Percutaneous transcarotid and transbrachial access in the endovascular management of tracheoinnominate artery fistulas and review of current therapies

Tracheoinnominate fistulas (TIFs) are rare but lethal complications of tracheostomy placement. Prevention of death by hemorrhagic shock requires early recognition and definitive surgical management. We present two cases of TIFs managed with endovascular techniques using a unique percutaneous access strategy. The first case involved a 36-year-old man with profound hypoxic brain injury after cardiac arrest owing to cocaine use, who underwent percutaneous tracheostomy for chronic ventilator management. On postprocedure day 16, he developed severe hemorrhage from the tracheostomy site. The tracheostomy was removed, the patient was intubated, and the Utley maneuver was performed for temporary hemostasis. Retrograde percutaneous access of the right common carotid artery allowed delivery of a 10 × 39 mm GORE VBX stent to the innominate artery, successfully controlling hemorrhagic shock with no change in neurological status. The second case involved a 69-year-old woman with cirrhosis, atrial fibrillation on apixaban, and respiratory failure, who presented with a 400-mL herald bleed from her tracheostomy. Imaging showed a vascular connection to the trachea at the balloon cuff level. Retrograde percutaneous access of the right brachial artery was used to deliver a 9 × 29 mm GORE VBX stent to the innominate artery. Post procedure, the brachial artery was repaired with a polytetrafluoroethylene graft. The patient stabilized and was eventually discharged. Hemorrhage from a TIF remains a lethal complication, but endovascular approaches can provide rapid hemorrhage control in unstable patients with survival outcomes comparable with prior reports in similar high-risk populations. Percutaneous access for stent graft delivery can be obtained from various sites.