Emergent Covered Stent Placement for Tracheoinnominate Artery Fistula with Acute Pulmonary Hemorrhage
Presenter
Samantha Gilg, MD, Children's Nebraska, Omaha, NE
Samantha Gilg, MD, Ryan Sewell, MD, Daniel Wehrmann, MD, Rachel Alison Taylor, M.D., Christopher Curzon, D.O., FSCAI and Jeffrey W. Delaney, MD, FSCAI, Children's Nebraska, Omaha, NE
Title
Emergent Covered Stent Placement for Tracheoinnominate Artery Fistula with Acute Pulmonary Hemorrhage Introduction
Formation of a tracheoinnominate artery fistula is a rare but life-threatening complication following tracheostomy and results in severe pulmonary hemorrhage with reported risk of mortality up to 50%. We present a case of a 15yo with a complex medical history including severe subglottic stenosis requiring tracheostomy placement who presented with massive pulmonary hemorrhage and was found to have a tracheoinnominate artery fistula requiring covered stent placement.
Clinical Case
A 15yo with complex medical history including severe subglottic stenosis with tracheostomy placement in infancy presented with massive pulmonary hemorrhage prompting concern for tracheoinnominate artery fistula. He was taken urgently to the cath lab where the airway bleeding was temporized with an over-inflated oral endotracheal tube and high airway pressures. A pigtail catheter was positioned in the innominate artery and angiography identified a fistulous connection between the trachea and base of the innominate artery just prior to its bifurcation into the right carotid and right subclavian arteries. The decision was made to proceed with covered stent placement. To avoid jailing either vessel, a double balloon technique was utilized. A 12Fr Gore Dryseal sheath was placed at the base of the innominate artery through which two 0.018” Abbott Steelcore wires were advanced into the right subclavian artery and the right common carotid artery. A 22mm 8 Zig covered CP stent was hand mounted and crimped onto two balloons (8 mm x 2 cm Cook and 7 mm x 2 cm Cook) for a double balloon inflation. The entire system was advanced through the Dryseal sheath with the 8mm balloon positioned into the right subclavian and the 7mm balloon positioned into the right common carotid which allowed the stent to be positioned at the base of the innominate artery. Simultaneous inflation of the two balloons was performed with successful deployment of the stent. Repeat angiogram showed the stent to be well expanded with no obstruction to flow into the head and neck vessels and no extravasation of contrast. The ETT cuff was deflated with no recurrence of airway bleeding. Bronchoscopy was then performed which showed the fistulous connection now sealed with the covered stent.
Discussion
We present a 15yo patient with massive pulmonary hemorrhage who was found to have a tracheoinnominate artery fistula. He underwent placement of a covered stent at the bifurcation of the innominate artery utilizing the double balloon technique. Historically, treatment for a tracheoinnominate artery fistula has included surgical repair or endovascular stent placement but again with high reported mortality rates. Two weeks after our intervention, the patient was taken to the OR for definitive repair with innominate artery ligation and tracheal reconstruction via median sternotomy. He was able to return to his baseline status and is now 9 months post-intervention. This case highlights the ability of temporizing his massive pulmonary hemorrhage with a catheter based intervention to allow for a period of stability prior to undergoing surgical repair.