aortic vessels.

 
Despite initial hemodynamic stability, hemothorax, hemopericardium, and massive hemoptysis developed in the postoperative period as a result of active bleeding from the innominate artery stump. Consequently, the patient underwent hypothermic cardiac arrest and urgent resternotomy. The aortic arch wall was found to be lacerated and was sutured with a bovine pericardial patch (Figure 2). Dehiscence of tracheal reconstruction was treated by sealing a pedicled left internal thoracic artery, parietal pleura, and pectoralis major muscle flap. Three days later, the patient underwent a new surgical operation under deep hypothermic circulatory arrest for septic necrosis of the tracheal reconstruction. A few days later, a new episode of massive bleeding occurred, leading to hemorrhagic shock and death.


Figure 2
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  		Figure 2. A, Intraoperative photograph during resternotomy and hypothermic cardiac arrest showing laceration of aortic arch wall (black arrow) and dehiscence of previous tracheal reconstruction (white arrow). B, Aortic arch repair with a bovine pericardial patch.

 
Discussion

Tracheal erosion by a vascular graft has been previously described only by Conklin and coworkers2Go in a patient who underwent graft reconstruction of the innominate artery for a mycotic pseudoaneurysm. In recent years, endovascular procedures have been performed with increasing frequency for the treatment of traumatic injuries of the supra-aortic trunks, especially of the innominate artery,3Go because they are considered minimally invasive and relatively easy to carry out. No documentation is yet available, however, regarding long-term results and specific delayed complications. The complication we observed was probably due either to oversized stent-grafts and multiple stent-grafts overlapping. It is well known that endograft diameter must be oversized between 10% and 20% relative to the estimated proximal neck diameter and that the graft length must be correctly selected to avoid multiple stent-grafts overlapping.3Go It is also important to evaluate the integrity of the vessel’s wall and the sterility of anatomic district affected by the trauma or infection.

Treatment of tracheoinnominate fistula as a result of stent-graft erosion is surgical and requires excision of the innominate artery and separation from the trachea.2Go The best access for exposure of the proximal innominate artery and of the trachea is through a midline sternotomy. In the presence of active bleeding, a femorofemoral cardiopulmonary bypass could be installed and deep hypothermic circulatory arrest obtained before opening the chest. The innominate artery should be cut close to its origin on the aortic arch and the trachea sewn with interposition of pleural or pericardial patch.4Go The revascularization of cerebral and brachial arteries is preferably obtained by extra-anatomic reconstruction. In our case, the best option to protect the brain before treating the innominate artery was retropharyngeal carotid–carotid crossover bypass.

In conclusion, the treatment of traumatic injuries of the innominate artery could be either surgical or endovascular. It is important to select correct materials and to avoid postoperative infection that could lead to a tracheoinnominate fistula. This occurrence represents a dangerous complication, requiring surgical treatment with extra-anatomic bypass grafting, excision of the innominate artery, and reconstruction of the trachea with autologous tissue.4Go

References

  1. Courcy PA, Rodriguez A, Garrett HE. Operative technique for repair of tracheoinnominate artery fistula. J Vasc Surg 1985;2:332-334.[Medline]
  2. Conklin LD, LeMaire SA, Casar GJ, Coselli JS. Tracheal erosion by an innominate artery graft: presentation and surgical repair. Ann Thorac Surg 2003;75:573-575.[Abstract/Free Full Text]
  3. Diaz-Daza O, Arraiza FJ, Barkley JM, Whigham CJ. Endovascular therapy of traumatic vascular lesions of the head and neck. Cardiovasc Intervent Radiol 2003;26:213-221.[Medline]
  4. Gasparri MG, Nicolosi AC, Almassi GH. A novel approach to the management of tracheoinnominate artery fistula. Ann Thorac Surg 2004;77:1424-1426.[Abstract/Free Full Text]



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