Tracheostomy: Bleeding and Tracheoinnominate Fistula (TIF)

Tracheostomy: Bleeding and Tracheoinnominate Fistula (TIF)

David Ray Velez, MD

Table of Contents

General Bleeding
Tracheoinnominate Fistula (TIF)

General Bleeding

Overview

  • Bleeding is Both Common but Potentially Life-Threatening
  • The Majority of Early Bleeding (Within the First 48 Hours) is Minor and Due to Local Trauma to the Superficial Veins at the Stoma Site
  • Most Often it is Self-Limited but Can Represent Major Life-Threatening Pathology

Timing

  • Early: Perioperative Bleeding < 48 Hours
    • Usually Benign
  • Late: Bleeding After > 48-72 Hours
    • More Concerning for Life-Threatening Emergency

Causes

  • Early Bleeding:
    • Trauma of the Superficial Veins at the Stoma Site
    • Suction Catheter Trauma
    • Operative Injury to a Major Vessel or Anomalous Vasculature
  • Late Bleeding:
    • Granulation Tissue
    • Erosion of an Adjacent Vessel
    • Infection and Friable Tissue
    • Tracheoinnominate Fistula (TIF)

Treatment of Early Peri-Stomal Bleeding

  • Silver Nitrate
  • Packing Petroleum Gauze
  • Packing Hemostatic Gauze (Surgicel)
  • Injection of Lidocaine with Epinephrine
  • Correct Any Underlying Coagulopathy

Tracheoinnominate Fistula (TIF)

Definition

  • Fistula Between the Innominate Artery and Trachea
  • Causes Rapid Exsanguination and Can Be Fatal within Minutes
  • Occurs Late (After 48-72 Hours)
  • A Rare Cause of Tracheostomy Bleeding (< 1 %)

Most Common Causes

  • Prolonged Exposure to Overinflated Cuff Pressures
  • Abnormally Low Tracheostomy Placement
  • Repetitive Head Movements Causing Repeated Contact

Sentinel Bleeding

  • 50% are Heralded by a Smaller Sentinel Bleed
  • Evaluate by Bronchoscopy in OR to Examine if Concerned
  • May Also Consider Angiography in Evaluation

Treatment

  • Initial Management: Temporize
    • First Assess ABC’s and Patient Stability
    • Overinflate the Cuff
    • Utley Maneuver – Finger Through the Incision into the Pretracheal Space to Apply Anterior Pressure Against the Sternum (Not into the Trachea Itself)
    • Correct Any Underlying Coagulopathy
    • Acute Respiratory Distress May Require In-Line Suctioning and Possible Bronchoscopy to Clear Blood in the Airway
  • Definitive Treatment: Median Sternotomy and Innominate Artery Ligation
    • Primarily Repair Trachea and Buttress with Viable Tissue
    • Failure to Ligate Has High Risk for Re-Fistulation
    • Do Not Use Interposition Graft (Will Infect)
    • 10% of Patients Experience a Neurologic Event After Ligation
    • Some Have Suggested Use of Endovascular Stents if Prohibitively High Surgical Risk

Tracheoinominate Fistula on Angiogram 1

Utley Maneuver

References

  1. Richter T, Gottschlich B, Sutarski S, Müller R, Ragaller M. Late life-threatening hemorrhage after percutaneous tracheostomy. Int J Otolaryngol. 2011;2011:890380. (License: CC BY-3.0)