Successful management of a tracheo-innominate fistula in a 7-year-old child

The purpose is to describe the presentation and management of a tracheo-innominate artery fistula in a tracheostomy-dependent child. The study design is case report and the method is retrospective chart review. 7-Year-old female with a history of anoxia at birth, seizure disorder, tracheostomy and ventilator dependency since infancy presented to community hospital after one episode of spontaneous bleeding around and through the tracheostomy tube. The patient was transported to a tertiary pediatric teaching hospital and had more profuse bleeding upon arrival. She was taken emergently to the Operating Room (OR) where the cuff of a 5.0 endotracheal tube (ETT) placed through the existing stoma was used to tamponade the bleeding. The airway was secured proximally with a rigid bronchoscope which also provided photodocumentation during the procedure. The cardiothoracic surgery service performed ligation of the innominate artery and repair of the anterior tracheal wall defect through a midline sternotomy approach. The patient was monitored for 7 days in the ICU sedated and paralyzed and returned the OR for a new airway endoscopy and replacement of the ETT with a 5.0 tracheostomy tube. The patient was discharged after 12 days of hospitalization. Subsequent interval endoscopies revealed well-healed fistulous site and no further complications after 12 months of follow-up. Tracheo-innominate artery fistulae can be successfully managed if recognized and treated early. Special attention should be given to "sentinel events" that often precede more catastrophic bleeds.