Innominate Artery Compression Syndrome Following Endovascular Stenting of Tracheoinnominate Artery Fistula

Tracheoinnominate artery fistula (TIF) is a life-threatening complication associated with tracheostomy placement. It is characterized by the development of a connection from the tracheal lumen to the innominate artery. We describe the multidisciplinary management of a patient who developed innominate artery compression syndrome as a sequela of endovascular stenting of a TIF, and the subsequent surgical repair that ultimately led to relief of airway obstruction, allowing for tracheostomy decannulation. A 17-year-old male underwent percutaneous tracheostomy after suffering a gunshot wound to the head. On the sixth postoperative day, he developed massive hemoptysis. Work-up suggested TIF and this was confirmed with interventional angiography. To urgently address this situation innominate artery stenting with an endovascular graft was successfully performed. Bronchoscopy performed at 4 months follow-up noted near-complete tracheal obstruction distal to the tracheostomy tube from extrinsic pressure exerted by the graft. Based on the tracheal obstruction and risk for additional erosion/fistula formation in the presence of two foreign bodies immediately adjacent to each other, he underwent excision of the stented innominate artery with vascular bypass grafting, along with exclusion of the tracheal fistula and primary repair of the trachea without the use of mechanical circulatory support. Prompt diagnosis and treatment of TIF in a patient with risk factors is crucial in preventing mortality and is optimally managed in a multidisciplinary fashion. Clinicians should exercise a high index of suspicion when encountering patients with a tracheostomy and development of hemoptysis.  We present a successful surgical repair of innominate artery compression syndrome secondary to an endovascular graft used to urgently treat a TIF without resultant neurocognitive deficits.