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A5260 - Successful Treatment of a Ruptured Tracheoinnominate Fistula Following Long-Term Tracheotomy and Mycobacteria Chelonae Tracheobronchitis with Extracorporeal Membrane Oxygenation, Endovascular Stent Graft Implantation, and Surgical Bypass
Author Block: Y. Chien1, K. Hsu2, Y. Chao3, M. Chen3; 1Critical Care Medicine, Mackay Memorial Hospital, Taipei City, Taiwan, 2Cardiovascular srugery, Mackay Memorial Hospital, Taipei City, Taiwan, 3Pediatric cardiology, Mackay Memorial Hospital, Taipei City, Taiwan.
Introduction Tracheoinnominate artery fistula (TIF) is a rare but fatal complication of tracheostomy. Prompt diagnosis, immediate control bleeding, and rapid establishment of airway are critical for survival. We reported a case of ruptured TIF in a 14-year-old boy with long term tracheostomy and chronic Mycobacteria chelonae tracheobronchitis. Case report A 14-year-old boy with history of endocardial cushion defect and congenital tracheal stenosis status post surgical repair and laryngeal reconstruction presented to otolaryngological clinic with hemosputum for two days. He had been hospitalized multiple times due to recurrent tracheobronchial stenosis and lower airway infections. He received tracheostomy at age of 2 and sliding tracheoplasty at age 12. At age 9 he was diagnosed with non-tuberculosis mycobacterial tracheobronchitis and mycobacterial culture never turned negative ever since, despite prolonged antibiotics treatment. When otolaryngologist tried to change his tracheostomy tube, massive hemorrhage emanated from stoma. The patient went into pulseless electricity activity and extracorporeal membrane oxygenation was installed. An intra-tracheal Foley catheter balloon inflation was used for control of bleeding and a contrast enhanced computed tomography confirmed the diagnosis of TIF. An endovascular stent graft was deployed to innominate artery under c-arm guidance. The patient presented with acute respiratory distress syndrome (PaO2/FiO2 ≦ 100) despite Foley catheter was shifted back to tracheostomy tube on hospital day 3. Massive hemorrhage recurred on day 7; angiography revealed a bleeding focus at the base of innominate artery. A covered stent was placed at aortic arch and debranching surgical bypass connecting left subclavian, left common carotid, right common carotid, and right subclavian artery was performed. On day 17 a followed-up CT showed contrast in innominate artery and coil embolization was done. On day 22 ECMO was removed successfully. Discussion TIF often occurred in patients with low-lying tracheostomy close to innominate artery and necrosis of anterior tracheal wall. Sentinel bleeding occurred in more than 50% of patients who developed massive hemorrhage but was often mistaken as presentation of other etiologies. In this case, ECMO was installed to ensure oxygenation and tissue perfusion and intra-tracheal Foley catheter was used for control bleeding. Ligation of innominate artery was the mainstream procedure but was difficult in our patient because of multiple previous cardiothoracic surgeries. An endovascular stent graft implantation was performed instead, followed by a surgical bypass and a coil embolization for recurrent bleeding. A combination of multidisciplinary treatments could be the key to successful treatment of TIF in pediatric patients.